Psychopathies and pathocharacteriological development of personality 

Psychopathies and pathocharacteriological development of personality 

Violation of psychological development

 

Psychopathy (Disorders of personality)

 Psychopathy (/saɪˈkɒpəθi/) is a personality disorder identified by characteristics such as a lack of empathy and remorse, criminality, antisocial behavior, egocentricity, superficial charm,manipulativeness, irresponsibility,

 impulsivity, and a parasitic lifestyle.

As a diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, psychopathy has been replaced by antisocial personality disorder (ASPD).

While no psychiatric or psychological organization has sanctioned a diagnosis of “psychopathy” itself, assessments of psychopathy characteristics are widely used in criminal justice settings in some nations and may have important consequences for individuals. The term is also used by the general public, in popular press, and in fictional portrayals.

Although there are behavioral similarities, psychopathy and ASPD, according to criteria in the Diagnostic and Statistical Manual of Mental Disorders, are not synonymous. The diagnosis of ASPD covers two to three times as many prisoners as those that have been labeled psychopaths. Most offenders scoring high on the Hare Psychopathy Checklist (PCL-R) also pass the ASPD criteria, but most of those with ASPD do not score high on the PCL-R. Psychopaths are, despite the similar names, rarely psychotic.

Etymology 

The word “psychopathy” is a joining of the Greek words psyche ψυχή (soul) and pathos πάθος (suffering, feeling). The first documented use is from 1847 in Germany as psychopatisch, and the noun psychopath has been traced to 1885.

In medicine, patho- has long had a specific meaning of disease. Thus pathology has meant the study of disease since 1610, and psychopathology the study of mental disorder since 1847. A sense of “worthy to be a subject of pathology, morbid, excessive” is attested from 1845, including the phrase pathological liar from 1891 in the medical literature.

Psychosis was also used in Germany from 1841, including in a general sense of any mental derangement. The suffix -ωσις (-osis) meant in this case “abnormal condition”. This term or its adjective psychotic would come to refer specifically to mental states or disorders characterized by hallucinations, delusions or being in some other sense out of touch with reality.

The term psychopathy initially had a very general meaning too, referring to all sorts of mental disorders. Some medical dictionaries still define it in the narrow and broad sense, for example MedlinePlus from the U.S. National Library of Medicine. Others, such as Stedman’s Medical Dictionary, define it only as an outdated term for an antisocial type of personality disorder.

The slang psycho has been traced to 1936 as a shortening of the adjective psychopathic, and from 1942 as a shortening of the noun psychopath, and it can also be short for psychotic.

The label psychopath has been described as strangely nonspecific but probably persisting because it indicates that the source of behavior lies in the psyche rather than in the situation. The media usually uses the term to designate any criminal whose offenses are particularly abhorrent and unnatural, but that is not its original or general psychiatric meaning. In the alternative term sociopath, socio has been common in compound words since around 1880, referring to social or society.

Measurement instruments 

Psychopathy Checklist 

Psychopathy is most commonly assessed with the Psychopathy Checklist, Revised (PCL-R) created by psychologist Robert D. Hare. Each of the 20 items in the PCL-R is scored on a three-point scale, with a rating of 0 if it does not apply at all, 1 if there is a partial match or mixed information, and 2 if there is a reasonably good match to the offender. This is sa idto be ideally done through a face-to-face interview together with supporting information on lifetime behavior (e.g. from case files), but is also done based only on file information. It can take up to three hours to collect and review the information.

Psychopathy Checklist-Revised: Factors, Facets, and Items
Factor 1	Factor 2	Other items
Facet 1: Interpersonal ·                    Glibness/superficial charm ·                    Grandiose sense of self-worth ·                    Pathological lying ·                    Cunning/manipulative Facet 2: Affective ·                    Lack of remorse or guilt ·                    Emotionally shallow ·                    Callous/lack of empathy ·                    Failure to accept responsibility for own actions	Facet 3: Lifestyle ·                    Need for stimulation/proneness to boredom ·                    Parasitic lifestyle ·                    Lack of realistic, long-term goals ·                    Impulsiveness ·                    Irresponsibility Facet 4: Antisocial ·                    Poor behavioral controls ·                    Early behavioral problems ·                    Juvenile delinquency ·                    Revocation of conditional release ·                    Criminal versatility	·                    Many short-term marital relationships ·                    Promiscuous sexual behavior

The PCL-R is referred to by some as the “gold standard”^{[according to whom?]} for assessing psychopathy. It was developed with and for criminal samples, based on the pioneer Hervey Cleckley‘s mid-20th century’s characterization but with his positive-adjustment indicators omitted. High PCL-R scores are positively associated with measures of impulsivity and aggression, Machiavellianism, persistent criminal behavior, and negatively associated with measures of empathy and affiliation. 30 out of a maximum score of 40 is recommended as the cut-off for the label of psychopathy, although there is little scientific support for this as a particular break point. For research purposes a cut-off score of 25 is sometimes used. In fact, the UK has used a cut-off of 25 rather than the 30 used in the United States.

The PCL-R items were designed to be split in two. Factor 1 involves interpersonal or affective (emotion) personality traits and higher values are associated with narcissism and low empathy as well as social dominance and less fear or depression. Factor 2 involves either impulsive-irresponsible behaviors or antisocial behaviors and is associated with a maladaptive lifestyle including criminality. The two factors correlate with each other to some extent. Each factor is sometimes further subdivided in two – interpersonal vs affect items for Factor 1, and impulsive-irresponsible lifestyle vs antisocial behavior items for Factor 2. “Promiscuous sexual behavior” and “many short-term marital relationships” have sometimes been left out in such divisions (Hare, 2003).

Cooke and Michie have argued that a three-factor structure provide a better model than the two-factor structure. Those items from factor 2 strictly relating to antisocial behavior (criminal versatility, juvenile delinquency, revocation of conditional release, early behavioral problems, and poor behavioral controls) are removed. The remaining items are divided into three factors: Arrogant and Deceitful Interpersonal Style, Deficient Affective Experience, and Impulsive and Irresponsible Behavioral Style. Hare and colleagues have published detailed critiques of the model and argue that there are statistical and conceptual problems.

Because an individual’s scores may have important consequences for his or her future, the potential for harm if the test is used or administered incorrectly is considerable. The test can only be considered valid if administered by a suitably qualified and experienced clinician under controlled conditions.

There is also a shorter version of the PCL-R, known as a screening version (PCL-SC), developed for quicker assessments of larger numbers or groups without criminal records. It has only 12 items and a maximum scores of 24 but correlates strongly with the main PCL-R. The corresponding cut-off score is 18.

Hare’s concept and checklist have also been criticized. In 2010 there was controversy after it emerged Hare had threatened legal action that stopped publication of a peer-reviewed article on the PCL-R. Hare alleged the article quoted or paraphrased him incorrectly. The article eventually appeared three years later. It alleged that the checklist is wrongly viewed by many as the basic definition of psychopathy, yet it leaves out key factors, while also making criminality too central to the concept. The authors claimed this leads to problems in overdiagnosis and in the use of the checklist to secure convictions. Hare has clarified that he receives less than $35,000 a year from royalties associated with the checklist and its derivatives.

In addition, Hare’s concept of psychopathy has been criticised as being only weakly applicable to real-world settings and tending towards tautology. It is also said to be vulnerable to “labeling effects”; to be over-simplistic; reductionistic; to embody the fundamental attribution error; and to not pay enough attention to context and the dynamic nature of human behavior. Some research suggests that ratings made using this system depend on the personality of the person doing the rating, including how empathic they themselves are. One forensic researcher has suggested that future studies need to examine the class background, race and philosophical beliefs of raters because they may not be aware of enacting biased judgments of people whose section of society or individual lives they have no understanding of or empathy for.

DSM and ICD 

There are currently two widely established systems for classifying mental disorders — Chapter V of the International Classification of Diseases (ICD-10) produced by the World Health Organization (WHO) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) produced by the American Psychiatric Association (APA). Both list categories of disorders thought to be distinct types, and have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain.

The DSM has never listed psychopathy as the official term for a personality disorder, although it shares behavioral characteristics with ASPD, which is characterized by “… a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood”, and requires three out of seven specific factors to be present. The ICD’s conceptually similar diagnosis is called Dissocial personality disorder, “usually coming to attention because of a gross disparity between behaviour and the prevailing social norms, and characterized by” 3 of 6 specific issues.

Although there are behavioral similarities, ASPD according the Diagnostic and Statistical Manual of Mental Disorders criteria and psychopathy are not synonymous. A diagnosis of ASPD is based on behavioral patterns, whereas psychopathy measurements also include personality characteristics. The diagnosis of ASPD covers two to three times as many prisoners as are rated as psychopaths. Most offenders scoring high on the PCL-R also pass the ASPD criteria but most of those with ASPD do not score high on the PCL-R. Some who meet criteria for ASPD may only score high on Factor 2 of the PLC-R.

Proponents claim that the Psychopathy Checklist is better able to predict future criminality, violence, and recidivism than the diagnosis of ASPD. Hare writes that there are also differences between PLC psychopaths and others on “processing and use of linguistic and emotional information”, while such differences are small between those diagnosed with ASPD and not. However, the Hare Psychopathy Checklist requires the use of a rather long interview and availability of considerable additional information as well as depending in part on judgments of character rather than observed behavior.

Hare wrote that the field trials for the DSM-IV found personality traits judgments to be as reliable as those diagnostic criteria relying only on behavior, but that the personality traits criteria were dropped in part because it was feared that the average clinician would not use them correctly. Hare criticizes the instead used DSM-IV criteria for being poorly empirically tested. In addition, the introductory text description describes the personality characteristics typical of psychopathy, which Hare argues make the manual confusing and actually containing two different sets of criteria. He has also argued that confusion regarding how to diagnose ASPD, confusion regarding the difference between ASPD and psychopathy, as well as the differing future prognoses regarding recidivism and treatability, may have serious consequences in settings such as court cases where psychopathy is often seen as aggravating the crime.

The DSM-V working party is recommending a revision of ASPD to be called antisocial/dyssocial personality disorder. There is also a suggestion to include a subtype “Antisocial/Psychopathic Type”.\

 

Other classification issues 

Distinct condition or not 

A crucial issue regarding the concept of psychopathy is whether it identifies a distinct condition that can be separated from other conditions and “normal” personality types, or whether it is simply a combination of scores on various dimensions of personality found throughout the population in varying combinations.

An early and influential analysis from Harris and colleagues indicated a discrete category may underlie PCL-R psychopathy, but this was only found for the behavioral Factor 2 items, indicating this analysis may be related to ASPD rather than psychopathy. Marcus, John, and Edens more recently performed a series of statistical analysis on PPI scores and concluded psychopathy may best be conceptualized as having a “dimensional latent structure” like depression.

Marcus et al. repeated the study on a larger sample of prisoners, using the PCL-R and seeking to rule out other experimental or statistical issues that may have produced the previously different findings. They again found that the psychopathy measurements do not appear to be identifying a discrete type (a taxon). They suggest that while for legal or other practical purposes an arbitrary cut-off point on trait scores might be used, there is actually no clear scientific evidence for an objective point of difference by which to call some people “psychopaths”. The Hare checklist was developed for research not clinical forensic diagnosis, and even for research purposes to improve understanding of the underlying issues, it is necessary to examine dimensions of personality in general rather than only this constellation of traits.

Triarchic model 

The triarchic model argues that various concepts of psychopathy can be explained by three factors:

·                    Boldness. Low fear including stress-tolerance, toleration of unfamiliarity and danger, and high self-confidence and social assertiveness. PCL-R measures this relatively poorly and mainly through Facet 1 of Factor 1. Similar to PPI Fearless dominance. May correspond to differences in the amygdala and other neurological systems associated with fear.

·                    Disinhibition. Poor impulse control including problems with planning and foresight, lacking affect and urge control, demand for immediate gratification, and poor behavioral restraints. Similar to PCL-R Factor 2 and PPI Impulsive antisociality. May correspond to impairments in frontal lobe systems that are involved in such control.

·                    Meanness. Lacking empathy and close attachments with others, disdain of close attachments, use of cruelty to gain empowerment, exploitative tendencies, defiance of authority, and destructive excitement seeking. PCL-R in general is related to this but in particular some elements in Factor 1. Similar to PPI Coldheartedness but also includes elements of subscales in Impulsive antisociality. Meanness may possibly be caused by either high boldness or high disinhibition combined with an adverse environment. Thus, a child with high boldness may respond poorly to punishment but may respond better to rewards and secure attachments which may not be available under adverse conditions. A child with high disinhibition may have increased problems under adverse conditions with meanness developing in response.

Psychopathy vs. sociopathy 

General 

Hare notes that sociopathy and psychopathy are often used interchangeably, but in some cases the term sociopathy is preferred because it is less likely than is psychopathy to be confused with psychoticism, whereas in other cases which term is used may “reflect the user’s views on the origins and determinates of the disorder,” with the term sociopathy preferred by those that see the causes as due to social factors and early environment, and the termpsychopathy preferred by those who believe that there are psychological, biological, and genetic factors involved in addition to environmental factors.

Primary-secondary distinction 

Several researchers have argued that there exist two variants of psychopathy. There is also empirical support for separating persons scoring high on the PCL-R into two groups that do not simply reflect Factor 1 and Factor 2. There is at least preliminary evidence of differences regarding cognition and affect as measured in laboratory tests. Different theories characterize these two variants somewhat differently. Compared to “primary” psychopaths, researchers agree that “secondary” psychopaths have more fear, anxiety, and negative emotions. They are often seen as more impulsive and with more reactive anger and aggression. Some preliminary research have suggested that secondary psychopaths may have had a more abusive childhood according to self-reports (which possibly may be inflated in secondary psychopathy), may have a higher risk of future violence, and may respond better to treatment.

Primary psychopathy has been seen as mainly due to genetic factors while secondary psychopathy has been seen as mainly due to environmental factors which also has implications for treatment possibilities. Such proposed environmental factors include an abusive childhood or a society presenting opportunities for cheating. Other researchers have argued that genetics and environment are important for both variants. David T. Lykken, using Gray’s biopsychological theory of personality, have argued that primary psychopaths innately have little fear while secondary psychopaths innately have increased sensitivity to rewards. Proponents of the triarchic model described above see primary psychopaths associated with increased boldness and secondary psychopathy as associated with increased disinhibition.

Other personality dimensions 

Some studies have linked psychopathy to other dimensions of personality. These include antagonism (high), conscientiousness (low) and anxiousness (low, or sometimes high). However, there are different views as to which personality dimensions are more central in regard to psychopathy, and in addition the traits are found throughout the general population in differing combinations. Some have also linked psychopathy to high psychoticism – a theorized dimension referring to tough, aggressive or hostile tendencies.

Aspects of this that appear associated with psychopathy are lack of socialization and responsibility, impulsivity, sensation-seeking in some cases, and aggression. Otto Kernberg, from a particular psychoanalytic perspective, believes psychopathy should be considered as part of a spectrum of pathological narcissism, that would range from narcissistic personality on the low end, malignant narcissism in the middle, and psychopathy at the high end. However, narcissism is generally seen as only one aspect of psychopathy as generally defined.

Cleckley checklist 

In his book Mask of Sanity, Hervey M. Cleckley described 16 “common qualities” that he thought were characteristic of the individuals he termed psychopaths: Cleckley checklist formed the basis for Hare’s more current PCL-R checklist (see above).

1.   Superficial charm and good “intelligence”

2.   Absence of delusions and other signs of irrational thinking

3.   Absence of “nervousness” or psychoneurotic manifestations

4.   Unreliability

5.   Untruthfulness and insincerity

6.   Lack of remorse and shame

7.   Inadequately motivated antisocial behavior

8.   Poor judgment and failure to learn by experience

9.   Pathologic egocentricity and incapacity for love

10.                     General poverty in major affective reactions

11.                     Specific loss of insight

12.                     Unresponsiveness in general interpersonal relations

13.                     Fantastic and uninviting behavior with drink and sometimes without

14.                     Suicide threats rarely carried out

15.                     Sex life impersonal, trivial, and poorly integrated

16.                     Failure to follow any life plan.

Cleckley also suggested there were milder forms. He ended his survey by saying “If we consider, in addition to these patients (nearly all of whom have records of the utmost folly and misery and idleness over many years and who have had to enter a psychiatric hospital), the vast number of similar people in every community who show the same behavior pattern in milder form but who are sufficiently protected and supported by relatives to remain at large, the prevalence of this disorder is seen to be appalling.”

 

Moral judgment 

Psychopaths have been considered notoriously amoral – an absence of, indifference towards, or disregard for moral beliefs. There are little firm data on patterns of moral judgment, however. Studies of developmental level (sophistication) of moral reasoning found all possible results – lower, higher or the same as non-psychopaths. Studies that compared judgments of personal moral transgressions versus judgments of breaking conventional rules or laws, found that psychopaths rated them as equally severe, whereas non-psychopaths rated the rule-breaking as less severe.

A study comparing judgments of whether personal or impersonal harm would be endorsed in order to achieve the rationally maximum (utilitarian) amount of welfare, found no significant differences between psychopaths and non-psychopaths. However, a further study using the same tests found that prisoners scoring high on the psychopathy checklist were more likely to endorse impersonal harm or rule violations thaon-psychopaths were. Psychopaths who scored low in anxiety were also more willing to endorse personal harm on average.

Assessing accidents, where one person harmed another unintentionally, psychopaths judged such actions to be more morally permissible. This result is perhaps a reflection of psychopaths’ failure to appreciate the emotional aspect of the victim’s harmful experience, and furnishes direct evidence of abnormal moral judgment in psychopathy.

Intelligence 

Hare and Neumann (2008) state that a large literature shows that there is at most only a weak association between psychopathy and IQ. They consider that the early pioneer Cleckley included high IQ in his checklist due to selection bias since many of his patients were “well educated and from middle-class or upper-class backgrounds” and state that “there is no obvious theoretical reason why the disorder described by Cleckley or other clinicians should be related to intelligence; some psychopaths are bright, others less so.”

In addition, studies indicate that different aspects of the definition of psychopathy (e.g. interpersonal, affective (emotion), behavioral and lifestyle components) can show different links to intelligence, and it can also depend on the type of “intelligence” assessment (e.g. verbal IQ, creative, practical, analytical). Those scoring high on psychopathy measures may tend to score lower on verbal IQ.

According to R. J. R. Blair, psychopaths demonstrate impairment in stimulus-reinforced learning (whether punishment-based or reward-based). This may be due to dysfunctions in the amygdala and ventromedial prefrontal cortex. People scoring ≥25 in the Psychopathy Checklist Revised, with an associated history of violent behavior, appear to have significantly reduced microstructural integrity in their uncinate fasciculus — white matter connecting the amygdala and orbitofrontal cortex. There is DT-MRI evidence of breakdowns in the white matter connections between these two important areas.

Co-occurrence with other mental conditions 

Psychopaths may have various other mental conditions. It has been found that psychopathy scores correlated with “antisocial, narcissistic, histrionic, and schizoid personality disorders … but not neurotic disorders or schizophrenia“. Additionally, the constellation of traits in psychopathy assessments overlaps considerably with ASPD criteria and also with histrionic personality disorder and narcissistic personality disorder criteria.

Psychopathy is associated with substance use disorders. This appears to be linked more closely to anti-social/criminal lifestyle, as measured by Factor 2 of the PCL-R, than the interpersonal-emotional traits assessed by Factor I of the PCL-R.

Attention deficit hyperactivity disorder (ADHD) is known to be highly comorbid with conduct disorder, and may also co-occur with psychopathic tendencies. This may be explained in part by deficits in executive function.

Anxiety disorders often co-occur with ASPD, and contrary to assumptions psychopathy can sometimes be marked by anxiety; however, this appears to be due to the antisocial aspect (factor 2 of the PCL), and anxiety may be inversely associated with the interpersonal-emotional traits (Factor I of the PCL-R).

Depression appears to be inversely associated with psychopathy. There is little evidence for a link between psychopathy and schizophrenia.

It has been suggested that psychopathy may be comorbid with several other diagnoses than these, but limited work on comorbidity has been carried out. This may be partly due to difficulties in using inpatient groups from certain institutions to assess comorbidity, owing to the likelihood of some bias in sample selection.

Offending 

The majority of crimes, including violent crimes, are committed by a small part of the population (5-7%). However, those who repeatedly commit crimes are a heterogeneous group with varying personality characteristics and psychopathy cannot be said to be the underlying type.

Correlation with criminality 

The PCL-R manual state an average score of 22.1 in North American prisoners samples and that 20.5% scored 30 or higher. An analysis of prisoner samples from outside North America found a somewhat lower average value of 17.5. A diagnosis of ASPD is about two to three times as common in prisoners as a label of psychopathy is. A 2009 study by Coid et al. of a representative sample of British prisoners, unlike selected samples used in many other studies, found a prevalence of PCL-R > 30 in 7.7% of men and in 1.9% of women. Psychopathy scores “correlated with younger age, repeated imprisonment, detention in higher security, disciplinary infractions, antisocial, narcissistic, histrionic, and schizoid personality disorders, and substance misuse, but not neurotic disorders or schizophrenia.” Most correlations were similar to those in other studies.

Psychopathy, as measured with the PCL-R in institutional settings, show in meta-analyses small to moderate effect sizes (r = 0.23 to 0.30) with institutional misbehavior, postrelease crime, or postrelease violent crime with similar effects for the three outcomes. Individual studies give similar results for adult offenders, forensic psychiatric samples, community samples, and youth. The PCL-R is poorer at predicting sexual re-offending.

However, this link appears to be due largely to the scale items that assess impulsive behaviors and past criminal history, which are well-established but very general risk factors. The aspects of core personality often held to be distinctively psychopathic, generally show little or no predictive link to crime by themselves. Thus Factor 1 of the PCL-R and Fearless dominance of the PPI-R have smaller or no relationship to crime, including violent crime. In contrast Factor 2 and Impulsive antisociality of the PPI-R are associated more strongly with criminality. Factor 2 has a relationship of similar strength to that of the PCL-R as a whole. The antisocial facet of the PCL-R is still predictive of future violence after controlling for past criminal behavior which, together with results regarding the PPI-R which by design does not include past criminal behavior, suggests that impulsive behaviors is an independent risk factor.

Some clinicians suggest that assessment of the construct of psychopathy does not necessarily add value to violence risk assessment. There are several other risk assessment instruments which can predict further crime with an accuracy similar to the PCL-R and some of these are considerably easier, quicker, and less expensive to administrate. This may even be done automatically by a computer simply based on data such as age, gender, number of previous convictions, and age of first conviction. Some of these assessments may also identify treatment change and goals, identify quick changes that may help short-term management, identify more specific kinds of violence that may be at risk, and may have established specific probabilities of offending for specific scores. PCL-R may continue to be popular for risk assessment because of is pioneering role and the large amount of research done using it. Although psychopathy is associated on average with an increased risk of violence, it is difficult to know how to manage the risk.

Violence 

Links have been suggested that psychopaths tend to commit more “instrumental” violence than “reactive” violence. One conclusion in this regard was made by a 2002 study of homicide offenders, which reported that the homicides committed by psychopaths were almost always (93.3%) primarily instrumental, while about half (48.4%) of those committed by non-psychopaths were. However, contrary to the equating of this to mean “in cold blood”, more than a third of the homicides by psychopaths involved emotional reactivity as well.

In addition, the non-psychopaths still accounted for most of the instrumental homicides, because most of these murderers were not psychopaths. In any case, FBI profilers indicate that serious victim injury is generally an emotional offense, and some research supports this, at least with regard to sexual offending. One study has found more serious offending by non-psychopaths on average than by psychopaths (e.g. more homicides versus more armed robbery and property offenses) and another that the Affective facet of PCL-R predicted reduced offense seriousness.

Sexual offending 

A 2011 study of conditional releases for Canadian male federal offenders found that psychopathy was related to more violent and non-violent offences but not more sexual offences. For child molesters, psychopathy was associated with more offences. Despite “their extensive criminal histories and high recidivism rate”, psychopaths showed “a great proficiency in persuading parole boards to release them into the community.” It is purported that high-psychopathy offenders (both sexual and non-sexual offenders) are about 2.5 times more likely to be granted conditional release compared to non-psychopathic offenders.”

Some studies have found only weak associations between psychopathy and sexual offending overall. The association is more certain for sexual violence. Psychopaths have higher sexual arousal to depictions of rape thaon-psychopaths. Rapists, especially sadistic rapists, and sexual homicide offenders have a high rate of psychopathy. Some researchers have argued that psychopaths have a preference for violent sexual behavior.

One study examined the relationship between psychopathy scores and types of aggression expressed in a sample of 38 sexual murderers. 84.2% of the sample had PCL-R scores above 20 and 47.4% above 30. 82.4% of those above 30 had engaged in sadistic violence (defined as enjoyment indicated by self-report or evidence) as compared to 52.6% of those below and total PCL-R and Factor 1 scores correlated significantly with sadistic violence. In considering the challenging issue of possible reunification of some sex offenders into homes with a non-offending parent and children, it has been advised that any sex offender with a significant criminal history should be assessed on the PCL-R, and if they score 18 or higher than they should be excluded from any consideration of being placed in a home with children under any circumstances.

 

Other offending 

Terrorists are sometimes called psychopaths, and comparisons can be drawn with traits such as antisocial violence, a selfish worldview that precludes welfare for others, lack of remorse or guilt, and blaming external events. However, such comparisons could also then be drawn more widely, for example to soldiers in wars. In addition, it has beeoted that coordinated terrorist activity requires organization, loyalty and ideology; traits such as self-centeredness, unreliability, poor behavioral controls, and unusual behaviors may be disadvantages.

Recently Häkkänen-Nyholm and Nyholm (2012) have discussed the possibility of psychopathy being associated with organised crime, economic crime and war crimes. 

It has been speculated that some psychopaths may be socially successful, due to factors such as low disinhibition in the triarchic model in combination with other advantages such as a favorable upbringing and good intelligence. However, there is little research on this, in part because the PCL-R does not include positive adjustment characteristics and most research have used the PCL-R on criminals. Some research using the PPI indicate that psychopathic interpersonal and affective traits/boldness and/or meanness in the triarchic model exist in noncriminals and correlate with stress immunity and stability.

Psychologists Fritzon and Board, in their study comparing the incidence of personality disorders in business executives against criminals detained in a mental hospital, found that some personality disorders were more common in the executives. They described the personality-disordered executives as “successful psychopaths” and the personality-disordered criminals as “unsuccessful psychopaths”.

Sex differences 

Research on psychopathy have largely been done on men and the PCL-R was developed using mainly male criminal samples raising the question how well the results apply to women. There have also been research investigating the sex differences. Men score higher than women on both the PCL-R and the PPI and on both of their main scales. The differences tend to be somewhat larger on the interpersonal-affective scale than on the antisocial scale. Most but not all studies have found broadly similar factor structure for men and women.

Many associations with other personality traits are similar although in one study the antisocial factor was more strongly related with impulsivity in men and more strongly related with openness to experience in women. It has been suggested that psychopathy in men manifest more as an antisocial pattern while it in women manifests more as a histrionic pattern. Studies on this have shown mixed results. PCL-R scores may be somewhat less predictive of violence and recidivism women. On the other hand, psychopathy may have stronger relationship with suicide and possibly internalizing symptoms in women. A suggestion is that psychopathy manifest more as externalizing behaviors in men and more as internalizing behaviors in women.

Causes and pathophysiology 

Childhood and adolescent precursors 

The “Psychopathy Checklist: Youth Version” (PCL:YV) is an adaptation of the PCL-R for 13–18 years old. It is, like the PCL-R, done by a trained rater based on an interview and an examination of criminal and other records. The “Antisocial Process Screening Device” (APSD) is also an adaptation of the PCL-R. It can be administered by parents or teachers for 6–13 year olds or it can be self-administered by 13–18 years olds. High psychopathy scores for both juveniles, as measured with these instruments, and adults, as measured with the PCL-R, have many similar associations with other variables. This include similar predictive ability regarding violence and criminality as well as this mainly being due to the scales measuring impulsive and antisocial behaviors rather than the scales measuring interpersonal and affective features. As for adults, several other measurement tools have similar predictive ability at risk assessment. One difference is that juvenile psychopathy appears to be associated with more negative emotionality such as anger, hostility, anxiety, and, depression. Some recent studies have also found poorer ability at predicting long-term, adult offending such as the predictive ability not being better than unaided clinical judgment in one study.

Conduct disorder is a diagnosis with similarities to ASPD. The DSM-IV allows differentiating between childhood onset before age 10 and adolescent onset at age 10 and later. Childhood onset is argued to be more due to a personality disorder caused by neurological deficits interacting with an adverse environment. For many, but not all, is childhood onset associated with what is in Terrie Moffitt’s developmental theory of crime is referred to as “life-course- persistent” antisocial behavior as well as poorer health and economic status. Adolescent onset is argued to more typically be associated with short-term antisocial behavior. It has been suggested that the combination of early-onset conduct disorder and ADHD may be associated with life-course-persistent antisocial behaviors as well as psychopathy.

There is evidence that this combination is more aggressive and antisocial than those with conduct disorder alone. However, it is not particularly distinct group since the vast majority of young children with conduct disorder also have ADHD. Some evidence indicates that this group have deficits in behavioral inhibition similar to adult psychopaths. They may not be more likely than those with conduct disorder alone to have the interpersonal/affective features and the deficits in emotional processing characteristic of adult psychopaths. Proponents of different types/dimensions of psychopathy have seen this type as possibly corresponding to adult secondary psychopathy/disinhibition in the triarchic model.

The DSM-V is proposing the specifier “With Significant Callous-Unemotional Traits” which would require at least two out of four of features for at least a year: lacking of remorse/guilt, lacking empathy (callousness), lacking affect, and lacking concern for performance. It has been suggested that this is a subgroup of early onset conduct disorder distinct from the larger group by having less deficits in inhibition, less fear and anxiety, less emotional reactivity and emotional negativity, more boldness and/or meanness, less intellectual impairment, and less exposure to poor parental practices although parental practices do affect outcomes for this group. It has been argued that this group is at increased risk for future of aggressive, criminal, and other antisocial behaviors but it is unclear how much the callous-unemotinal traits contribute to this since this group also often have higher impulsivity and more prior antisocial behavior compared to children with conduct disorder without callous-unemotional traits. Proponents of different types/dimensions of psychopathy have seen this type as possibly corresponding to adult primary psychopathy/boldness in the triarchic model.

There are moderate to high correlations between psychopathy rankings from late childhood to early adolescence. The correlations are considerably lower from early- or mid-adolescence to adulthood. In one study most of the similarities were on the Impulsive- and Antisocial-Behavior scales. Of those adolescents who scored in the top 5% highest psychopathy scores at age 13, less than one third (29%) were classified as psychopathic at age 24.

Three behaviors — bedwetting, cruelty to animals and firestarting, known as the Macdonald triad — were first described by J.M. MacDonald as possible indicators, if occurring together over time during childhood, of future episodic aggressive behavior. However, subsequent research has found that bedwetting is not a significant factor and the triad as a particular profile has been called an urban legend. Questions remain about a connection between animal cruelty and later violence, though it has been included in the DSM as a possible factor in conduct disorder and later antisocial behavior.

Environmental 

A study by Farrington of a sample of London males followed between age 8 and 48 included studying which factors predicted scoring 10 or more on the PCL: SV at age 48. The strongest factors were “having a convicted father or mother, physical neglect of the boy, low involvement of the father with the boy, low family income, and coming from a disrupted family.” Other significant factors included poor supervision, harsh discipline, large family size, delinquent sibling, young mother, depressed mother, low social class, and poor housing.

There has also been association between psychopaths and detrimental treatment by peers. Henry Lee Lucas, a serial killer and diagnosed psychopath, was bullied as a child and later said that his hatred for everyone spawned from mass social rejection.

Proponents of the triarchic model described earlier see psychopathy as due to the interaction of an adverse environment and genetic predispositions. What is adverse may differ depending on the underlying predisposition. Thus, persons having high boldness may respond poorly to punishment but may respond better to rewards and secure attachments.

Clinical management 

Psychopathy has often been considered untreatable. Harris and Rice’s Handbook of Psychopathy says that there is little evidence of a cure or effective treatment for psychopathy; no medications can instill empathy, and psychopaths who undergo traditional talk therapy might become more adept at manipulating others and more likely to commit crime. The only study finding increased criminal recidivism after treatment was in a 2011 review a retrospective study with several methodological problems on a today likely not approved treatment program in the 1960s. Some relatively rigorous quasi-experimental studies using more modern treatment methods have found improvements regarding reducing future violent and other criminal behavior, regardless of PCL-R scores, although none was a randomized controlled trial. Some other studies have found improvements in risk factors for crime such as substance abuse. No study had in a 2011 review examined if the personality traits could be changed by such treatments. It has been shown in some studies that punishment and behavior modification techniques may not improve the behavior of psychopaths.

Legal response 

The PCL-R, the PCL:SV, and the PCL:YV are highly regarded and widely used in criminal justice settings in particular in North America. They may be used for risk assessment and for assessing treatment potential and be used as part of the decisions regarding bail, sentence, which prison to use, parole, and regarding whether to a youth should be tried as a juvenile or as an adult. There have been several criticisms against this. They include the general criticisms against the PCL-R, the availability of other risk assessment tools which may have advantages, and excessive pessimism regarding prognosis and treatment possibilities (see earlier sections).

The interrater reliability of the PCL-R can be high when used carefully in research but tend to be poor in applied settings. In particular Factor 1 items are somewhat subjective. In sexually violent predator cases the PCL-R scores given by prosecution experts were consistently higher than those given by defense experts in one study. The scoring may also be influenced by other differences between raters. In one study it was estimated that of the PCL-R variance, about 45% was due to true offender differences, 20% was due to which side the rater testified for, and 30% was due to other rater differences.

United Kingdom 

In the United Kingdom, “Psychopathic Disorder” was legally defined in the Mental Health Act (UK) as, “a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned.” This term, which did not equate to psychopathy, was intended to reflect the presence of a personality disorder, in terms of conditions for detention under the Mental Health Act 1983. With the subsequent amendments to the Mental Health Act 1983 within the Mental Health Act 2007, the term “psychopathic disorder” has been abolished, with all conditions for detention (e.g. mental illness, personality disorder, etc.) now being contained within the generic term of “mental disorder”.

In England and Wales, the diagnosis of dissocial personality disorder is grounds for detention in secure psychiatric hospitals under the Mental Health Act if they have committed serious crimes, but since such individuals are disruptive for other patients and not responsive to treatment this alternative to prison is not often used.

United States 

“Sexual psychopath” laws 

Starting in the 1930s, before the modern concept of psychopathy, “sexual psychopath” laws were introduced by some states until by the mid-1960s more than half of the states had such laws. “Sexual psychopaths” were seen as a distinct group of sex offenders who were not seriously mentally ill but had a “psychopathic personality” that could be treated. This was in agreement with the general rehabilitative trends at this time. Courts sent such sex offenders to a mental health facility for community protection and treatment.

Starting in 1970 many of these laws were modified or abolished in favor of more traditional responses such as imprisonment due to criticism of the “sexual psychopath” concept as lacking scientific evidence, the treatment being ineffective, and predictions of future offending being dubious. There were also a series of cases where persons treated and released committed new sex crimes. Starting in the 1990s several states have passed sexually dangerous person laws, not synonymous with the modern concept of psychopathy, which permit confinement after a sentence has been completed. Psychopathy measurements may be used in the confinement decision process.

Epidemiology 

A 2008 study using the Psychopathy Checklist: Screening Version (PCL: SV) found that 1.2% of a US sample scored 13 or more which indicates “potential psychopathy”. Over half of those studied had scores of 0 or 1 and about two-thirds scored 2 or less. Higher scores were significantly associated with more violence, higher alcohol use, and estimated lower intelligence.

A 2009 British study by Coid et al., also using the PCL: SV, reported a community prevalence of 0.6% scoring 13 or more. The lower prevalence than in the 2008 study may be due to the 2009 sample being more representative of the general population. The scores “correlated with: younger age, male gender; suicide attempts, violent behavior, imprisonment and homelessness; drug dependence; histrionic, borderline and adult antisocial personality disorders; panic and obsessive–compulsive disorders.”

PCL-R creator Robert Hare has stated that many (male) psychopaths have a pattern of mating with, and quickly abandoning women, and as a result, have a high fertility rate. These children may inherit a predisposition to psychopathy. Hare describes the implications as chilling. However, empirical evidence regarding the reproductive success of psychopaths is lacking.

 

 

Personality disorders

Personality disorder refers to a class of personality types and enduring behaviors associated with significant distress or disability, which appear to deviate from social expectations particularly in relating to other humans.

Personality disorders are included as mental disorders on Axis II of the diagnostic manual of the American Psychiatric Association and in the mental and behavioral disorders section of the ICD manual of the World Health Organization. Personality, defined psychologically, is the set of enduring behavioral and mental traits that distinguish human beings. Hence, personality disorders are defined by experiences and behaviors that differ from societal norms and expectations. Those diagnosed with a personality disorder may experience difficulties in cognition, emotiveness, interpersonal functioning or control of impulses. In general, personality disorders are diagnosed in 40–60 percent of psychiatric patients, making them the most frequent of all psychiatric diagnoses.

These behavioral patterns in personality disorders are typically associated with substantial disturbances in some behavioral tendencies of an individual, usually involving several areas of the personality, and are nearly always associated with considerable personal and social disruption. A person is classified as having a personality disorder if their abnormalities of behavior impair their social or occupational functioning. Additionally, personality disorders are inflexible and pervasive across many situations, due in large part to the fact that such behavior may be ego-syntonic (i.e. the patterns are consistent with the ego integrity of the individual) and are, therefore, perceived to be appropriate by that individual. This behavior can result in maladaptive coping skills, which may lead to personal problems that induce extreme anxiety, distress or depression. The onset of these patterns of behavior can typically be traced back to early adolescence and the beginning of adulthood and, in some instances, childhood.

There are many issues with classifying a personality disorder, is it really a disorder; or just hard to get along with. There are many categories of definition, some mild and some extreme. Because the theory and diagnosis of personality disorders stem from prevailing cultural expectations, their validity is contested by some experts on the basis of invariable subjectivity. They argue that the theory and diagnosis of personality disorders are based strictly on social, or even sociopolitical and economic considerations.

History 

Personality disorder is a term with a distinctly modern meaning, owing in part to its clinical usage and the institutional character of modern psychiatry. The currently accepted meaning must be understood in the context of historical changing classification systems such as DSM-IV and its predecessors. Although highly anachronistic, and ignoring radical differences in the character of subjectivity and social relations, some have suggested similarities to other concepts going back to at least the ancient Greeks. For example, the Greek philosopher Theophrastus described 29 ‘character’ types that he saw as deviations from the norm, and similar views have been found in Asian, Arabic and Celtic cultures. A long-standing influence in the Western world was Galen‘s concept of personality types which he linked to the four humours proposed by Hippocrates.

Such views lasted into the 18th century, when experiments began to question the supposed biologically based humours and ‘temperaments’. Psychological concepts of character and ‘self’ became widespread. In the 19th century, ‘personality’ referred to a person’s conscious awareness of their behavior, a disorder of which could be linked to altered states such as dissociation. This sense of the term has been compared to the use of the term ‘multiple personality disorder’ in the first versions of the DSM.

Physicians in the early 19th century started to diagnose forms of insanity that involved disturbed emotions and behaviors but seemingly without significant intellectual impairment or delusions or hallucinations. Philippe Pinel referred to this as ‘manie sans délire’ – insanity without delusion – and described a number of cases mainly involving excessive or inexplicable anger or rage. James Cowles Prichard advanced a similar concept he called moral insanity, which would be used to diagnose patients for some decades. ‘Moral’ in this sense referred to affect (emotion or mood) rather thaecessarily ethics, but it was arguably based in part on religious, social and moral beliefs, with a pessimism about medical intervention so that social control should take precedence. These categories were much different and broader than later definitions of personality disorder, while also being developed by some into a more specific meaning of moral degeneracy akin to later ideas about ‘psychopaths’. Separately, Richard von Krafft-Ebing popularized the terms sadism and masochism, as well as homosexuality, as psychiatric issues.

The German psychiatrist Koch sought to make the moral insanity concept more scientific, suggesting in 1891 the phrase ‘psychopathic inferiority’, theorized to be a congenital disorder. This referred to continual and rigid patterns of misconduct or dysfunction in the absence of apparent mental retardation or illness, supposedly without a moral judgement. Described as deeply rooted in his Christian faith, his work has been described as a fundamental text on personality disorders that is still of use today.

20th century 

In the early 20th century, another German psychiatrist, Emil Kraepelin, included a chapter on psychopathic inferiority in his influential work on clinical psychiatry for students and physicians. He suggested six types – excitable, unstable, eccentric, liar, swindler and quarrelsome. The categories were essentially defined by the most disordered criminal offenders observed, distinguished between criminals by impulse, professional criminals, and morbid vagabondswho wandered through life. Kraepelin also described three paranoid (meaning then delusional) disorders, resembling later concepts of schizophrenia, delusional disorder and paranoid personality disorder. A diagnostic term for the latter concept would be included in the DSM from 1952, and from 1980 the DSM would also include schizoid and schizotypal personality disorders; interpretations of earlier (1921) theories of Ernst Kretschmer led to a distinction between these and another type later included in the DSM, avoidant personality disorder.

In 1933 Russian psychiatrist Pyotr Borisovich Gannushkin published his book Manifestations of psychopathies: statics, dynamics, systematic aspects, which was one of the first attempts to develop a detailed typology of psychopathies. Regarding maladaptaion, ubiquity, and stability as the three main symptoms of behavioral pathology, he distinguished 9 clusters of psychopaths: cycloids (including constitutionally depressive, constitutionally excitable, cyclothymics, and emotionally labile), asthenics (including psychasthenics), schizoids (including dreamers), paranoiacs (including fanatics), epileptoids, hysterical personalities (including pathological liars), unstable psychopaths, antisocial psychopaths, and constitutionally stupid. Some elements of Gannushkin’s typology were later incorporated into the theory developed by a Russian adolescent psychiatrist, Andrey Yevgenyevich Lichko, who was also interested in psychopathies along with their milder forms, the so-called accentuations of character.^[56]

Psychiatrist David Henderson published in 1939 a theory of ‘psychopathic states’ which ended up contributing to the term becoming popularly linked to anti-social behavior. Hervey M. Cleckley’s 1941 text, The Mask of Sanity, based on his personal categorization of similarities he noted in some prisoners, marked the start of the modern clinical conception of psychopathy and its popularist usage.

Towards the mid 20th century, psychoanalytic theories were coming to the fore based on work from the turn of the century being popularized by Sigmund Freud and others. This included the concept of ‘character disorders’, which were seen as enduring problems linked not to specific symptoms but to pervasive internal conflicts or derailments of normal childhood development. These were typically understood as weaknesses of character or willful deviance, and were distinguished from neurosis or psychosis. The term ‘borderline’ stems from a belief that some individuals were functioning on the edge of those two categories, and a number of the other personality disorder categories were also heavily influenced by this approach, including dependent, obsessive-compulsive and histrionic, the latter starting off as a conversion symptom of hysteria particularly associated with women, then a hysterical personality, then renamed histrionic personality disorder in later versions of the DSM. A passive aggressive style was defined clinically by Colonel William Menninger during World War II in the context of men’s reactions to military compliance, which would later be referenced as a personality disorder in the DSM. Otto Kernberg was influential with regard to the concepts of the borderline and narcissistic personalities which were later incorporated as disorders into the DSM in 1980.

Meanwhile, a more general personality psychology had been developing in academia and to some extent clinically. Gordon Allport was publishing theories of personality traits from the 1920s, and Henry Murray advanced a theory called ‘personology’ which influenced a later key advocate of personality disorders, Theodore Millon. Tests were developing or being applied for personality evaluation, including projective tests such as the Rorshach, as well as questionnaires such as the Minnesota Multiphasic Personality Inventory. Around mid-century, Hans Eysenck was analysing traits and personality types, and psychiatrist Kurt Schneider was popularising a clinical use in place of the previously more usual terms ‘character’, ‘temperament’ or ‘constitution’.

American psychiatrists officially recognised concepts of enduring personality disturbances in the first Diagnostic and Statistical Manual of Mental Disorders in the 1950s, which relied heavily on psychoanalytic concepts. Somewhat more neutral language was employed in the DSM-II in 1968, though the terms and descriptions had only a slight resemblance to current definitions. The DSM-III published in 1980 made some major changes, notably putting all personality disorders onto a second separate ‘axis’ along with mental retardation, intended to signify more enduring patterns, distinct from what were considered axis one mental disorders. ‘Inadequate’ and ‘asthenic‘ personality disorder’ categories were deleted, and others were unpacked into more types, or changed from being personality disorders to regular disorders. Sociopathic Personality Disorder, which had been the term for psychopathy, was renamed Antisocial Personality Disorder. Most categories were given more specific ‘operationalized’ definitions, with standard criteria that psychiatrists could agree on in order to conduct research and diagnose patients. In the DSM-III revision, self-defeating personality disorder and sadistic personality disorder were included as provisional diagnoses requiring further study. They were dropped in the DSM-IV, though a proposed ‘depressive personality disorder’ was added; in addition, the official diagnosis of passive-aggressive personality disorder was dropped, tentatively renamed ‘negativistic personality disorder.’

International differences have beeoted in how attitudes have developed towards the diagnosis of personality disorder. Kurt Schneider had argued that they were simply ‘abnormal varieties of psychic life’ and therefore not necessarily the domain of psychiatry, a view said to still have influence in Germany today. British psychiatrists have also been reluctant to address such disorders or consider them on a par with other mental disorders, which has been attributed partly to resource pressures within the National Health Service, as well as to negative medical attitudes towards behaviors associated with personality disorders. In the US, the prevailing healthcare system and psychanalytic tradition has been said to provide a rationale for private therapists to diagnose some personality disorders more broadly and provide ongoing treatment for them.

 

Classification 

The two major systems of classification, the ICD and DSM, have deliberately merged their diagnoses to some extent, but some differences remain. For example, ICD-10 does not include narcissistic personality disorder as a distinct category, while DSM-IV does not include enduring personality change after catastrophic experience or after psychiatric illness. ICD-10 classifies the DSM-IV schizotypal personality disorder as a form of schizophrenia rather than as a personality disorder. DSM-IV places personality disorders on a separate ‘axis’ to mental disorders, while the ICD does not use a multiaxial system. There are accepted diagnostic issues and controversies with regard to either section, in terms of distinguishing personality disorders as a category from other types of mental disorder or from general personality functioning, or distinguishing particular personality disorder categories from each other. ICD classifies Transsexualism as a personality disorder; the equivalent DSM classification is not a personality disorder.

World Health Organization 

The ICD-10 section on mental and behavioral disorders includes categories of personality disorder and enduring personality changes. They are defined as ingrained patterns indicated by inflexible and disabling responses that significantly differ from how the average person in the culture perceives, thinks and feels, particularly in relating to others.

The specific personality disorders are: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, anankastic, anxious (avoidant) and dependent.

There is also an ‘Other’ category involving conditions characterized as eccentric, haltlose (derived from “haltlos” (German) = drifting, aimless and irresponsible), immature, narcissistic, passive-aggressive or psychoneurotic. An additional category is for unspecified personality disorder, including character neurosis and pathological personality.

There is also a category for Mixed and other personality disorders, defined as conditions that are often troublesome but do not demonstrate the specific pattern of symptoms in the named disorders. Finally there is a category of Enduring personality changes, not attributable to brain damage and disease. This is for conditions that seem to arise in adults without a diagnosis of personality disorder, following catastrophic or prolonged stress or other psychiatric illness.

American Psychiatric Association 

The Diagnostic and Statistical Manual of Mental Disorders (currently the DSM-IV) lists ten personality disorders, grouped into three clusters in Axis II. The DSM also contains a category for behavioral patterns that do not match these ten disorders, but nevertheless exhibit characteristics of a personality disorder. This category is labeled Personality disorder not otherwise specified.

Cluster A (odd or eccentric disorders and fears Social relation) 

Not to be confused with Type A personality.

·                    Paranoid personality disorder: characterized by irrational suspicions and mistrust of others.

·                    Schizoid personality disorder: lack of interest in social relationships, seeing no point in sharing time with others, anhedonia, introspection.

·                    Schizotypal personality disorder: characterized by odd behavior or thinking.

Cluster B (dramatic, emotional or erratic disorders) 

Not to be confused with Type B personality.

·                    Antisocial personality disorder: a pervasive disregard for the rights of others, lack of empathy, and (generally) a pattern of regular criminal activity.

·                    Borderline personality disorder: extreme “black and white” thinking, instability in relationships, self-image, identity and behavior often leading to self-harm and impulsivity.

·                    Histrionic personality disorder: pervasive attention-seeking behavior including inappropriately seductive behavior and shallow or exaggerated emotions.

·                    Narcissistic personality disorder: a pervasive pattern of grandiosity, need for admiration, and a lack of empathy. Characterized by self-importance, preoccupations with fantasies, belief that they are special, including a sense ofentitlement and a need for excessive admiration, and extreme levels of jealousy and arrogance.

Cluster C (anxious or fearful disorders)

·                    Avoidant personality disorder: pervasive feelings of social inhibition and social inadequacy, extreme sensitivity to negative evaluation and avoidance of social interaction.

·                    Dependent personality disorder: pervasive psychological dependence on other people.

·                    Obsessive-compulsive personality disorder (not the same as obsessive-compulsive disorder): characterized by rigid conformity to rules, moral codes and excessive orderliness.

Appendix B: Criteria Sets and Axes Provided for Further Study 

Appendix B contains the following disorders.

·                    Depressive personality disorder – is a pervasive pattern of depressive cognitions and behaviors beginning by early adulthood.

·                    Passive-aggressive (negativistic) personality disorder – is a pattern of negative attitudes and passive resistance in interpersonal situations.

Other 

Some types of personality disorder were in previous versions of the diagnostic manuals but have been deleted. This includes two types that were in the DSM-III-R appendix as “Proposed diagnostic categories needing further study” without specific criteria, namely Sadistic personality disorder (a pervasive pattern of cruel, demeaning and aggressive behavior) and Self-defeating personality disorder (masochistic personality disorder) (characterised by behaviour consequently undermining the person’s pleasure and goals). The psychologist Theodore Millon and others consider some relegated diagnoses to be equally valid disorders, and may also propose other personality disorders or subtypes, including mixtures of aspects of different categories of the officially accepted diagnoses.

 

Antisocial Personality Disorder

Antisocial personality disorder is characterized by a long-standing pattern of a disregard for other people’s rights, often crossing the line and violating those rights. It usually begins in childhood or as a teen and continues into their adult lives.

Antisocial personality disorder is often referred to as psychopathy or sociopathy in popular culture.

Individuals with Antisocial Personality Disorder frequently lack empathy and tend to be callous, cynical, and contemptuous of the feelings, rights, and sufferings of others. They may have an inflated and arrogant self-appraisal (e.g., feel that ordinary work is beneath them or lack a realistic concern about their current problems or their future) and may be excessively opinionated, self-assured, or cocky. They may display a glib, superficial charm and can be quite voluble and verbally facile (e.g., using technical terms or jargon that might impress someone who is unfamiliar with the topic). Lack of empathy, inflated self-appraisal, and superficial charm are features that have been commonly included in traditional conceptions of psychopathy and may be particularly distinguishing of Antisocial Personality Disorder in prison or forensic settings where criminal, delinquent, or aggressive acts are likely to be nonspecific. These individuals may also be irresponsible and exploitative in their sexual relationships.

 

Symptoms of Antisocial Personality Disorder

 

Antisocial personality disorder is diagnosed when a person’s pattern of antisocial behavior has occurred since age 15 (although only adults 18 years or older can be diagnosed with this disorder) and consists of the majority of these symptoms:

• 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

As with all personality disorders, the person must be at least 18 years old before they can be diagnosed with it. There should also be evidence of Conduct Disorder in the individual as a child, whether or not it was ever formally diagnosed by a professional.

Antisocial personality disorder is more prevalent in males (3 percent) versus females (1 percent) in the general population.

Like most personality disorders, antisocial personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

 

How is Antisocial Personality Disorder Diagnosed?

 

Personality disorders such as antisocial personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose antisocial personality disorder.

Many people with antisocial personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.

A diagnosis for antisocial personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

 

Causes of Antisocial Personality Disorder

 

Researchers today don’t know what causes antisocial personality disorder. There are many theories, however, about the possible causes of antisocial personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

 

 

Avoidant Personality Disorder

People with avoidant personality disorder experience a long-standing feeling of inadequacy and are extremely sensitive to what others think about them. This leads to the person to be socially inhibited and feel socially inept. Because of these feelings of inadequacy and inhibition, the person with avoidant personality disorder will seek to avoid work, school and any activities that involve socializing or interacting with others.

Individuals with Avoidant Personality Disorder often vigilantly appraise the movements and expressions of those with whom they come into contact. Their fearful and tense demeanor may elicit ridicule from others, which in turn confirms their self-doubts. They are very anxious about the possibility that they will react to criticism with blushing or crying. They are described by others as being “shy,” “timid,” “lonely,” and “isolated.”

The major problems associated with this disorder occur in social and occupational functioning. The low self-esteem and hypersensitivity to rejection are associated with restricted interpersonal contacts. These individuals may become relatively isolated and usually do not have a large social support network that can help them weather crises. They desire affection and acceptance and may fantasize about idealized relationships with others. The avoidant behaviors can also adversely affect occupational functioning because these individuals try to avoid the types of social situations that may be important for meeting the basic demands of the job or for advancement.

Symptoms of Avoidant Personality Disorder

Avoidant personality disorder is characterized by a long-standing pattern of feelings of inadequacy, extreme sensitivity to what other people think about them, and social inhibition. It typically manifests itself by early adulthood and includes a majority of the following symptoms:

• 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 iew interpersonal situations because of feelings of inadequacy
• Views themself 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

As with all personality disorders, the person must be at least 18 years old before they can be diagnosed with it.

Avoidant personality disorder appears to occur between 0.5 and 1.0 percent in the general population.

Like most personality disorders, avoidant personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

How is Avoidant Personality Disorder Diagnosed?

Personality disorders such as avoidant personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose avoidant personality disorder.

Many people with avoidant personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.

A diagnosis for avoidant personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

 

Causes of Avoidant Personality Disorder

Researchers today don’t know what causes avoidant personality disorder. There are many theories, however, about the possible causes of avoidant personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

 

 

Borderline Personality Disorder

 

The main feature of borderline personality disorder (BPD) is a pervasive pattern of instability in interpersonal relationships, self-image and emotions. People with borderline personality disorder are also usually very impulsive.

This disorder occurs in most by early adulthood. The unstable pattern of interacting with others has persisted for years and is usually closely related to the person’s self-image and early social interactions. The pattern is present in a variety of settings (e.g., not just at work or home) and often is accompanied by a similar lability (fluctuating back and forth, sometimes in a quick manner) in a person’s emotions and feelings. Relationships and the person’s emotion may often be characterized as being shallow.

A person with this disorder will also often exhibit impulsive behaviors and have a majority of the following symptoms:

• 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, such as a significant and persistent 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
• Emotional instability due to significant 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 thoughts or severe dissociative symptoms

As with all personality disorders, the person must be at least 18 years old before they can be diagnosed with it.

Borderline personality disorder is more prevalent in females (75 percent of diagnoses made are in females). It is thought that borderline personality disorder affects approximately 2 percent of the general population.

Like most personality disorders, borderline personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

Details about Borderline Personality Disorder Symptoms

Frantic efforts to avoid real or imagined abandonment.

The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, emotion, thinking and behavior. Someone with borderline personality disorder will be very sensitive to things happening around them in their environment. They experience intense abandonment fears and inappropriate anger, even when faced with a realistic separation or when there are unavoidable changes in plans. For instance, becoming very angry with someone for being a few minutes late or having to cancel a lunch date. People with borderline personality disorder may believe that this abandonment implies that they are “bad.” These abandonment fears are related to an intolerance of being alone and a need to have other people with them. Their frantic efforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal behaviors.

Unstable and intense relationships.

People with borderline personality disorder may idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship. However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, is not “there” enough. These individuals can empathize with and nurture other people, but only with the expectation that the other person will “be there” in return to meet their oweeds on demand. These individuals are prone to sudden and dramatic shifts in their view of others, who may alternately be seen as beneficient supports or as cruelly punitive. Such shifts other reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected.

Identity disturbance.

There are sudden and dramatic shifts in self-image, characterized by shifting goals, values and vocational aspirations. There may be sudden changes in opinions and plans about career, sexual identity, values and types of friends. These individuals may suddenly change from the role of a needy supplicant for help to a righteous avenger of past mistreatment. Although they usually have a self-image that is based on being bad or evil, individuals with borderline personality disorder may at times have feelings that they do not exist at all. Such experiences usually occur in situations in which the individual feels a lack of a meaningful relationship, nurturing and support. These individuals may show worse performance in unstructured work or school situations.

You can also learn more about the detailed characteristics of borderline personality disorder.

How is Borderline Personality Disorder Diagnosed?

Personality disorders such as borderline personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose borderline personality disorder.

Many people with borderline personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.

A diagnosis for borderline personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

Causes of Borderline Personality Disorder

Researchers today don’t know what causes borderline personality disorder. There are many theories, however, about the possible causes of borderline personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

 

 

Dependent Personality Disorder

 

Dependent personality disorder is characterized by a long-standing need for the person to be taken care of and a fear of being abandoned or separated from important individuals in his or her life. This leads the person to engage in dependent and submissive behaviors that are designed to elicit care-giving behaviors in others. The dependent behavior may be see as being “clingy” or “clinging on” to others, because the person fears they can’t live their lives without the help of others.

Individuals with Dependent Personality Disorder are often characterized by pessimism and self-doubt, tend to belittle their abilities and assets, and may constantly refer to themselves as “stupid.” They take criticism and disapproval as proof of their worthlessness and lose faith in themselves. They may seek overprotection and dominance from others. Occupational functioning may be impaired if independent initiative is required. They may avoid positions of responsibility and become anxious when faced with decisions. Social relations tend to be limited to those few people on whom the individual is dependent.

Chronic physical illness or Separation Anxiety Disorder in childhood or adolescence may predispose an individual to the development of dependent personality disorder.

Symptoms of Dependent Personality Disorder

Dependent personality disorder is characterized by a pervasive fear that leads to “clinging behavior” and usually manifests itself by early adulthood. It includes a majority of the following symptoms:

• Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
• Needs others to assume responsibility for most major areasof 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 obtaiurturance 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

As with all personality disorders, the person must be at least 18 years old before they can be diagnosed with it.

Dependent personality disorder is the most commonly diagnosed personality disorder in mental health clinics.

Like most personality disorders, dependent personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

How is Dependent Personality Disorder Diagnosed?

Personality disorders such as dependent personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose dependent personality disorder.

Many people with dependent personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.

A diagnosis for dependent personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

Causes of Dependent Personality Disorder

Researchers today don’t know what causes dependent personality disorder. There are many theories, however, about the possible causes of dependent personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

Histrionic Personality Disorder

Histrionic personality disorder is characterized by a long-standing pattern of attention seeking behavior and extreme emotionality. Someone with histrionic personality disorder wants to be the center of attention in any group of people, and feel uncomfortable when they are not. While often lively, interesting and sometimes dramatic, they have difficulty when people aren’t focused exclusively on them. People with this disorder may be perceived as being shallow, and may engage in sexually seductive or provocating behavior to draw attention to themselves.

Individuals with Histrionic Personality Disorder may have difficulty achieving emotional intimacy in romantic or sexual relationships. Without being aware of it, they often act out a role (e.g., “victim” or “princess”) in their relationships to others. They may seek to control their partner through emotional manipulation or seductiveness on one level, whereas displaying a marked dependency on them at another level.

Individuals with this disorder often have impaired relationships with same-sex friends because their sexually provocative interpersonal style may seem a threat to their friends’ relationships. These individuals may also alienate friends with demands for constant attention. They often become depressed and upset when they are not the center of attention.

People with histrionic personality disorder may crave novelty, stimulation, and excitement and have a tendency to become bored with their usual routine. These individuals are often intolerant of, or frustrated by, situations that involve delayed gratification, and their actions are often directed at obtaining immediate satisfaction. Although they often initiate a job or project with great enthusiasm, their interest may lag quickly.

Longer-term relationships may be neglected to make way for the excitement of new relationships.

Symptoms of 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 themself
• Has a style of speech that is excessively impressionistic and lacking in detail
• Shows self-dramatization, theatricality, and exaggerated expression of emotion
• Is highly suggestible, i.e., easily influenced by others or circumstances
• Considers relationships to be more intimate than they actually are

As with all personality disorders, the person must be at least 18 years old before they can be diagnosed with it.

Histrionic personality disorder is more prevalent in females than males. It occurs about 2 to 3 percent in the general population.

Like most personality disorders, histrionic personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

How is Histrionic Personality Disorder Diagnosed?

Personality disorders such as histrionic personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose histrionic personality disorder.

Many people with histrionic personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.

A diagnosis for histrionic personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

Causes of Histrionic Personality Disorder

Researchers today don’t know what causes histrionic personality disorder. There are many theories, however, about the possible causes of histrionic personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

 

Narcissistic Personality Disorder

Narcissistic Personality Disorder is characterized by a long-standing pattern of grandiosity (either in fantasy or actual behavior), an overwhelming need for admiration, and usually a complete lack of empathy toward others. People with this disorder often believe they are of primary importance in everybody’s life or to anyone they meet. While this pattern of behavior may be appropriate for a king in 16th Century England, it is generally considered inappropriate for most ordinary people today.

People with narcissistic personality disorder often display snobbish, disdainful, or patronizing attitudes. For example, an individual with this disorder may complain about a clumsy waiter’s “rudeness” or “stupidity” or conclude a medical evaluation with a condescending evaluation of the physician.

In laypeople terms, someone with this disorder may be described simply as a “narcissist” or as someone with “narcissism.” Both of these terms generally refer to someone with narcissistic personality disorder.

Symptoms of Narcissistic Personality Disorder

In order for a person to be diagnosed with narcissistic personality disorder (NPD) they must meet five or more of the following symptoms:

• 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 very strong sense of entitlement, e.g., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
• Is exploitative of others, e.g., takes advantage of others to achieve his or her own ends
• Lacks empathy, e.g., 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
• Regularly shows arrogant, haughty behaviors or attitudes

As with all personality disorders, the person must be at least 18 years old before they can be diagnosed with it.

Narcissistic personality disorder is more prevalent in males than females, and is thought to occur in less than 1 percent in the general population.

Like most personality disorders, narcissistic personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

Learn more about the symptoms and characteristics of someone with narcissitic personality disorder.

How is Narcissistic Personality Disorder Diagnosed?

Personality disorders such as narcissistic personality disorder are typically diagnosed

by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose personality disorder.

Many people with narcissistic personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.

A diagnosis for narcissistic personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

Causes of Narcissistic Personality Disorder

Researchers today don’t know what causes narcissistic personality disorder. There are many theories, however, about the possible causes of narcissistic personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

 

 

Obsessive-Compulsive Personality Disorder

Obsessive-Compulsive Personality Disorder is characterized by a preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. This

When rules and established procedures do not dictate the correct answer, decision making may become a time-consuming, often painful process. Individuals with Obsessive-Compulsive Personality Disorder may have such difficulty deciding which tasks take priority or what is the best way of doing some particular task that they may never get started on anything.

They are prone to become upset or angry in situations in which they are not able to maintain control of their physical or interpersonal environment, although the anger is typically not expressed directly. For example, a person may be angry when service in a restaurant is poor, but instead of complaining to the management, the individual ruminates about how much to leave as a tip. On other occasions, anger may be expressed with righteous indignation over a seemingly minor matter.

People with this disorder may be especially attentive to their relative status in dominance-submission relationships and may display excessive deference to an authority they respect and excessive resistance to authority that they do not respect.

Individuals with this disorder usually express affection in a highly controlled or stilted fashion and may be very uncomfortable in the presence of others who are emotionally expressive. Their everyday relationships have a formal and serious quality, and they may be stiff in situations in which others would smile and be happy (e.g., greeting a lover at the airport). They carefully hold themselves back until they are sure that whatever they say will be perfect. They may be preoccupied with logic and intellect.

Symptoms of Obsessive-Compulsive Personality Disorder

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:

• 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 of doing things
• Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes
• Shows significant rigidity and stubbornness

As with all personality disorders, the person must be at least 18 years old before they can be diagnosed with it.

Obsessive-Compulsive personality disorder is approximately twice as prevalent in males than females, and occurs in about 1 percent of the general population.

Like most personality disorders, Obsessive-Compulsive personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

How is Obsessive-compulsive Personality Disorder Diagnosed?

Personality disorders such as obsessive-compulsive personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose obsessive-compulsive personality disorder.

Many people with obsessive-compulsive personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.

A diagnosis for obsessive-compulsive personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

Causes of Obsessive-compulsive Personality Disorder

Researchers today don’t know what causes obsessive-compulsive personality disorder. There are many theories, however, about the possible causes of obsessive-compulsive personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

 

Paranoid Personality Disorder

People with paranoid personality disorder are generally characterized by having a long-standing pattern of pervasive distrust and suspiciousness of others. A person with paranoid personality disorder will nearly always believe that other people’s motives are suspect or even malevolent. Individuals with this disorder assume that other people will exploit, harm, or deceive them, even if no evidence exists to support this expectation. While it is fairly normal for everyone to have some degree of paranoia about certain situations in their lives (such as worry about an impending set of layoffs at work), people with paranoid personality disorder take this to an extreme  it pervades virtually every professional and personal relationship they have.

Individuals with Paranoid Personality Disorder are generally difficult to get along with and often have problems with close relationships. Their excessive suspiciousness and hostility may be expressed in overt argumentativeness, in recurrent complaining, or by quiet, apparently hostile aloofness. Because they are hypervigilant for potential threats, they may act in a guarded, secretive, or devious manner and appear to be “cold” and lacking in tender feelings. Although they may appear to be objective, rational, and unemotional, they more often display a labile range of affect, with hostile, stubborn, and sarcastic expressions predominating. Their combative and suspicious nature may elicit a hostile response in others, which then serves to confirm their original expectations.

Because individuals with Paranoid Personality Disorder lack trust in others, they have an excessive need to be self-sufficient and a strong sense of autonomy. They also need to have a high degree of control over those around them. They are often rigid, critical of others, and unable to collaborate, and they have great difficulty accepting criticism.

Symptoms of 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 of spouse or sexual partner

As with all personality disorders, the person must be at least 18 years old before they can be diagnosed with it.

Paranoid personality disorder is more prevalent in males than females, and occurs somewhere between 0.5 and 2.5 percent in the general population.

Like most personality disorders, paranoid personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

How is Paranoid Personality Disorder Diagnosed?

Personality disorders such as paranoid personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose paranoid personality disorder.

Many people with paranoid personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.

A diagnosis for paranoid personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

Causes of Paranoid Personality Disorder

Researchers today don’t know what causes paranoid personality disorder. There are many theories, however, about the possible causes of paranoid personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

 

 

Schizoid Personality Disorder

Schizoid Personality Disorder is characterized by a long-standing pattern of detachment from social relationships. A person with schizoid personality disorder often has difficulty expression emotions and does so typically in very restricted range, especially when communicating with others.

A person with this disorder may appear to lack a desire for intimacy, and will avoid close relationships with others. They may often prefer to spend time with themselves rather than socialize or be in a group of people. In laypeople terms, a person with schizoid personality disorder might be thought of as the typical “loner.”

Individuals with Schizoid Personality Disorder may have particular difficulty expressing anger, even in response to direct provocation, which contributes to the impression that they lack emotion. Their lives sometimes seem directionless, and they may appear to “drift” in their goals. Such individuals often react passively to adverse circumstances and have difficulty responding appropriately to important life events. Because of their lack of social skills and lack of desire for sexual experiences, individuals with this disorder have few friendships, date infrequently, and often do not marry. Employment or work functioning may be impaired, particularly if interpersonal involvement is required, but individuals with this disorder may do well when they work under conditions of social isolation.

Symptoms of Schizoid Personality Disorder

Schizoid personality disorder is characterized by a 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

As with all personality disorders, the person must be at least 18 years old before they can be diagnosed with it.

Schizoid personality disorder is more prevalent in males than females. Its prevalence in the general population is not known.

Like most personality disorders, schizoid personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

How is Schizoid Personality Disorder Diagnosed?

Personality disorders such as schizoid personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose schizoid personality disorder.

Many people with schizoid personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.

A diagnosis for schizoid personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

Causes of Schizoid Personality Disorder

Researchers today don’t know what causes schizoid personality disorder. There are many theories, however, about the possible causes of schizoid personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

 

 

Schizotypal Personality Disorder

Schizotypal personality disorder is characterized by someone who has great difficulty in establishing and maintaining close relationships with others. A person with schizotypal personality disorder may have extreme discomfort with such relationships, and therefore have less of a capacity for them. Someone with this disorder usually has cognitive or perceptual distortions as well as eccentricities in their everyday behavior.

Individuals with Schizotypal Personality Disorder often have ideas of reference (e.g., they have incorrect interpretations of casual incidents and external events as having a particular and unusual meaning specifically for the person). People with this disorder may be unusually superstitious or preoccupied with paranormal phenomena that are outside the norms of their subculture.

Individuals with Schizotypal Personality Disorder often seek treatment for the associated symptoms of anxiety, depression, or other dysphoric affects rather than for the personality disorder features per se.

Symptoms of Schizotypal Personality Disorder

Schizotypal personality disorder is characterized by a 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 thaegative judgments about self

As with all personality disorders, the person must be at least 18 years old before they can be diagnosed with it.

Schizotypal personality disorder appears in less than 3 percent of the general population.

Like most personality disorders, schizotypal personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

How is Schizotypal Personality Disorder Diagnosed?

Personality disorders such as schizotypal personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose schizotypal personality disorder.

Many people with schizotypal personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.

A diagnosis for schizotypal personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

Causes of Schizotypal Personality Disorder

Researchers today don’t know what causes schizotypal personality disorder. There are many theories, however, about the possible causes of schizotypal personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible – rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

 

Millon’s description of personality disorders 

Psychologist Theodore Millon, who has writteumerous popular works on personality, proposed the following description of personality disorders:

Millon’s brief description of personality disorders
Type of personality disorder	Description
Paranoid	Guarded, defensive, distrustful and suspiciousness. Hypervigilant to the motives of others to undermine or do harm. Always seeking confirmatory evidence of hidden schemes. Feels righteous, but persecuted.
Schizoid	Apathetic, indifferent, remote, solitary, distant, humorless. Neither desires nor need human attachments. Withdrawal from relationships and prefer to be alone. Little interest in others, often seen as a loner. Minimal awareness of feelings of self or others. Few drives or ambitions, if any.
Schizotypal	Eccentric, self-estranged, bizarre, absent. Exhibits peculiar mannerisms and behaviors. Thinks can read thoughts of others. Preoccupied with odd daydreams and beliefs. Blurs line between reality and fantasy. Magical thinking and strange beliefs.
Antisocial	Impulsive, irresponsible, deviant, unruly. Acts without due consideration. Meets social obligations only when self-serving. Disrespects societal customs, rules, and standards. Sees self as free and independent.
Borderline	Unpredictable, manipulative, unstable. Frantically fears abandonment and isolation. Experiences rapidly fluctuating moods. Shifts rapidly between loving and hating. Sees self and others alternatively as all-good and all-bad. Unstable and frequently changing moods.
Histrionic	Dramatic, seductive, shallow, stimulus-seeking, vain. Overreacts to minor events. Exhibitionistic as a means of securing attention and favors. Sees self as attractive and charming. Constant seeking for others’ attention.
Narcissistic	Egotistical, arrogant, grandiose, insouciant. Preoccupied with fantasies of success, beauty, or achievement. Sees self as admirable and superior, and therefore entitled to special treatment.
Avoidant	Hesitant, self-conscious, embarrassed, anxious. Tense in social situations due to fear of rejection. Plagued by constant performance anxiety. Sees self as inept, inferior, or unappealing. Feels alone and empty.
Dependent	Helpless, incompetent, submissive, immature. Withdraws from adult responsibilities. Sees self as weak or fragile. Seeks constant reassurance from stronger figures.
Obsessive–compulsive	Restrained, conscientious, respectful, rigid. Maintains a rule-bound lifestyle. Adheres closely to social conventions. Sees the world in terms of regulations and hierarchies. Sees self as devoted, reliable, efficient, and productive.
Depressive	Somber, discouraged, pessimistic, brooding, fatalistic. Presents self as vulnerable and abandoned. Feels valueless, guilty, and impotent. Judges self as worthy only of criticism and contempt.
Passive–aggressive (Negativistic)	Resentful, contrary, skeptical, discontented. Resist fulfilling others’ expectations. Deliberately inefficient. Vents anger indirectly by undermining others’ goals. Alternately moody and irritable, then sullen and withdrawn.
Sadistic	Explosively hostile, abrasive, cruel, dogmatic. Liable to sudden outbursts of rage. Feels selfsatisfied through dominating, intimidating and humiliating others. Is opinionated and closeminded.
Self-defeating (Masochistic)	Deferential, pleasure-phobic, servile, blameful, self-effacing. Encourages others to take advantage. Deliberately defeats own achievements. Seeks condemning or mistreatful partners.

Additional classification factors 

Except for classifying by category and cluster, it is possible to classify personality disorders using such additional factors as severity, impact on social functioning, and attribution.

 

 

 

Severity 

This involves both the notion of personality difficulty as a measure of subthreshold scores for personality disorder using standard interviews and the evidence that those with the most severe personality disorders demonstrate a “ripple effect” of personality disturbance across the whole range of mental disorders. In addition to subthreshold (personality difficulty) and single cluster (simple personality disorder), this also derives complex or diffuse personality disorder (two or more clusters of personality disorder present) and can also derive severe personality disorder for those of greatest risk.

Dimensional System of Classifying Personality Disorders
Level of Severity	Description	Definition by Categorical System
0	No Personality Disorder	Does not meet actual or subthreshold criteria for any personality disorder
1	Personality Difficulty	Meets sub-threshold criteria for one or several personality disorders
2	Simple Personality Disorder	Meets actual criteria for one or more personality disorders within the same cluster
3	Complex (Diffuse) Personality Disorder	Meets actual criteria for one or more personality disorders within more than one cluster
4	Severe Personality Disorder	Meets criteria for creation of severe disruption to both individual and to many in society

There are several advantages to classifying personality disorder by severity:

·                    It not only allows for but also takes advantage of the tendency for personality disorders to be comorbid with each other.

·                    It represents the influence of personality disorder on clinical outcome more satisfactorily than the simple dichotomous system of no personality versus personality disorder.

·                    This system accommodates the new diagnosis of severe personality disorder, particularly “dangerous and severe personality disorder” (DSPD). Politicians and the public both want to know who comprise the most dangerous group.

Effect on social functioning 

Social function is affected by many other aspects of mental functioning apart from that of personality. However, whenever there is persistently impaired social functioning in conditions in which it would normally not be expected, the evidence suggests that this is more likely to be created by personality abnormality than by other clinical variables. The Personality Assessment Schedule gives social function priority in creating a hierarchy in which the personality disorder creating the greater social dysfunction is given primacy over others in a subsequent description of personality disorder.

Attribution 

Many who have a personality disorder do not recognize any abnormality and defend valiantly their continued occupancy of their personality role. This group have been termed the Type R, or treatment-resisting personality disorders, as opposed to the Type S or treatment-seeking ones, who are keen on altering their personality disorders and sometimes clamor for treatment. The classification of 68 personality disordered patients on the caseload of an assertive community team using a simple scale showed a 3 to 1 ratio between Type R and Type S personality disorders with Cluster C personality disorders being significantly more likely to be Type S, and paranoid and schizoid (Cluster A) personality disorders significantly more likely to be Type R than others.

Diagnosis 

The DSM-IV lists General diagnostic criteria for a personality disorder, which must be met in addition to the specific criteria for a particular named personality disorder. This requires that there be (to paraphrase):

There are 2 main pattern of diagnosing comorbidity: 1) Internalizing: the core vulnerability which is common to unipolar mood, somatization, anxiety disorder 2) Externalizing: common factor of ASPD, substance use disorder 

·                    An enduring pattern of psychological experience and behavior that differs prominently from cultural expectations, as shown in two or more of: cognition (i.e. perceiving and interpreting the self, other people or events); affect (i.e. the range, intensity, lability, and appropriateness of emotional response); interpersonal functioning; or impulse control.

·                    The pattern must appear inflexible and pervasive across a wide range of situations, and lead to clinically significant distress or impairment in important areas of functioning.

·                    The pattern must be stable and long-lasting, have started as early as at least adolescence or early adulthood.

·                    The pattern must not be better accounted for as a manifestation of another mental disorder, or to the direct physiological effects of a substance (e.g. drug or medication) or a general medical condition (e.g. head trauma).

The ICD-10 ‘clinical descriptions and diagnostic guidelines’ introduces its specific personality disorder diagnoses with some general guideline criteria that are similar. To quote:

·                    Markedly disharmonious attitudes and behavior, generally involving several areas of functioning; e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;

·                    The abnormal behavior pattern is enduring, of long standing, and not limited to episodes of mental illness;

·                    The abnormal behavior pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;

·                    The above manifestations always appear during childhood or adolescence and continue into adulthood;

·                    The disorder leads to considerable personal distress but this may only become apparent late in its course;

·                    The disorder is usually, but not invariably, associated with significant problems in occupational and social performance.

The ICD adds: “For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations.”

In clinical practice, individuals are generally diagnosed by an interview with a psychiatrist based on a mental status examination, which may take into account observations by relatives and others. One tool of diagnosing personality disorders is a process involving interviews with scoring systems. The patient is asked to answer questions, and depending on their answers, the trained interviewer tries to code what their responses were. This process is fairly time consuming.

Normal personality 

The issue of the relationship betweeormal personality and personality disorders is one of the important issues in personality and clinical psychology. The personality disorders classification (DSM IV TR and ICD-10) follows a categorical approach that views personality disorders as discrete entities that are distinct from each other and from normal personality. In contrast, the dimensional approach is an alternative approach that personality disorders represent maladaptive extensions of the same traits that describe normal personality. Thomas Widiger and his collaborators have contributed to this debate significantly. He discussed the constraints of the categorical approach and argued for the dimensional approach to the personality disorders. Specifically, he proposed that Five Factor Model of personality is alternative to the classification of personality disorders. For example, this view specifies that Borderline Personality Disorder can be understood as a combination of emotional lability (i.e., high neuroticism), impulsivity (i.e., low conscientiousness), and hostility (i.e., low agreeableness). Many studies across cultures have explored the relationship between personality disorders and the Five Factor Model. This research has demonstrated that personality disorders largely correlate in expected ways with measures of the Five Factor Model and has set the stage for including the Five Factor Model within the upcoming DSM-5.

Personality disorder traits 

There are 2 main pattern of diagnosing comorbidity: 1) Internalizing: the core vulnerability which is common to unipolar mood, somatization, anxiety disorder 2) Externalizing: common factor of ASPD, substance use disorder.

Lower-order factors (externalizing psychopathology)

·                    Aggression

Aggression reflects pure angry and antagonistic behavior whereas obsessive-compulsive PD reflect rigidity and stubbornness. And there are co-variation between antisocial personality disorder and obsessive-compulsive personality disorder

·                    Emotional Dysregulation reflect lability (specific to the domains of anger and arousal making this factor more specific to disinhibited negative emotional arousal). There are greater contribution of generalized distress and negative emotional valence to the construct

·                    Impulsivity is common features across socially deviant, reckless, and sensation-seeking, and it is negatively associated with perfectionism and moral inflexibility

Other externalizing factor:

·                    gender

·                    age

·                    greater exposure to trauma

·                    exposure to combat trauma

Higher-order factor (internalizing):

·                    Social Alienation

·                    Exhibitionism

·                    Dependency/ Insecure Attachments

There are three traits:

·                    Odd/Peculiar is marked by cognitive and affective aberrations (associated with social isolation and psychological distress

·                    Mistrust measure anxiety and perseveration about potential harm and trustworthiness of other. It is also associated with a primary anxiety disorder.Social avoidance and detachment will be the consequence

·                    Compulsivity/ Achievement is a rigid and adherence to rules and a single-minded focus on productivity and goals at the expense of social relationships

In children and adolescents 

Early stages and preliminary forms of personality disorders need a multi-dimensional and early treatment approach. Personality development disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood.^[36] In addition, in Robert F.Krueger’s review of their research indicates that some children and adolescents do suffer from clinically significant syndromes that resemble adult personal disorders, and that these syndromes have meaningful correlates and are consequential. Much of this research has been framed by the adult personality disorder constructs from Axis II of the Diagnostic and Statistical Manual. Hence, they are less likely to encounter the first risk they described at the outset of their review: clinicians and researchers are not simply avoiding use of the PD construct in youth. However, they may encounter the second risk they described: under-appreciation of the developmental context in which these syndromes occur. That is, although PD constructs show continuity over time, they are probabilistic predictors; not all youths who exhibit PD symptomatology become adult PD cases.

Prevalence 

The prevalence of personality disorder in the general community was largely unknown until surveys starting from the 1990s. In 2008 the median rate of diagnosable PD was estimated at 10.6%, based on six major studies across three nations. This rate of around one in ten, especially as associated with high use of services, is described as a major public health concern requiring attention by researchers and clinicians.

The prevalence of individual personality disorders ranges from about 2% to 3% for the more common varieties, such as schizotypal, antisocial, borderline, and histrionic, to 0.5–1% for the least common, such as narcissistic and avoidant.

A screening survey across 13 countries by the World Health Organization using DSM-IV criteria, reported in 2009 a prevalence estimate of around 6% for personality disorders. The rate sometimes varied with demographic andsocioeconomic factors, and functional impairment was partly explained by co-occurring mental disorders. In the US, screening data from the National Comorbidity Survey Replication between 2001 and 2003, combined with interviews of a subset of respondents, indicated a population prevalence of around 9% for personality disorders in total. Functional disability associated with the diagnoses appeared to be largely due to co-occurring mental disorders (Axis I in the DSM).

A UK national epidemiological study (based on DSM-IV screening criteria), reclassified into levels of severity rather than just diagnosis, reported in 2010 that the majority of people show some personality difficulties in one way or another (short of threshold for diagnosis), while the prevalence of the most complex and severe cases (including meeting criteria for multiple diagnoses in different clusters) was estimated at 1.3%. Even low levels of personality symptoms were associated with functional problems, but the most severely ieed of services was a much smaller group.^[42]

There are also some gender differences in the frequency of personality disorders.

 

Relationship between personality disorder subtypes and other mental disorders 

The disorders in each of the three clusters may share some underlying common vulnerability factors involving cognition, affect and impulse control, and behavioral maintenance or inhibition, respectively, and may have a spectrum relationship to certain syndromal mental disorders:

·                    Paranoid or schizotypal personality disorders may be observed to be premorbid antecedents of delusional disorders or schizophrenia.

·                    Borderline personality disorder is seen in association with mood and anxiety disorders and with impulse control disorders, eating disorders, ADHD, or a substance use disorder.

·                    Avoidant personality disorder is seen with social anxiety disorder.

Specific approaches 

There are many different forms (modalities) of treatment used for personality disorders:

·                    Individual psychotherapy has been a mainstay of treatment. There are long-term and short-term (brief) forms.

·                    Family therapy, including couples therapy.

·                    Group therapy for personality dysfunction is probably the second most used.

·                    Psychological-education may be used as an addition.

·                    Self-help groups may provide resources for personality disorders.

·                    Psychiatric medications for treating symptoms of personality dysfunction or co-occurring conditions.

·                    Milieu therapy, a kind of group-based residential approach, has a history of use in treating personality disorders, including therapeutic communities.

There are different specific theories or schools of therapy within many of these modalities. They may, for example, emphasize psychodynamic techniques, or cognitive or behavioral techniques. In clinical practice, many therapists use an ‘eclectic’ approach, taking elements of different schools as and when they seem to fit to an individual client. There is also often a focus on common themes that seem to be beneficial regardless of techniques, including attributes of the therapist (e.g. trustworthiness, competence, caring), processes afforded to the client (e.g. ability to express and confide difficulties and emotions), and the match between the two (e.g. aiming for mutual respect, trust and boundaries).

 

Challenges 

The management and treatment of personality disorders can be a challenging and controversial area, for by definition the difficulties have been enduring and affect multiple areas of functioning. This often involves interpersonal issues, and there can be difficulties in seeking and obtaining help from organizations in the first place, as well as with establishing and maintaining a specific therapeutic relationship. On the one hand, an individual may not consider themselves to have a mental health problem, while on the other, community mental health services may view individuals with personality disorders as too complex or difficult, and may directly or indirectly exclude individuals with such diagnoses or associated behaviors.^[44] The disruptiveness people with personality disorders can create in an organisation makes these, arguably, the most challenging conditions to manage. In a four year organizational study by Fischer at the University of Oxford, he found people with personality disorders created ‘trouble’ that escalated to disrupt organizational functioning, producing interorganizational ‘turbulence’. Whereas skilful clinical and hospital leadership proved key to restoring therapeutic functioning, the imposition of external risk controls by health officials critically undermined trust between patients and clinicians, provoking a crisis and organizational breakdown.

Apart from all these issues, an individual may not consider their personality to be disordered or the cause of problems. This perspective may be caused by the patient’s ignorance or lack of insight into their own condition, an ego-syntonic perception of the problems with their personality that prevents them from experiencing it as being in conflict with their goals and self-image, or by the simple fact that there is no distinct or objective boundary between ‘normal’ and ‘abnormal’ personalities. Unfortunately, there is substantial social stigma and discrimination related to the diagnosis.

The term ‘personality disorder’ encompasses a wide range of issues, each with different a level of severity or disability; thus, personality disorders can require fundamentally different approaches and understandings. To illustrate the scope of the matter, consider that while some disorders or individuals are characterized by continual social withdrawal and the shunning of relationships, others may cause fluctuations in forwardness. The extremes are worse still: at one extreme lie self-harm and self-neglect, while at another extreme some individuals may commit violence and crime. There can be other factors such as problematic substance use or dependency or behavioral addictions. A person may meet criteria for multiple personality disorder diagnoses and/or other mental disorders, either at particular times or continually, thus making coordinated input from multiple services a potential requirement.

Therapists in this area can become disheartened by lack of initial progress, or by apparent progress that then leads to setbacks. Clients may be experienced as negative, rejecting, demanding, aggressive or manipulative. This has been looked at in terms of both therapist and client; in terms of social skills, coping efforts, defence mechanisms, or deliberate strategies; and in terms of moral judgements or the need to consider underlying motivations for specific behaviors or conflicts. The vulnerabilities of a client, and indeed therapist, may become lost behind actual or apparent strength and resilience. It is commonly stated that there is always a need to maintain appropriate professional personal boundaries, while allowing for emotional expression and therapeutic relationships. However, there can be difficulty acknowledging the different worlds and understandings that client and therapist may live with. A therapist may assume that the kinds of relationships and ways of interacting that make them feel safe and comfortable, have the same effect on clients. As an example at one extreme, people who may in their lives have been used to hostility, deceptiveness, rejection, aggression or abuse, may in some cases be made confused, intimidated or suspicious by presentations of warmth, intimacy or positivity. On the other hand, reassurance, openness and clear communication are usually helpful and needed. It can take several months of sessions, and perhaps several stops and starts, to begin to develop a trusting relationship that can meaningfully address issues.

Occupational functioning 

Depending on the diagnosis, severity and individual, and the job itself, personality disorders can be associated with difficulty coping with work or the workplace- potentially leading to problems with others by interfering with interpersonal relationships. Indirect effects also play a role; for example, impaired educational progress or complications outside of work, such as substance abuse and co-morbid mental diseases, can plague sufferers. However, personality disorders can also bring about above-average work abilities by increasing competitive drive or causing the sufferer to exploit his or her co-workers.

In 2005, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed and gave personality tests to high-level British executives and compared their profiles with those of criminal psychiatric patients atBroadmoor Hospital in the UK. They found that three out of eleven personality disorders were actually more common in executives than in the disturbed criminals:

·                    Histrionic personality disorder: including superficial charm, insincerity, egocentricity and manipulation

·                    Narcissistic personality disorder: including grandiosity, self-focused lack of empathy for others, exploitativeness and independence.

·                    Obsessive-compulsive personality disorder: including perfectionism, excessive devotion to work, rigidity, stubbornness and dictatorial tendencies.

According to leading leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable these days that there will be some personality disorders in a senior management team.