PERSONALITY DISORDERS. Submitted by: Rhodeliza Mae R. Perhis S Psy!holo"y #
%$Submitted to: Pro&. Sera&i'a Ma(i'o.
Perso'ality disorder: A p e r s o n a l i t y di s o r de r i s an e n d u r i n g p a t t e r n o f inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. Personality disorders are conditions in which an individual differs significantly significantly from an average person, in terms of how they think, perceive, feel or relate to others.
Changes in how a person feels and distorted beliefs about other people can lead to odd behavior, which can be distressing and may upset others. Common features include: •
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being overwhelmed by negative feelings such as distress, anxiety, worthlessness or anger avoiding other people and feeling empty and emotionally disconnected difficulty managing negative feelings without selfharming !for example, abusing drugs and alcohol, or taking overdoses" or, in rare cases, threatening other people odd behavior difficulty maintaining stable and close relationships, especially with partners, children and professional careers
#ometimes, periods of losing contact with reality. #ymptoms typically get worse with stress. $he personality disorders are grouped into three clusters based on descriptive similarities. )luster A includes paranoid, schi%oid, and schi%otypal personality disorders . &ndividuals with these disorders often appear odd or e!!e'tri! . )luster includes antisocial, borderline, histrionic, and narcissistic personality disorders. &ndividuals with these disorders often appear dramati!* emotio'al* or errati! . )luster ) includes avoidant, dependent, and obsessive compulsive personality disorders . &ndivid uals with these diso rders ofte n appear a'(ious or &ear&ul.
+ENERAL PERSONALITY DISORDER )riteria:
A. An enduring pattern of inner experience and behavior that devi ates markedly from the expectations of the individuals culture. $his pattern is manifested in two !or more" of the following areas: (. Cognition !i.e., ways of perceiving and interpreting self, other people, and events". ). Affectivity !i.e., the range, intensity, lability, and appropriateness of emotional response". *. &nterpersonal functioning. +. &mpulse control. . $he enduring pattern is inflexible and pervasive across a broad range of personal and social situations. C. $he enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. -. $he pattern is stable and of long duration, and &ts onset can be traced back at least to adolescence or early adulthood. . $he enduring pattern is not better explained as a manifestation or conse/uence of another mental disorder. 0. $he enduring pattern is not attributable to the physiological effects of a substance !e.g., a drug of abuse, a medication" or another medical condition !e.g., head trauma".
)L,STER A PERSONALITY DISORDER Para'oid Perso'ality Disorder: Persons with paranoid personality disorder are characteri%ed by longstanding suspiciousness and mistrust of persons in general. $hey refuse responsibility for their own feelings and assign responsibility to others. $hey are often hostile, irritable, and angry. igots, in1ustice collectors, pathologically 1ealous spouses, and litigious cranks often have paranoid personality disorder. DIA+NOSTI) )RITERIA:
A. A p ervasive 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: (. #uspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
). &s preoccupied with un1ustified doubts about the loyalty or trustworthiness of friends or associates. *. &s reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her. +. 2eads hidden demeaning or threatening meanings into benign remarks or events. 3. Persistently bears grudges !i.e., is unforgiving of insults, in1uries, or slights". 4. Perceives attacks on his or her character or reputation that are not apparent to others and is /uick to react angrily or to counterattack. 5. 6as recurrent suspicions, without 1ustification, regarding fidelity of spouse or sexual partner. . -oes not occur exclusively during the course of schi%ophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition. 7ote: &f criteria are met prior to the onset of schi%ophrenia, add 8premorbid,9 i.e., 8paranoid personality disorder !premorbid".9
)-ARA)TERISTI)S:
&ndividuals with paranoid personality disorder are generally difficult to get along with and often have problems with close relationships. $heir excessive suspiciousness and hostility may be expressed in overt argumentativeness, in recurrent complaining, or by /uiet, apparently hostile aloofness. ecause 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 ob1ective, rational, and unemotional, they more often display a labile range of affect, with hostile, stubborn, and sarcastic expressions predominating. $heir combative and suspicious nature may elicit a hostile response in others, which then serves to confirm their original expectations. ecause individuals with paranoid personality disorder lack trust in others, they have an excessive need to be selfsufficient and a strong sense of autonomy. $hey also need to have a high degree of
control over those around them. $hey are often rigid, critical of others, and unable to collaborate, although they have great difficulty accepting criticism themselves. $hey may blame others for their own shortcomings. ecause of their /uickness to counterattack in response to the threats they perceive around them, they may be litigious and fre/uently become involved in legal disputes.
DEELOPMENT AND )O,RSE.
Paranoid personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, social anxiety, underachievement in school, hypersensitivity, peculiar thoughts and language, and idiosyncratic fantasies. $hese children may appear to be odd or eccentric and attract teasing. &n clinical samples, this disorder appears to be more commonly diagnosed in males. humorless and serious. Although some premises of their arguments may be false, their speech is goal directed and logical. $heir thought content shows evidence of pro1ection, pre1udice, and occasional ideas of reference
S!hizoid Perso'ality Disorder: #chi%oid personality disorder is characteri%ed by a lifelong pattern of social withdrawal. Persons with schi%oid personality disorder are often seen by others as eccentric, isolated, or lonely. $heir discomfort with human interaction; their introversion; and their bland, constricted affect are noteworthy. DIA+NOSTI) )RITERIA:
A. A p ervasive pattern of detachment from social relation ships 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: (. 7either desires nor en1oys close relationships, including being part of a family. ). Almost always chooses solitary activities. *. 6as little, if any, interest in having sexual experiences with another person.
+. $akes pleasu re in fe w, if any, activities. 3.
)-ARA)TERISTI)S:
&ndividuals with schi%oid personality disorder may have particular difficulty expressing anger, even in response to direct provocation, which contributes to the impression that they lack emotion. $heir li ves sometimes seem directionless, and they may appear to drift in their goals. #uch individuals often react passively to adverse circumstances and have difficulty responding appropriately to important life events. ecause of their lack of social skills and lack of desire for sexual experiences, individuals with this disorder have few friendships, date infre/uently, and often do not marry. =ccupational functioning may be impaired, particularly if interpersonal involvement is re/uired, but individuals with this disorder may do well when they work under conditions of social isolation. Particularly in response to stress, individuals with this disorder may experience very brief psychotic episodes !lasting minutes to hours". &n some instances, schi%oid personality disorder may appear as the premorbid antecedent of delusional disorder or schi%ophrenia. &ndividuals with this disorder may sometimes develop ma1or depressive disorder. #chi%oid personality disorder most often cooccurs with schi%otypal, paranoid, and avoidant personality disorders. Persons with schi%oid personality disorder seem to be cold and aloof; they display a remote reserve and show no involvement with everyday events and the concerns of others. $hey appear /uiet, distant, seclusive, and unsociable. $hey may pursue their own lives with remarkably little need or longing for emotional ties, and they are the last to be aware of changes in popular fashion. $he life histories of such persons reflect solitary interests and
success at noncompetitive, lonely 1obs that others find difficult to tolerate. $heir sexual lives may exist exclusively in fantasy, and they may postpone mature sexuality indefinitely. >en may not marry because they are unable to achieve intimacy; women may passively agree to marry an aggressive man who wants the marriage. Persons with schi%oid personality disorder usually reveal a lifelong inability to express anger directly. $hey can invest enormous affective energy in nonhuman interests, such as mathematics and astronomy, and they may be very attached to animals. -ietary and health fads, philosophical movements, and social improvement schemes, especially those that re/uire no personal involvement, often engross them. Although persons with schi%oid personality disorder appear selfabsorbed and lost in daydreams, they have a normal capacity to recogni%e reality. ecause aggressive acts are rarely included in their repertoire of usual responses, most threats, real or imagined, are dealt with by fantasi%ed omnipotence or resignation. $hey are often seen as aloof, yet such persons can sometimes conceive, develop, and give to the world genuinely original, creative ideas.
DEELOPMENT AND )O,RSE.
#chi%oid personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, and underachievement in school, which mark these children or adolescents as different and make them sub1ect to teasing.
S!hizoty/al Perso'ality Disorder: Persons with schi%otypal personality disorder are strikingly odd or strange, even to laypersons. >agical thinking, peculiar notions, ideas of reference, illusions, and dereali%ation are part of a schi%otypal person's everyday world. DIA+NOSTI) )RITERIA:
A. A p ervasive 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: (. &deas of reference !excluding delusions of reference".
). =dd beliefs or m agical thinking that influences behavior and is inconsistent with subcultural norms !e.g., superstitiousness, belief in clairvoyance, telepathy, or 8sixth sense9: in children and adolescents, bi%arre fantasies or preoccupations". *. ?nusual perceptual experiences, including bodily illusions. +. =dd thinking and speech !e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped". 3. #uspiciousness or paranoid ideation. 4. &nappropriate or constricted affect. 5. ehavior or appearance that is odd, eccentric, or peculiar. @.
)-ARA)TERISTI)S.
&ndividuals with schi%otypal personality disorder often seek treatment for the associated symptoms of anxiety or depression rather than for the personality disorder features per se. Particularly in response to stress, individuals with this disorder ma y experience transient psychotic episodes !lasting minutes to hours", although they usually are insufficient in duration to warrant an additional diagnosis such as brief psychotic disorder or schi%ophreniform disorder. &n some cases, clinically significant psychotic symptoms may develop that meet criteria for brief psychotic disorder, schi%ophreniform disorder, delusional disorder, or schi%ophrenia. =ver half may have a history of at least one ma1or depressive episode. 0rom *B to 3B of individuals diagnosed with this disorder have a concurrent diagnosis of ma1or depressive disorder when admitted to a
clinical setting. $here is considerable cooccurrence with schi%oid, paranoid, avoidant, and borderline personality disorders. Patients with schi%otypal personality disorder exhibit disturbed thinking and communicating. Although frank thought disorder is absent, their speech may be distinctive or peculiar, may have meaning only to them, and often needs interpretation. As with patients with schi%ophrenia, those with schi%otypal personality disorder may not know their own feelings and yet are ex/uisitely sensitive to, and aware of, the feelings of others, especially negative affects such as anger. $hese patients may be superstitious or claim powers of clairvoyance and may believe that they have other special powers of thought and insight. $heir inner world may be filled with vivid imaginary relationships and childlike fears and fantasies. $hey may admit to perceptual illusions or macropsia and confess that other persons seem wooden and all the same. ecause persons with schi%otypal personality disorder have poor interpersonal relationships and may act inappropriately, they are isolated and have few, if any, friends. Patients may show features of borderline personality disorder, and indeed, both diagnoses can be made. ?nder stress, patients with schi%otypal personality disorder may decompensate and have psychotic symptoms, but these are usually brief. Patients with severe cases of the disorder may exhibit anhedonia and severe depression.
DEELOPMENT AND )O,RSE.
#chi%otypal personality disorder has a relatively stable course, with only a small proportion of individuals going on to develop schi%ophrenia or another psychotic disorder. #chi%otypal personality disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, social anxiety, underachievement in school, hypersensitivity, peculiar thoughts and language, and bi%arre fantasies. $hese children may appear odd or eccentric and attract teasing.
)L,STER PERSONALITY DISORDER
A'tiso!ial Perso'ality Disorder: Antisocial perso nality disorder is an inability to conform to the social norms that ordinarily govern many aspects of a person's adolescent and adult behavior. Although characteri%ed by continual antisocial or criminal acts, the disorder is not synonymous with criminality. DIA+NOSTI) )RITERIA:
A. A p ervasive pattern of disregard for and violation of the rights of others, occurring since age (3 years, as indicated by three !or more" of the following: (. 0ailure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest. ). -eceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. *. &mpulsivity or failure to plan ahead. +. &rritability and aggressiveness, as indicated by repeated physical fights or assaults. 3. 2eckless disregard for safety of self or others. 4. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. 5.
)-ARA)TERISTI)S.
&ndividuals with antisocial personality disorder fre/uently lack empathy and tend to be callous, cynical, and contemptuous of the feelings, rights, and sufferings of others. $hey 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, selfassured, or cocky. $hey may display a glib, superficial charm and can be /uite voluble and verbally facile !e.g., using technical terms or 1argon that might impress someone who is unfamiliar with the topic".
pathology. A diagnostic workup should include a thorough neurological examination. ecause patients often show abnormal E results and soft neurological signs suggesting minimal brain damage in childhood, these findings can be used to confirm the clinical impression.
DEELOPMENT AND )O,RSE.
Antisoci al personalit y disorder ha s a chronic course but may become less evident or remit as the individual grows older, particularly by the fourth decade of life. Although this remission tends to be particularly evident with respect to engaging in criminal behavior, there is likely to be a decrease in the full spectrum of antisocial behaviors and substance use. y definition, antisocial personality cannot be diagnosed before age (@ years.
orderli'e Perso'ality Disorder: Patients with borderline personality disorder stand on the border between neurosis and psychosis, and they are characteri%ed by extraordinarily unstable affect, mood, behavior, ob1ect relations, and selfimage. $he disorder has also been called ambulatory schi%ophrenia, asif personality !a term coined by 6elene -eutsch", pseudoneurotic schi%ophrenia !described by Paul 6och and Phillip Politan", and psychotic character disorder !described by Fohn 0rosch". $he (Bth revision of the &nternational Classification of -iseases (B !&C-(B" uses the term emotionally unstable personality disorder. DIA+NOSTI) )RITERIA:
A pervasive pattern of instability of interperso nal relationships, selfimage, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five !or more" of the following: (. 0rantic efforts to avoid real or imagined abandonment. !7ote: -o not include suicidal or selfmutilating behavior covered in Criterion 3." ). A pattern of unstable and intense interpersonal relationships characteri%ed by alternating between extremes of ideali%ation and devaluation. *. &dentity disturbance: markedly and persistently unstable selfimage or sense of self.
+. &mpulsivity in at least two areas that are potentially selfdamaging !e.g., spending, sex, substance abuse, reckless driving, binge eating". !7ote: -o not include suicidal or self mutilating behavior covered in Criterion 3." 3. 2ecurrent suicidal behavior, gestures, or threats, or selfmutilating behavior. 4. Affective instability due to a marked reactivity of mood !e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days". 5. Chronic feelings of emptiness. @. &nappropriate, intense anger or difficulty controlling anger !e.g., fre/uent displays of temper, constant anger, recurrent physical fights". . $ransient, stressrelated paranoid ideation or severe dissociative symptoms.
)-ARA)TERISTI)S.
Persons with borderline personality disorder almost always appear to be in a state of crisis. >ood swings are common. Patients can be argumentative at one moment, depressed the next, and later complain of having no feelings. Patients can have shortlived psychotic episodes !so called micropsychotic episodes" rather than fullblown psychotic breaks, and the psychotic symptoms of these patients are almost always circumscribed, fleeting, or doubtful. $he behavior of patients with borderline personality disorder is highly unpredictable, and their achievements are rarely at the level of their abilities. $he painful nature of their lives is reflected in repetitive selfdestructive acts. #uch patients may slash their wrists and perform other selfmutilations to elicit help from others, to express anger, or to numb themselves to overwhelming affect. ecause they feel both dependent and hostile, persons with this disorder have tumultuous interpersonal relationships. $hey can be dependent on those with whom they are close and, when frustrated, can express enormous anger toward their intimate friends. Patients with borderline personality disorder cannot tolerate being alone, and they prefer a frantic search for companionship, no matter how unsatisfactory, to their own company. $o assuage loneliness, if only for brief periods, they accept a
stranger as a friend or behave promiscuously. $hey often complain about chronic feelings of emptiness and boredom and the lack of a consistent sense of identity !identity diffusion"; when pressed, they often complain about how depressed they usually feel, despite the flurry of other affects. =tto Gemberg described the defense mechanism of pro1ective identification that occurs in patients with borderline personality disorder. &n this primitive defense mechanism, intolerable aspects of the self are pro1ected onto another; the other person is induced to play the pro1ected role, and the two persons act in unison. $herapists must be aware of this process so they can act neutrally toward such patients. >ost therapists agree that these patients show ordinary reasoning abilities on structured tests, such as the Hechsler Adult &ntelligence #cale, and show deviant processes only on unstructured pro1ective tests, such as the 2orschach test. 0unctionally, patients with borderline personality disorder distort their relationships by considering each person to be either all good or all bad. $hey see persons as either nurturing attachment figures or as hateful, sadistic figures who deprive them of security needs and threaten them with abandonment whenever they feel dependent. As a result of this splitting, the good person is ideali%ed and the bad person devalued. #hifts of allegiance from one person or group to another are fre/uent. #ome clinicians use the concepts of panphobia, pananxiety, panambivalence, and chaotic sexuality to delineate these patients' characteristics.
DEELOPMENT AND )O,RSE.
orderline personality disorder is fairly stable; patients change little over time.
-istrio'i! Perso'ality Disorder: Persons with histrionic personality disorder are excitable and emotional and behave in a colorful, dramatic, extroverted fashion. Accompanying their flamboyant aspects, however, is often an inability to m aintain deep, longlasting attachments. DIA+NOSTI) )RITERIA:
A pervasive pattern of exc essive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five !or more" of the following: (. &s uncomfortable in situations in which he or she is not the center of attention. ). &nteraction with others is often characteri%ed by inappropriate sexually seductive or provocative behavior. *. -isplays rapidly shifting and shallow expression of emotions. +. Consistently uses physical appearance to draw attention to self. 3. 6as a style of speech that is excessively impressionistic and lacking in detail. 4. #hows selfdramati%ation, theatricality, and exaggerated expression of emotion. 5. &s suggestible !i.e., easily influenced by others or circumstances". @. Considers relationships to be more intimate than they actually are.
)-ARA)TERISTI)S.
&ndividuals with histrionic personality disorder may have difficulty achieving emotional intimacy in romantic or sexual relationships. Hithout being aware of it, they often act out a role !e.g., victim or princess" in their relationships to others. $hey may seek to control their partner through emotional manipulation or seductiveness on one level, while displaying a marked dependency on them at another level. &ndividuals with this disorder often have impaired relationships with samesex friends because their sexually provocative interpersonal style may seem a threat to their friends' relationships. $hese individuals may also alienate friends with demands for constant attention. $hey often become depressed and upset when they are not the center of attention. $hey may crave novelty, stimulation, and excitement and have a tendency to become bored with their usual routine. $hese 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 1ob or pro1ect wi th grea t enthusiasm, their interest may lag /uickly.
excitement of new relationships. $he actual risk of suicide is not known, but clinical experience suggests that individuals with this disorder are at increased risk for suicidal gestures and threats to get attention and coerce better caregiving. 6istrionic personality disorder has been associated with higher rates of somatic symptom disorder, conversion disorder !functional neurological symptom disorder", and ma1or depressive disorder. orderline, narcissistic, antisocial, and dependent personality disorders often cooccur.
DEELOPMENT AND )O,RSE.
Hith age, persons with histrionic personality disorder show fewer symptoms, but because they lack the energy of earlier years, the difference in number of symptoms may be more apparent than real. Persons with this disorder are sensation seekers, and they may get into trouble with the law, abuse substances, and act promiscuously.
Nar!issisti! Perso'ality Disorder: Persons with narcissistic personality disorder are characteri%ed by a heightened sense of selfimportance, lack of empathy, and grandiose feelings of uni/ueness. ?nderneath, however, their selfesteem is fragile and vulnerable to e ven minor criticism. DIA+NOSTI) )RITERIA:
A pervasive pattern of grandiosi ty !in fantasy or behavi or", need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five !or more" of the following: (. 6as a grandiose sense of selfimportance !e.g., exaggerates achievements and talents, expects to be recogni%ed as superior without commensurate achievements". ). &s preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
*. elieves that he or she is 8special9 and uni/ue and can only be understood by, or should associate with, other special or highstatus people !or institutions". +. 2e/uires excessive admiration. 3. 6as a sense of entitlement !i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations". 4. &s interpersonally exploitative !i.e., takes advantage of others to achieve his or her own ends". 5.
)-ARA)TERISTI)S.
Persons with narcissistic personality disorder have a grandiose sense of selfimportance; they consider themselves special and expect special treatment. $heir sense of entitlement is striking. $hey handle criticism poorly and may become enraged when someone dares to critici%e them, or they may appear completely indifferent to criticism. Persons with this disorder want their own way and are fre/uently ambitious to achieve fame and fortune. $heir relationships are tenuous, and they can make others furious by their refusal to obey conventional rules of behavior. &nterpersonal exploitiveness is commonplace. $hey cannot show empathy, and they feign sympathy only to achieve their own selfish ends. ecause of their fragile selfesteem, they are susceptible to depression. &nterpersonal difficulties, occupational problems, re1ection, and loss are among the stresses that narcissists commonly produce by their behavior stresses they are least able to handle.
DEELOPMENT AND )O,RSE.
7arcissistic personality disorder is chronic and difficult to treat. Patients with the disorder must constantly deal with blows to their narcissism resulting from their own behavior or from life experience. Aging is handled poorly; patients value beauty, strength, and youthful attributes, to which they cling inappropriately. $hey may be more vulnerable, therefore, to midlife crises than are other groups.
)L,STER ) PERSONALITY DISORDERS A0oida't Perso'ality Disorder: Persons with avoidant personality disorder show extreme sensitivity to re1ection and may lead socially
withdrawn lives. Although shy, they are not asocial and show a great desire for companionship, but they need unusually strong guarantees of uncritical acceptance. #uch persons are commonly described as having an inferiority complex. DIA+NOSTI) )RITERIA:
A pervasive pattern of social inhibition, feelings of inade/uacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four !or more" of the following: (. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or re1ection. ). &s unwilling to get involved with people unless certain of being liked. *. #hows restraint within intimate relationships because of the fear of being shamed or ridiculed. +. &s preoccupied with being critici%ed or re1ected in social situations. 3. &s inhibited in new interpersonal situations because of feelings of inade/uacy. 4. Iiews self as socially inept, personally unappealing, or inferior to others. 5. &s unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
)-ARA)TERISTI)S.
6ypersensitivity to re1ection by others is the central clinical feature of avoidant personality disorder, and patients' main personality trait is timidity. $hese persons desire the warmth and security of human companionship but 1ustify their avoidance of relationships by their alleged fear of re1ection. Hhen talking with someone, they express uncertainty, show a lack of selfconfidence, and may speak in a selfeffacing manner. ecause they are hypervigilant about re1ection, they are afraid to speak up in public or to make re/uests of others. $hey are apt to misinterpret other persons' comments as derogatory or ridiculing. $he refusal of any re/uest leads them to withdraw from others and to feel hurt. &n the vocational sphere, patients with avoidant personality disorder often take 1obs on the sidelines. $h ey rarely attain much personal adva ncement or exercise much authority but seem shy and eager to please. $hese persons are generally unwilling to enter relationships unless they are given an unusually strong guarantee of uncritical acceptance. Conse/uently, they often have no close friends or confidants.
DEELOPMENT AND )O,RSE.
$he avoidant behavior often starts in infancy or childhood with shyness, isolation, and fear of strangers and new situations. Although shyness in childhood is a common precursor of avoidant personality disorder, in most individuals it tends to gradually dissipate as they get older. &n contrast, individuals who go on to develop avoidant personality disorder may become increasingly shy and avoidant during adolescence and early adulthood, when social relationships with new people become especially important. $here is some evidence that in adults, avoidant personality disorder tends to become less evident or to remit with age. $his diagnosis should be used with great caution in children and adolescents, for whom shy and avoidant behavior may be developmentally appropriate.
De/e'de't Perso'ality Disorder: Persons with dependent personality disorder subordinate their own needs to those of others, get others to assume responsibility for ma1or areas of their lives, lack selfconfidence, and may experience intense discomfort when alone for more than a brief period. $he disorder has been called passivedependent personality.
0reud described an oraldependent personality dimension characteri%ed by dependence, pessimism, fear of sexuality, self doubt, passivity, suggestibility, and lack of perseverance; his description is similar to the -#>3 categori%ation of dependent personality disorder. DIA+NOSTI) )RITERIA:
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five !or more" of the following: (. 6as difficulty making everyday decisions without an excessive amount of advice and reassurance from others. ). 7eeds others to assume responsibility for most ma1or areas of his or her life. *. 6as difficulty expressing disagreement with others because of fear of loss of support or approval. !7ote: -o not include realistic fears of retribution." +. 6as difficulty initiating pro1ects or doing things on his or her own !because of a lack of selfconfidence in 1udgment or abilities rather than a lack of motivation or energy". 3. Eoes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. 4. 0eels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself. 5. ?rgently seeks another relationship as a source of care and support when a close relationship ends. @. &s unrealistically preoccupied with fears of being left to take care of himself or herself.
)-ARA)TERISTI)S.
-ependent personality disorder is characteri%ed by a pervasive pattern of dependent and submissive behavior. Persons with the disorder cannot make decisions without an excessive amount of advice and reassurance
from others. $hey avoid positions of responsibility and become anxious if asked to assume a leadership role. $hey prefer to be submissive. Hhen on their own, they find it difficult to persevere at tasks but may find it easy to perform these tasks for someone else. ecause persons with the disorder do not like to be alone, they seek out others on whom they can depend; their relationships, thus, are distorted by their need to be attached to another person. &n folie a deux !shared psychotic disorder", one member of the pair usually has dependent personality disorder; the submissive partner takes on the delusional system of the more aggressive, assertive partner on whom he or she depends. Pessimism, selfdoubt, passivity, and fears of expressing sexual and aggressive feelings all typify the behavior of persons with dependent personality disorder. An abusive, unfaithful, or alcoholic spouse ma y be tolerated for long periods to avoid disturbing the sense of attachment.
DEELOPMENT AND )O,RSE.
Obsessi0e$!om/ulsi0e Perso'ality Disorder: =bsessivecompulsive personality disorder is characteri%ed by emotional constriction, orderliness, perseverance, stubbornness, and indecisiveness. $he essential feature of the disorder is a pervasive pattern of perfectionism and inflexibility. DIA+NOSTI) )RITERIA:
A pervasive pattern of preoccupation wi th orderliness, perfectionism , and mental and intrapersonal 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:
(. &s preoccupied with details, rules, lists, order, organi%ation, or schedules to the extent that the ma1or point of the activity is lost. ). #hows perfectionism that interferes with task completion !e.g., is unable to complete a pro1ect because his or her own overly strict standards are not met". *. &s excessively devoted to work and productivity to the exclusion of leisure activities and friendships !not accounted for by obvious economic necessity". +. &s overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values !not accounted for by cultural or religious identification". 3. &s unable to discard wornout or worthless ob1ects even when they have no sentimental value. 4. &s reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. 5. Adopts a mi serly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. @. #hows rigidity and stubbornness.
)-ARA)TERISTI)S.
Persons with obsessivecompulsive personality disorder are preoccupied with rules, regulations, orderliness, neatness, details, and the achievement of perfection. $hese traits account for the general constriction of the entire personality. $hey insist that rules be followed rigidly and cannot tolerate what they consider infractions. Accordingly, they lack flexibility and are intolerant. $hey are capable of prolonged work, provided it is routini%ed and does not re/uire changes to which they cannot adapt. Persons with obsessivecompulsive personality disorder have limited interpersonal skills. $hey are formal and serious and often lack a sense of humor. $hey alienate persons, are unable to compromise, and insist that others submit to their needs. $hey are eager to please those whom they see as more powerful than they are, however, and they carry out these persons' wishes in an authoritarian manner. ecause they fear making mistakes, they are indecisive and ruminate about making
decisions. Although a stable marriage and occupational ade/uacy are common, persons with obsessivecompulsive personality disorder have few friends. Anything that threatens to upset their perceived stability or the routine of their l ives can precipitate much anxiety otherwise bound up in the rituals that they impose on their lives and try to impose on others. 1 )ATE+ORIES O2 O)D. 3 Hashers !people who are terrified of contamination"
J Checkers !people who are afraid that something terrible could happen K because they forgot to take some action" J -oubters and sinners !people who are afraid of being less than perfect K and are 8waiting9 to be caught and punished for mistakes" J Counters and arrangers !people who have an obsession with order and symmetry. $hey are often very superstitious, too" J 6oarders !people who cant throw anything away". $hus, they compulsively store things theyll never use such as newspapers, receipts and old medicine bottles.
DEELOPMENT AND )O,RSE.
$he course of obsessivecompulsive personality disorder is variable and unpredictable. 0rom time to time, persons may develop obsessions or compulsions in the course of their disorder. #ome adolescents with obsessivecompulsive personality disorder evolve into warm, open, and loving adults; in others, the disorder can be either the harbinger of schi%ophrenia ordecades later and exacerbated by the aging process ma1or depressive disorder. Persons with obsessivecompulsive personality disorder may flourish in positions demanding methodical, deductive, or detailed work, but they are vulnerable to unexpected changes, and their personal lives may remain barren. -epressive disorders, especially those of late onset, are common.
OT-ER SPE)I2IED PERSONALITY DISORDER. Passi0e$a""ressi0e Perso'ality: Althoug h no longer an official diagnosis, persons with this personality type are not uncommon. Persons
with passiveaggressive personality are characteri%ed by covert obstructionism, procrastination, stubbornness, and inefficiency. #uch behavior is a manifestation of passively expressed underlying aggression.
)-ARA)TERISTI)S.
Patients with passiveaggressive personality characteristically procrastinate, resist demands for ade/uate performance, find excuses for delays, and find fault with those on whom they depend, yet they refuse to extricate themselves from the dependent relationships. $hey usually lack assertiveness and are not direct about their own needs and wishes. $hey fail to ask needed /uestions about what is expected of them and may become anxious when forced to succeed or when their usual defense of turning anger against themselves is removed. &n interpersonal relationships, these persons attempt to manipulate themselves into a position of dependence, but others often experience this passive, self detrimental behavior as punitive and manipulative. Persons with this personality type expect others to do their errands and to carry out their routine responsibilities. 0riends and clinicians may become enmeshed in trying to assuage the patients' many claims of un1ust treatment. $he close relationships of persons with passiveaggressive personality, however, are rarely tran/uil or happy. ecause they are bound to their resentment more closely than to their satisfaction, they may never even formulate goals for finding en1oyment in life. Persons with passiveaggressive personality lack selfconfidence and are typically pessimistic about the future.
DEELOPMENT AND )O,RSE.
&n a followup study averaging (( years of ( BB inpatients diagnosed with passiveaggressive disorder, &vor #mall found that the primary diagnosis in 3+ was passiveaggressive personality disorder; (@ were also alcohol abusers, and *B could be clinically labeled as depressed. =f the 5* former patients located, 3@ !5 percent" had persistent psychiatric difficulties, and !() percent" were considered symptom free. >ost seemed irritable, anxious, and depressed; somatic complaints were numerous. =nly *) ! ++ percent" were employed full time as workers or homemakers. Although neglect of responsibility and suicide attempts were common, only one patient had committed suicide in the interim. $wentyeight !*@ percent"
had been readmitted to a hospital, but only three had been diagnosed as having schi%ophrenia.
De/ressi0e Perso'ality: Persons with depressive personality are characteri%ed by lifelong traits that fall along the depressive spectrum. $hey are pessimistic, anhedonic, duty bound, selfdoubting, and chronically unhappy. >elancholic personality was described by early )B century uropean psychiatrists such as rnst Gretschmer.
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)-ARA)TERISTI)S.
Patients with depressive personality feel little of the normal 1oy of living and are inclined to be lonely and solemn, gloomy, submissive, pessimistic, and selfdeprecatory. $hey are prone to express regrets and feelings of inade/uacy and hopelessness. $hey are often meticulous, perfectionistic, overconscientious, and preoccupied with work; feel responsibility keenly; and are easily discouraged under new conditions. $hey are fearful of disapproval; tend to suffer in silence; and perhaps to cry easily, although usually not in the presence of others. A tendency to hesitation, indecision, and caution betrays an inherent feeling of insecurity. >ore recently, 6agop Akiskal described seven groups of depressive traits: !(" /uiet, introverted, passive, and nonassertive; !)" gloomy, pessimistic, serious, and incapable of fun; !*" selfcritical, selfreproachful, and selfderogatory; ! +" skeptical, critical of others, and hard to please; !3" conscientious, responsible, and selfdisciplined; !4" brooding and given to worry; and !5" preoccupied with negative events, feelings of
inade/uacy, and personal shortcomings. Patients with depressive personality complain of chronic feelings of unhappiness. $hey admit to low selfesteem and difficulty finding anything in their lives about which they are 1oyful, hopeful, or optimistic. $hey are selfcritical and derogatory and are likely to denigrate their work, themselves, and their relationships with others. $heir physiognomy often reflects their moodpoor posture, depressed facies, hoarse voice, and psychomotor retardation.
Sadisti! Perso'ality: #adistic personality is not included in -#>3, but it still appears in the literature and may be of descriptive use. eginning in early adulthood, persons with sadistic personality show a pervasive pattern of cruel, demeaning, and aggressive behavior that is directed toward others. Physical cruelty or violence is used to inflict pain on others, not to achieve another goal, such as mugging a person to steal. Persons with sadistic personality like to humiliate or demean persons in front of others and have usually treated or disciplined persons uncommonly harshly, especially children. &n general, persons with sadistic personality are fascinated by violence, weapons, in1ury, or torture. $o be included in this category, such persons cannot be motivated solely by the desire to derive sexual arousal from their behavior; if they are so motivated, the paraphilia of sexual sadism should be diagnosed.
Sel&$de&eati'" Perso'ality Disorder 4Maso!histi!5: #elfdefeating Personality -isorder is a pervasive pattern of selfdefeating behavior, beginning by early adulthood and present in a variety of contexts. $he person may often avoid or undermine pleasurable experiences, be drawn to situations or relationships in which he or she will suffer, and prevent others from helping him or her, as indicated by at least five of the following:
(. Chooses people and situations that lead to disappointment, failure, or mistreatment even when better options are clearly available. ). 2e1ects or renders ineffective the attempts of others to help him of her.
*. 0ollowing positive personal events !e.g., new achievement", responds with depression, guilt, or a behavior that produces pain ! e.g., an accident". +. &ncites angry or re1ecting responses from others and then feels hurt, defeated, or humiliated !e.g., makes fun of spouse in public, provoking an angry retort, then feels devastated". 3. 2e1ects opportunities for pleasure, or is reluctant to acknowledge en1oying himself or herself !despite having ade/uate social skills and the capacity for pleasure". 4. 0ails to accomplish tasks crucial to his or her personal ob1ectives despite demonstrated ability to do so, !e.g., helps fellow students write papers , but is unable to write his or her own". 5. &s uninterested in or re1ects people who consistently treat him or her well, !e.g., is not attracted to caring sexual partners". @. ngages in excessive selfsacrifice that is unsolicited by the intended recipients of the sacrifice; . $he behaviors do not occur exclusively in response to, or in anticipation of , being physically, sexually, or psychologically abused. (B. $he behaviors do not occur only when the person is depressed. ((. $he behaviors do not occur exclusively in response to, or in anticipation of , being physically, sexually, or psychologically abused. Di&&ere'tial Dia"'osis.
#ome disorders have similar or even overlapping symptoms. $he clinician, therefore, in his diagnostic attempt has to differentiate against the following disorders which need to be ruled out to establish a precise diagnosis.People with selfdefeating personalities are drawn to situations and relationships in which they are sub1ect to failure, humiliation, suffering, and distress. Although sexual masochism may be present, it has no necessary connection with this disorder. )ause.
$here is no clear cause for sadistic personality disorder; some theories suggest that it is a function of how one is brought up, but biological
factors are likely as well. $his disorder is fairly uncommon and there is little information about occurrence by gender or about family pattern.
