Source: Abnormal Psychology, University of Florida
Tags: personality disorders, Cluster A, Cluster B, Cluster C, borderline, antisocial, narcissistic, avoidant, dependent, obsessive-compulsive personality, paranoid, schizoid, schizotypal, histrionic, DBT, five-factor model
Difficulty: Intermediate-Advanced | Prerequisites: Schizophrenia spectrum notes (for Cluster A), basic CBT concepts
Personality disorders represent enduring, inflexible patterns of perceiving, thinking, feeling, and relating to others that deviate markedly from cultural expectations and cause significant distress or impairment. They are organised into three clusters: Cluster A (odd-eccentric), Cluster B (dramatic-emotional), and Cluster C (anxious-fearful). Unlike most other disorders, personality disorders are pervasive and chronic rather than episodic. The DSM-5 retains the categorical model for clinical use but introduces an alternative dimensional model for research, reflecting longstanding criticism that the categorical approach creates too much diagnostic overlap, unreliable boundaries, and poor fit for many patients.
Personality disorders are enduring, inflexible patterns of behaviour and inner experience that cause distress or impaired functioning. Cluster A disorders resemble mild schizophrenia, Cluster B disorders involve dramatic and impulsive behaviour, and Cluster C disorders are driven by anxiety and fearfulness. Most are difficult to treat, often co-occur with other disorders, and were historically placed on a separate diagnostic axis (Axis II) before the DSM-5 collapsed the multiaxial system.
Personality
An enduring pattern of perceiving, feeling, thinking about, and relating to oneself and the environment.
Personality Trait
A prominent aspect of personality that is relatively consistent across time and situations. Must be evident by early adulthood.
Five-Factor Model (Big Five)
A dimensional framework positing five broad personality traits: negative emotionality, extraversion, openness to experience, agreeableness, and conscientiousness. Strongly influenced by genetics and replicated across cultures.
Splitting
A defence mechanism in which a person cannot integrate the positive and negative qualities of themselves or others and instead vacillates between seeing them as all good or all bad. Characteristic of borderline personality disorder.
Dialectical Behaviour Therapy (DBT)
A psychotherapy developed by Marsha Linehan for borderline personality disorder. Focuses on building a realistic self-concept, emotion regulation, correcting dichotomous thinking, and developing assertiveness skills.
Pattern deviates markedly from cultural expectations in cognition, emotional expression, interpersonal functioning, or impulse control
Pattern is pervasive and inflexible across situations, stable over time
Onset in adolescence or early adulthood, leading to significant distress or impairment
Cannot be explained by another mental, substance use, or medical disorder
Under 18: can only be diagnosed if personality patterns present for at least one year (except antisocial, which cannot be diagnosed before 18)
DSM-5 removed the multiaxial system, collapsing Axis I and Axis II into a common section
Most people with a personality disorder also meet criteria for at least one other disorder
Behaviour resembles a milder version of schizophrenia. People retain their grasp on reality but may be paranoid, speak in odd ways, have difficulty relating to others, and hold unusual beliefs or perceptual experiences. More common in first-degree relatives of people with schizophrenia.
Paranoid Personality Disorder (PPD)
Pervasive distrust and suspicion that others' motives are malevolent
Preoccupied with being exploited, hypervigilant for evidence confirming suspicions
Penetrating observers of detail, considering events to be highly meaningful
Sensitive and angrily reactive to criticism, hold grudges, resistant to rational arguments
Increased risk for depression, anxiety, substance abuse, psychotic episodes
Heritability ~0.50. Cognitive theorists: underlying belief that others are malevolent + lack of self-confidence in self-defence
Blacks report higher rates, likely reflecting exposure to discrimination and childhood trauma
Treatment: very difficult due to mistrust. Therapist must be calm, respectful, straightforward. Cannot directly confront paranoia. Cognitive therapy aims to increase self-efficacy and reduce hostility.
Schizoid Personality Disorder
Pervasive detachment from social relationships, restricted emotional expression
Indifferent to praise, criticism, and opportunities for relationships
Take pleasure in few activities, view relationships as unrewarding and intrusive
Uncommon; more in males. No clear genetic link to schizophrenia.
Treatment: may not be motivated. Therapy focuses on increasing awareness of feelings, social skills, emotional expression. Group therapy may help.
Schizotypal Personality Disorder
Milder versions of schizophrenia symptoms: paranoia, ideas of reference, odd beliefs and magical thinking, illusions, tangential speech, inappropriate emotional responses, eccentric behaviour
Retain basic contact with reality
More common in males; at increased risk for depression and schizophrenia
Genetically transmitted; first-degree relatives of people with schizophrenia more likely to have it
Similar cognitive deficits and dopamine dysregulation as schizophrenia, but less severe
Brain abnormalities similar to schizophrenia but milder, with grey matter reductions in temporal lobe
Treatment: low-dose neuroleptics or atypical antipsychotics. Cognitive therapy to challenge bizarre thoughts. Social skills training.
Dramatic, impulsive behaviour with little regard for personal or others' safety. May be hostile or violent. Lack of concern for others is the core feature.
Borderline Personality Disorder (BPD)
Out-of-control emotions, hypersensitivity to abandonment, tendency to cling, history of self-harm
Distorted and unstable self-concept: alternating between extreme self-doubt and grandiose self-importance
Transient dissociative states; unstable relationships (idealisation then sudden devaluation)
Unstable mood with bouts of depression, anxiety, or anger; impulsive self-damaging behaviours
Usually diagnosed with at least one other disorder; higher suicide rates, especially in the first two years after diagnosis
More common in women (small difference), people of colour, lower socioeconomic classes, Hispanics
Recent studies show higher remission rates within 10 to 15 years; relapse is uncommon once remission occurs, but stable social relationships remain difficult
Theories: fundamental deficits in emotion regulation; hyperattention to negative stimuli; negatively biased memories and interpretations; childhood instability, neglect, and abuse. Linehan: exposure to abuse, neglect, and criticism undermines development of emotion-regulation skills. Psychoanalytic view: never differentiated self from others, leading to splitting. Smaller amygdala and hippocampus, greater amygdala activation, prefrontal cortex abnormalities; heritable and runs in families.
Treatment:
DBT: monitor and challenge self-disparaging thoughts and dichotomous evaluations, learn assertiveness, emotion regulation, impulse control. Reduces depression, anxiety, self-mutilation; increases interpersonal functioning.
STEPPS (Systems Training for Emotional Predictability and Problem Solving): group cognitive-behavioural intervention. Reduces negative affect, impulsivity; fewer hospitalisations and suicide attempts.
Transference-focused therapy (psychodynamic): uses the therapist-patient relationship to develop healthier self-understanding. Reduces suicide, impulsivity, aggression.
Mentalization-based treatment: helps patients understand mental states of self and others. Improves mood and functioning, fewer suicide attempts.
Medications: mood stabilisers, atypical antipsychotics (olanzapine). No evidence SSRIs improve BPD. Adding drugs to psychotherapy does not improve outcomes.
Histrionic Personality Disorder (HPD)
Dramatic, attention-seeking, overly seductive, shallow, dependent, demanding
Shares features with BPD (rapidly shifting emotions, unstable relationships)
More common in women; higher rates of suicidal threats; often seek treatment for depression or anxiety
Little is known about causes; some family linkage but unclear genetics
Treatment: psychodynamic (uncovering repressed emotions), cognitive (challenging assumption that one cannot function independently). No therapies empirically tested.
Narcissistic Personality Disorder (NPD)
Grandiosity, preoccupation with self-importance, fantasies of power and success, exploitative, arrogant
Do not share BPD's abandonment concerns despite needing admiration
Grossly overestimate abilities, leading to failures; alienate others
Can be grandiose or vulnerable (hypersensitive to rejection, avoidant)
History of childhood adversity common
Treatment: very difficult. Collaborative cognitive approach to develop realistic expectations and sensitivity to others. Patients often leave therapy once the acute problem (e.g. depression) resolves. No systematic treatment studies published.
Antisocial Personality Disorder
Cannot be diagnosed before age 18
(Covered extensively in Chapter 10 as part of conduct disorder trajectory)
Chronic anxiety or fearfulness driving avoidance behaviours. Each disorder fears something different, but all are characterised by nervousness and unhappiness.
Avoidant Personality Disorder (APD)
Low self-esteem, prone to shame, extremely anxious about being criticised
May choose socially isolated occupations; interactions are restrained and hypersensitive
Crave relationships but feel unworthy, so isolate
Substantial overlap with social anxiety disorder (may be alternate forms of the same condition)
Cognitive distortions: "If my parents rejected me, why would anyone else want me?"
Treatment: graduated exposure, social skills training, challenging negative automatic thoughts. Shows increased social contact and decreased avoidance.
Dependent Personality Disorder (DPD)
Deep need to be cared for; deny own thoughts and feelings to please others
Submit to unreasonable demands, frantically cling to relationships
Cannot make everyday decisions without excessive advice and reassurance
May tolerate exploitation and abuse to maintain relationships
More common in women; depressive and anxiety disorders commonly co-occur
Often seek treatment willingly (unlike most other personality disorders) and develop positive relationships with therapists quickly
Treatment: psychodynamic (insight into early caregiver patterns), humanistic (fostering autonomy), CBT (assertiveness training, challenging beliefs about needing others, graduated exposure to anxiety-provoking independence)
Obsessive-Compulsive Personality Disorder (OCPD)
Rigid, perfectionistic, dogmatic, ruminative, emotionally blocked
Preoccupied with rules, details, and order; persist in failing approaches; have difficulty tolerating others' quirks
Base self-esteem on productivity; workaholics with little leisure
Overlap with OCD and Type A personality, but OCPD is a more general way of interacting with the world
Most prevalent personality disorder; no gender differences
Treatment: no psychological treatment studies published. Supportive therapy for crises, behavioural techniques to decrease rigidity, relaxation, challenging automatic thoughts. SSRIs may help.
Designed to address the categorical model's weaknesses: diagnostic overlap, poor inter-rater reliability, criteria that do not capture many pathological personalities
Step 1: Assess impairment in sense of self and interpersonal functioning on the Level of Personality Functioning Scale (0 = healthy, 4 = extreme; level 2 required for diagnosis)
Step 2: Assess pathological personality traits across five dimensions: negative affectivity, detachment, antagonism, disinhibition, psychoticism
Step 3: Determine if criteria for a specific disorder are met (antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, schizotypal); if not, assign "personality disorder-trait specified"
Hybrid model combining categorical and dimensional approaches
"OCPD and OCD are the same thing." OCPD is a pervasive personality style (rigidity, perfectionism, need for control). OCD involves specific obsessions and compulsions. They co-occur at moderate to high rates, but are distinct conditions.
"Personality disorders are just extreme versions of normal personality." The categorical model treats them as qualitatively different, though the alternative dimensional model views them as extreme points on a continuum.
"All people with BPD are manipulative." The behaviours associated with BPD (clinging, impulsive actions, emotional outbursts) are driven by genuine distress and deficits in emotion regulation, not calculated manipulation.
"Narcissists are always grandiose." NPD includes a vulnerable subtype characterised by hypersensitivity, shame, and avoidance of others.
⚠️ Know the three clusters and which disorders belong to each.
⚠️ BPD is the most extensively covered personality disorder in this chapter: know the theories (emotion regulation, splitting, Linehan's model) and the treatments (DBT, STEPPS, mentalization-based treatment, transference-focused therapy).
⚠️ Be able to distinguish APD from social anxiety disorder, and OCPD from OCD.
⚠️ The alternative DSM-5 dimensional model and its three-step process is likely exam material.
⚠️ Know which personality disorders cannot be treated effectively and why (e.g. NPD, HPD lack empirical treatment studies).
⚠️ Cluster A disorders and their genetic relationship to schizophrenia.
True or False: Antisocial personality disorder can be diagnosed in a 16-year-old.
Fill in the blank: The __________ subtype of narcissism is characterised by hypersensitivity and shame rather than overt grandiosity.
True or False: OCPD is the most prevalent personality disorder.
Fill in the blank: The DSM-5 alternative dimensional model requires at least Level __________ impairment on the personality functioning scale for a personality disorder diagnosis.
True or False: Adding medication to DBT significantly improves outcomes for BPD.
Q: What are the three clusters of personality disorders, and what is the general theme of each?
A: Cluster A (odd-eccentric): paranoid, schizoid, schizotypal. Cluster B (dramatic-emotional): borderline, histrionic, narcissistic, antisocial. Cluster C (anxious-fearful): avoidant, dependent, obsessive-compulsive.
Q: How does DBT address borderline personality disorder?
A: DBT helps clients monitor and challenge self-disparaging thoughts and black-and-white evaluations, learn assertiveness skills for relationships, regulate emotions, and control impulsive behaviour. It has been shown to reduce depression, anxiety, and self-mutilation and to improve interpersonal functioning.
Q: What distinguishes avoidant personality disorder from social anxiety disorder?
A: There is substantial overlap, and some researchers consider them alternate forms of the same condition. People with APD tend to have more severe and generalised social anxiety. A further distinction is that people with APD still desire acceptance and sometimes fantasise about idealised relationships.
Q: What are the three steps of the DSM-5 alternative dimensional model for personality disorders?
A: (1) Assess impairment in sense of self or interpersonal functioning (minimum Level 2). (2) Determine whether pathological personality traits are present across five dimensions. (3) Determine whether criteria for a specific named disorder are met; if not, assign "personality disorder-trait specified."
Q: Why is paranoid personality disorder difficult to treat?
A: The core feature of PPD is pervasive mistrust, which makes forming a therapeutic alliance extremely difficult. Attempts to challenge paranoid thinking are often interpreted as evidence of conspiracy. Therapists must be indirect, build trust slowly, and focus on increasing self-efficacy rather than directly confronting the paranoia.
Cluster A personality disorders connect directly to the schizophrenia spectrum (Chapter 8). BPD connects to emotion regulation, which is relevant to mood disorders and PTSD. The dimensional model of personality connects to the five-factor model used in personality psychology. OCPD connects to OCD (anxiety disorders). Antisocial personality disorder connects to conduct disorder in childhood (Chapter 10).
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