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Personality Disorders
Personality Disorders
Personality Disorders 1. General Considerations Until the 1980s, both the scientific and the therapeutic aspect of personality disorders constituted a rather underdeveloped field despite their great significance for clinic and practice. Since the introduction of separate Axis II personality registration used in DSMIII (APA 1980) and the subsequent editions, DSM-IIIR and DSM-IV (APA 1987, 1994), research and publication worldwide have been considerably stepped up, leading to the inception of professional journals and scientific societies devoted solely to the field of personality disorders. As of the beginning of the twenty-first century there is a veritable deluge of theoretical concepts and therapeutic methods. More than in any other area of psychiatry, one still sees many inaccurate terms and concepts, and hard data on nosology, etiology, and pathogenesis of the various personality disorders remain rare. To be sure, there is a wealth of isolated pieces of etiological and pathogenetic knowledge on factors influencing the formation and progress of accentuated personality traits, but a comprehensive theoretical or empirical model remains as elusive as ever. We can therefore only address certain points and make some qualified references, as the exceedingly complex nature of the subject still does not allow any more definite statements. ‘Personality disorder’ is a value-free term which encompasses all those deviations from a normal personality development which require treatment. There are, necessarily, fluid borders to mental health on the one hand and mental disorder on the other. Concepts with meaning similar or identical to personality disorder are psychopathy, abnormal personality, psychopathic development, psychopathic or dissocial personality, sociopathy, etc. In Sect. 3, the author will give an overview of the historical roots of
these concepts while also addressing recent diagnostic and therapeutic developments.
2. Terms and Definitions The most comprehensive term in this field must surely be ‘personality.’ One of the most complex terms in our language, it can be defined in a variety of ways. Popularly, personality is often used as an ethicalpedagogical value judgment to mean character or temper, as when referring to someone as a strong personality or a person of character. Moral judgments are likewise made, as when we say that all human beings are persons, but we do not mean that everyone is a personality, which is characterized by a conscious and sustained exercise of thought and will. The current psychological and psychiatric definition of personality is: the sum of all mental and behavioural characteristics which make each of us a unique individual. On the other hand, a personality disorder occurs if, due to degree and\or a particular combination of psychopathologically relevant features in any of these areas, there is considerable suffering and\or lasting impairment of social adaptiveness (Saß 1987). According to DSM-IV, only when personality traits are inflexible and maladaptive and cause either significant functional impairment or subjective distress do they constitute personality disorders (Table 1).
3. A History of the Concepts of Abnormal Personality The concept of psychopathy arises from a confluence of views entertained by the French, the German, and the Anglo-American psychiatric traditions. Sociocultural factors caused these conceptions of psychopathy to develop more or less independently well into the twentieth century. The following section deals with all three traditions.
Table 1 General diagnostic criteria for personality disorder A. A lasting pattern of inner experiences and behavior which deviates markedly from the expectations of the culture the individual lives in. This pattern is manifested in two or more of the following areas: 1. cognition (i.e., ways of perceiving and interpreting oneself, others, and events) 2. emotiveness (i.e., range, intensity, stability, and appropriateness of emotional response) 3. interpersonal functioning 4. impulse control B. The pattern is inflexible and pervasive across a broad range of personal and social situations. C. The pattern leads to clinically significant distress or impairment in social, occupational, or other important areas. D. The pattern is stable and longlasting, and its onset can be traced back to adolescence or early adulthood. E. The pattern is not better accounted for as a manifestation or consequence of another mental disorder. F. The pattern is not due to direct physiological effects of a substance (e.g., drug or medication) or a general medical condition (e.g., head trauma).
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Personality Disorders 3.1 French Concepts Pinel’s (1809) concept of manie sans deT lire includes instances of ‘deranged personality’ and can be looked upon as the beginning of the scientific study of personality disorder as a nosological entity. In the eighteenth century, all mental diseases were regarded as fundamental disturbances of the intellect. Pinel was one of the first to point out that in some disorders, the emotions were primarily involved. Nevertheless, the early nineteenth-century definitions of madness remained centered mostly around the intellect. Indeed, to this day, psychiatric phenomenology neglects the disorders of affect. Esquirol (1838) developed the concept of monomania, a diagnostic category based on the partial, primary–and independent–involvement of the intellectual, emotional, and\or volitional functions of the mind, including states where a single behavioral disturbance became the sole diagnostic criterion for the condition (e.g., pyromania or kleptomania). Not surprisingly, monomania was one of the sources of the concept of psychopathy. Since its inception, the concept of monomania has been criticized on clinical and medicolegal grounds both in France and abroad. Morel’s (1857) idea of degeneration was a pseudobiological account strongly tinged with the idea of original sin. He proposed that: (a) degenerative alterations are pathological deviations from the normal; (b) mental illness is mostly hereditary; and (c) degeneration is both quantitative and qualitative, i.e., new disorders may appear. According to Morel’s model, all types of mental and neurological disorders can be traced back to one common hereditary origin. His idea of progressive and polymorphic degeneration was accepted as an explanation of mental illness.
3.2 Anglo-American Concepts Prichard (1835) defined moral insanity as ‘madness consisting of a morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions and natural impulses without any remarkable disorder or defect of the interest or the reasoning faculties, and particularly without any illusion or hallucinations.’ During the early nineteenth century, the word ‘moral’ had many uses, in the psychological sense chiefly to denote the affective and the conative (rather than the purely intellectual) functions. The British concept of psychopathy was shaped by D. K. Henderson (1939), who saw ‘psychopathic states’ as a condition of ‘constitutional abnormality.’ In contrast to other (especially German) psychiatrists, he thought of constitution as deriving from both heredity and environment. There were three psychopathic states, the predominantly aggressive, the inadequate, and the creative. The former two were 11302
characterized by antisocial traits and soon became part of the Anglo-American concept of personality disorder. Rush (1812) was the first Anglo-American psychiatrist to study individuals whose disturbances were primarily characterized by irresponsibility and aggressiveness; who showed, as he put it, a ‘moral alienation of the mind.’ He believed that these reprehensible acts were the manifestations of mental disease, that they were unmotivated and driven by ‘a kind of involuntary power.’ Partridge (1930) defined the concept of psychopathic personality as a persistent maladjustment which cannot be corrected by ordinary methods of education or by punishment. From Partridge on, the emphasis has been on description, and etiological speculation has taken the back seat. To this day, a view of psychopathy as sociopathy dominates AngloAmerican psychiatry. A parallel concept, that of the antisocial personality disorder, appeared in DSM-III (APA 1980) and was kept in DSM-III-R (APA 1987) and DSM-IV (APA 1994).
3.3 German Concepts In Germany, the concept of psychopathy embraces most forms of abnormal personality. The current German definition can be traced back to Koch, whose monograph Psychopathische Minderwertigkeiten [Psychopathic Inferiorities] (1891–93) was as decisive in shaping the concept of abnormal personality in Germany as Pinel’s work was in France, Rush’s in the USA, and Prichard’s in Great Britain. German ideas of psychopathy also influenced French and AngloAmerican views, especially after the 1930s, when many German-speaking psychiatrists and psychoanalysts emigrated to these countries. Kraepelin’s concept of psychopathy, influenced by the French theory of degeneration, formed the basis of Kurt Schneider’s typology, and via the latter, of today’s German doctrine of psychopathy. In successive editions of his textbook, Kraepelin elaborated on his concept of ‘psychopathic states’ as abnormal personality. He employed the term ‘psychopathic personalities’ in a predominantly social sense, including also innate delinquents, unstable liars, swindlers, and pseudo-querulous individuals. During this period, there also appeared various ‘systematic’ typologies to draw ‘psychopathic’ categories from prototypic personality theories. Foremost amongst these is Kretschmer’s konstitutionstypologisches Modell (1919). He suggested a specific correlation between body type and personality. Kretschmer (1921) and Ewald (1924) also introduced the concept of Reaktionstypologiento account for specific styles of dealing with experience. Systematic typologies lost influence after the publication of Schneider’s monograph in 1923.
Personality Disorders Kurt Schneider is known especially for his famous monograph Die psychopathischen PersoW nlichkeiten [The Psychopathic Personalities] (1923). He used a ‘typological approach’ to personality types and tried to avoid value judgments by not including antisocial forms of behavior. Schneider defines abnormal personalities as statistical deviations from an estimated average norm, although the concept of norm is poorly formulated in his work. In his model, eminently creative and intelligent individuals are also abnormal; hence, not all abnormal personalities could be said to have psychiatric implications. Schneider defined ‘psychopathic personalities [as] those abnormal personalities that suffer from their abnormality or whose abnormality causes society to suffer.’ It is very important to stress that Schneider did not consider psychopathy a form of mental illness, which by definition must be associated with a brain lesion or a recognized disease process. In this, he opposed Kretschmer and Bleuler, who believed that psychosis and psychopathy were just different degrees on the same spectrum of derangement. Schneider’s doctrine influenced all subsequent typologies, and current classification systems include essential parts of his concept of psychopathy. The appendix to DSM-IV even includes the ‘depressive type’ to encourage further research on this subject.
4. Epidemiology, Course of Illness, and Prognosis According to German and American studies, 3–10 percent of the general population meet the diagnostic criteria of a personality disorder. Compared to numbers in earlier manuals, these are rather high. However, simply meeting these criteria need not imply that the individuals in question are so dysfunctional and impaired as to require treatment. Prevalence rates are much higher among unselected psychiatric patients. After the first classification systems appeared, clinical studies found surprisingly high frequencies for personality disorders—50–80 percent—while more recent studies reported prevalence rates of 40–60 percent on the average. Forensicpsychiatric random samples yielded prevalence rates of up to 80 percent. In a large-scale international WHO study (Loranger et al. 1994), 39.5 percent of 716 psychiatric patients examined showed at least one personality disorder according to ICD-10, individual prevalence rates falling between 15.2 percent (anxious personality disorder) and 1.8 percent (schizoid personality disorder). Clinical experience has shown that increasing age and decreasing vitality tend to attenuate ‘sharp’ personality traits, especially those which seriously impair social functioning, such as inconstancy, antisocial behavior, and impulsiveness. Other traits can become sharper with advancing age, above all obstinacy and rigidity.
The prognosis depends on the particular type of personality disorder, on any eventual comorbidity, and on the degree of severity. Further prognostic factors are psychostructural maturity as well as the level of psychological and social functioning. Prognostically favorable characteristics are motivation, trust in others, flexibility, and insight into one’s own role in difficulties with interpersonal contact. Cases are complicated by concomitant illness, especially addiction and affective disorders. Thus, the mortality rate for patients with personality disorders and substance abuse is three times that of patients with a single personality disorder (Bohus et al. 1999). Generally speaking, the risk of suicide is three times higher for individuals with a personality disorder than for the general population, with borderline, narcissistic, and antisocial personality disorders showing the highest incidence. These groups also show the highest degree of psychosocial impairment, with deviant actions, decreased capacity for work, and deficient skills at establishing dependable interpersonal relations.
5. Diagnostic Problems In view of the complexity of the concept of personality, it becomes clear that difficulties exist in distinguishing between a normal range of varying personality traits (as many as 1800 features have been identified which might aid in characterizing possible personality traits) and personality disorders which might be of psychiatric relevance. Towards the end of the twentieth century there has been a trend towards reducing the myriad personality traits to 3, 5, or 7 essential dimensions from which the individual variations can be derived (Table 2). Interestingly, the factor structure of behavior and its abnormalities seems to be essentially the same in the general population and in clinical groups of behaviourally abnormal patients. The differences lie mainly in the degree and the particular combination of the various dimensions, not in a fundamental difference of personality traits. Categorical classifications are based on somatic models where the various diseases can be clearly separated from each other; personality disorders, however, show fluid borders, both between the various types and towards normality. Dimensional personality models, developed especially for scientific research, measure degree—or severity—by means of trait factors and thus assign it a position corresponding to its extent along various dimensional axes. It must be kept in mind that there is no inherent qualitative difference in personality traits between the general population and clinical groups of patients with personality disorders, only a difference in degree or severity, or eventually in a particular combination of traits. By means of factor analyses, these personality models 11303
Personality Disorders Table 2 Factor models of dimensional personality description 3-factor personality models
5-factor personality models
7-factor personality model
Eysenck (1977) neuroticism extroversion psychoticism
Costa and McCrae (1990) extroversion neuroticism agreeability conscientiousness
Cloninger (1994) harm avoidance novelty seeking reward dependence persistence
Millon (1981) joy\pain self\other-centeredness activity\passivity
openness to new experiences
self-directedness cooperativeness self-transcendence
von Zerssen (1988) extroversion neuroticism aggressivity conscientiousness openness (devoutness)
Widiger et al. (1994) free-floating anxiety\eccentric behavior assertiveness\dominance social integration DSM-IV (1994) eccentricity dramatic affect fear Table 3 Classification of personality disorders DSM-IV paranoid schizoid schizotypical antisocial borderline histrionic narcissistic avoidant obsessive-compulsive not otherwise specified
ICD-10 paranoid schizoid — dissocial impulsive histrionic — anxious obsessive-compulsive not otherwise specified and others
reduce the myriad personality traits to a few essential personality dimensions, independent of culture, from which the individual variants may then be derived. However, given the clinical usefulness of the categorical approach, and hence the widespread hesitancy in abandoning it, recent efforts have tended more towards a synthesis of the categorical and dimensional elements. The classification systems used today, which increasingly determine personality diagnosis, are the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), published by the American Psychiatric Association (APA 1994), and the International Classification of Diseases, 10th Edition (ICD10), published by the World Health Organization (WHO 1992). Both are used for making diagnoses, thus forcing clinicians, practitioners, and researchers 11304
alike to opt for one of the two systems. While the two systems resemble each other in many aspects, there are others where they completely disagree. Table 3 gives an overview of the most important discrepancies (see Differential Diagnosis in Psychiatry).
6. Therapy of Personality Disorders Following a thorough anamnesis, there are two main options: psychotherapy and therapy with psychopharmaceuticals. In detail:
6.1 Thorough Initial Examination The general procedure in treating personality disorders follows the usual rules of psychiatry. It is important that a thorough initial examination be done, with an exact medical and psychiatric anamnesis. Due to the lacking self-dystonia, the patient’s self-perception may be lower than in cases showing acute psychopathological symptoms. Hence, anamnesis by significant others can also be helpful in assessing social conflict when dealing with personality disorders.
6.2 Psychotherapy of Personality Disorders In the psychotherapy of personality disorders, the choice of the therapeutic procedure will depend on the particular form of personality disorder, its severity, as well as any concomitant mental disorders. Currently accepted forms of therapy include: cognitive\
Personality Disorders behavioral therapeutic and supportive techniques, depth psychology, disorder-oriented and interdisciplinary therapies with treatments for specific problem areas of a personality, pedagogic or psychogogic therapies, sociotherapy, and dialogue sessions for couples or families. An important element of every therapy is that disorder-related behavior and interaction abnormalities also be dealt with in the patient– therapist relation, so that a big step in the therapy will consist in opening up new self-awareness and possibilities of change to the patient via the therapeutic interaction itself. Psychotherapy of personality disorders usually requires a long time, since it involves a gradual reshaping of long-lasting characteristics in the areas of experiencing, feeling, and social behavior. Short-term crisis intervention can also be helpful if the problematic personality traits bring situations to a head and cause social conflicts. Building up a regular, trusting relation is of great importance. The frequency usually chosen is one to two hours per week. Aside from discussing current life conflicts, exploring past issues is also important as it can outline the development of the personality traits which are at the root of the trouble. Group therapy is well suited for many personalities (provided they are not seriously deranged) since observing other patients allows learning by example. The positive feedback or criticism from the other group members can reinforce desirable behavior and put undesirable behavior in perspective (see Cognitie and Interpersonal Therapy: Psychiatric Aspects). 6.3 Pharmacotherapy The second important therapy for personality disorders, one which in recent years has been increasingly developed, consists in the use of psychopharmaceuticals. It rests on the assumption that personality disorders can also have a biological cause which may be either constitutional or due to functional anomalies which were acquired later. The aim is to reduce the vulnerability to affective and cognitive dysfunctions neurochemically and to modify certain behavioral reaction patterns, the target symptoms or syndromes being: (a) the characteristics of the personality disorder (e.g., cognitive deficits, impulsive behavior, strong mood swings); (b) complications due to the personality disorder (e.g., suicidal tendencies, aggressivity towards others, deficient social skills); and (c) the axis I disorders associated with these (e.g., depressive or anxiety syndromes, compulsion, eating disorders). The pharmacological treatment of personality disorders is by no means an alternative to psychotherapy. Rather, it is used in support and preparation for psychotherapy, as well as for crisis intervention (especially with suicidal tendencies).
Due to the dangers of side effects and habituation or dependence associated with it, long-term pharmaceutical therapy of personality disorders must always be viewed critically. Likewise, the therapist must be aware of the danger that the patient may start believing in external control or attribute therapeutic success solely to the action of the psychopharmaceuticals. Moreover, there are special counterindications: alcohol and medicine abuse, social unreliability, bad compliance (incoming to therapy or in taking the medication). Due to the danger of late dyskinesias following long-term use, neuroleptics should be employed judiciously and substances of low or medium potency be considered. With benzodiazepines there is a particularly high risk of addiction, which is why they are generally not indicated for the treatent of personality disorders. Medication can also be tricky with some patients, who may harbor unrealistical expectations or fear to lose control. Due to these difficulties, such individuals may have to be admitted as inpatients before psychopharmaceutical therapy can be initiated (see Psychotherapy and Pharmacotherapy, Combined ).
7. The Most Important Personality Disorders According to DSM-IV This section offers classification of personality disorders, followed by an overview of the most important forms of abnormal personalities in DSM-IV. Please consult the manual for a complete list of the diagnostic criteria for the following personality disorders. The differential diagnosis refers solely to the Axis-I disorders (because of limited space). 7.1 Paranoid Personality Disorder According to DSM-IV, persons with a paranoid personality disorder show a pattern of distrust and suspicion, reading malevolence into the motives of others without sufficient basis for that supposition. They often doubt the loyalty of their friends, partners, or associates and are reluctant to confide in others for fear that the information might be used against them. Persons with a paranoid personality disorder quickly react to perceived insults with excessive force, counterattacks, and\or long-lasting enmity. Mistakes are usually blamed on others. Persons with this disorder usually have recurrent suspicions regarding the fidelity of their spouse or partner. These persons are easily insulted, emotionally rigid, and persevering while at the same time appearing humorless and restrictive in their expression of warm emotions. 7.2 Schizoid Personality Disorder The chief characteristics of the schizoid personality disorder are an inability to develop close emotional 11305
Personality Disorders attachments to others, seclusiveness, and a reduced capacity for emotional experience and expression in interpersonal settings. Schizoid personalities neither desire nor enjoy close relationships, have little, if any, interest in sexual experiences, and do not have friends or confidants. Persons with a schizoid personality disorder are shy, show emotional coldness and detachment, and are seemingly indifferent to praise or criticism. They take pleasure in few activities and distinctly prefer solitary ones. They may function adequately at work, especially if their job requires little social contact.
7.3 Schizotypal Personality Disorder The schizotypal personality disorder is characterized by strong deficits in establishing interpersonal contact. Persons with schizotypal personality disorder show a pronounced fear of social situations and actively avoid them. They do not have close friends or confidants. Their interpersonal deficits are marked by acute discomfort with close relationships, constricted affect, cognitive and perceptual distortions, and eccentricities of behavior, as in their choice of dress and movement. Persons with this disorder often develop magical thinking and a belief in the occult, and sometimes ideas of reference or paranoid ideation may influence their behavior. Regarding language, there are unclear, strange, or stereotyped expressions and incorrect use of words, though not to the point of associative loosening and incoherence. Phenomenological, biological, genetic, and outcome data (e.g., the Danish adoption studies) show a relation between schizotypal personality disorder and schizophrenia. Therefore, it is often considered a schizophrenia-spectrum disorder.
7.4 Antisocial Personality Disorder The main characteristic of the antisocial personality disorder is a permanent and deep-seated tendency to violate and abuse the rights of others occuring from the age 15 years on. These persons show little introspection and self-criticism, lack empathy, show coldness, egotism, an exaggerated sense of entitlement, a paradoxical idea of adaptation, and weak or faulty social norms. Their behavior is marked by impulsiveness, unreliability, weak commitment, and absence of guilt feelings. They are practically beyond therapy and prognosis is generally unfavorable.
7.5 Borderline Personality Disorder The borderline personality disorder shows a pattern of interpersonal and affective instability which often 11306
leads to sudden, short-lived bursts of extreme mood swings. The affective outbursts usually take place under conditions which are perceived as threatening, such as real or imagined abandonment or rejection. Especially characteristic for borderline personality disorder is an alternating lifelong pattern of impulsively inflicting harm on oneself or others, including self-inflicted wounds, bulimic binge-and-purge attacks, periods of excessive alcohol consumption, or fights. Repetitive suicide threats and attempts are common. Unlike antisocial personalities, most patients try to restrain or suppress their impulses, although these attempts often fail. This leads to unpredictable swings between a tense holding back of affective impulses on the one hand and sudden outbursts on the other. Predominant emotions are dysphoria, anxiety, anger, and chronic feelings of emptiness. Borderline personality disorder patients are furthermore characterized by a highly unstable image and perception of themselves, which can also include aspects of gender identity, deficient orientation and plans for the future, as well as indiscriminate choice of social groups or partners. In their unstable and intense interpersonal relationships they often alternate between extremes of idealization and devaluation (splitting). A last and important area are the transient, stress-related dissociative or (pseudo)psychotic symptoms or paranoid ideas (see Borderline Personality Disorder).
7.6 Histrionic Personality Disorder The main characteristics of this personality disorder are a strong need to be at the center of attention and to gain recognition. Persons with histrionic personality disorder show a pattern of excessive emotionality with self-dramatization, theatricality, and coquetry that may be reflected in their style of speech, which is impressionistic and lacking in detail. There is a tendency for affective instability and superficiality, displaying rapidly shifting emotions. Most patients are largely suggestible and unable to maintain a steadfast pursuit of goals or value orientation. They are thus inconstant, especially in relationships. Persons with histrionic personality disorder often interact with others in an inappropriate, sexually seductive or provocative manner, using their physical appearance to draw attention to themselves. Relationships are often considered to be more intimate than they actually are. Also clinically relevant, though uncommon, are the sometimes drastic ‘pseudohysterical’ cases showing aggravation, conversion, dramaticism, and improper behavior. Manic states may be accompanied by exaggerated expression of emotion and impressionistic behavior,
Personality Disorders but can be distinguished from histrionic personality disorder by the temporary nature of these symptoms and, of course, the presence of other specific\typical symptoms of mania.
7.7 Narcissistic Personality Disorder According to DSM-IV, individuals with a narcissistic personality disorder have an exaggerated sense of self-importance, are preoccupied with fantasies of grandiosity or superiority, and require excessive admiration. They believe that they are ‘special’ and can only be understood by other special people. Patients with narcissistic personality disorder tend to exploit others involuntarily, thinking that their own qualities and abilities entitle them to special treatment. There is a lack of empathy which becomes obvious in the unwillingness to identify with the feelings and needs of others. Further symptoms are a basically fragile self-esteem and feelings of envy and distrust towards others. With a clearly increased self-awareness and egotism, social discomfort and fear of negative opinions predominate. A particular problem is a tendency for depressive crises and resolute suicidality following an imagined insult.
might result in a loss of support or approval. This leads to submissive behavior, sometimes to the point of being self-effacing and obsequious. In a relationship, these patients experience a constant fear of loss and abandonment, and urgently seek out somebody for support and care when a close relationship ends. They further show a cognitive distortion known as catastrophizing, which is a fearful and exaggerated estimate of the worst possible consequences of the relation ending.
7.10 Obsessie-compulsie Personality Disorder
The avoidant-insecure personality disorder is characterized by a pervasive pattern of low self-esteem and hypersensivity to negative evaluation. Despite their strong wish for affection, persons with avoidantinsecure personality disorder avoid social relations, being insecure, shy, tense, and anxious. Their feelings of inferiority and inadequacy in social contact lead to a severe restriction of their social skills and roles, causing them to be reluctant to take personal risks or to engage in any new activities because they may prove embarrassing. Patients with avoidant personality disorder often show restraint with intimate relationships out of a strong fear of shame.
The main characteristics of the obsessive-compulsive personality disorder are conscientiousness, perfectionism, conformism, and devotedness to work, which can be overvalued to the point of adversely affecting professional productivity and interpersonal relationships. They dislike teamwork or delegating tasks unless the others conform exactly to their way of thinking or acting. These persons show a severity and rigidity both with themselves and with others which often interferes with social functioning. They are overconscientious, inflexible, and rule-minded about matters of morality or ethics. Obsessive-compulsive personalities are unable to separate the important from the unimportant (e.g., they cannot bring themselves to throw away old, worthless objects even when these have no sentimental value) and they have an inability to make decisions. Where money is concerned, they are miserly both with themselves and with others. Of great importance are the interactions between the obsessive-compulsive personality disorder and depression. On the one hand, obsessive-compulsive personality traits can intensify during depression or first become disturbing, as in the form of depressive insecurity or difficulties in making decisions; on the other hand, obsessive-compulsive behavior can lead to difficulties, and hence to reactive depression, where obsessive-compulsive personality traits and depressive symptoms are closely interwoven.
7.9 Dependent Personality Disorder
7.11 Personality Disorders not Otherwise Specified
The dependent personality disorder is characterized by an overpowering feeling of not being able to conduct one’s own life. With a self-image of weakness and helplessness, patients will seek support from others in all situations, especially from their partners. Persons with a dependent personality disorder need others to assume responsibility in most major areas of their life. They have difficulties doing things on their own or making everyday decisions without advice from others, and fear that expressing disagreement
This category applies to personality disorders which are not designated by a DSM-IV diagnosis, but which cause clinically significant distress or impairment. It may also be used when the features of more than one Axis II disorder are present but the full criteria for any one disorder are not met. It also includes the depressive and passive-aggressive (negativistic) personality disorder, which are actually found in the appendix to DSM-IV, being currently under research to determine whether they should be included in DSM-V or not.
7.8 Aoidant Personality Disorder
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8. Concluding Remarks Concluding, it should be noted that that all typologically arranged classifications of personality disorders are merely conventions. By giving a good description of the reality of life, they may acquire a certain plausibility, self-evidence, and clinical usefulness. A nosological diagnosis and therapy of personality disorders can only be expected for special forms, and even then only as long as it can be shown that they were caused by illnesses. Most personality disorders, however, lie at the fringe of mental health. Instead of pathological processes, one has to deal with difficult developments in life due to a strained constitution and biography. First and foremost, these people need psychotherapeutic and psychogogic support. Far more than in mental illness, the manifestations in personality disorders are in great part shaped by such phenomena as will, decision-making, self-control, temper, intentionality, bearing, and character. Even more than mental illness, personality disorders require the biological and the psychopathological planes to be complemented by an anthropological dimension. See also: Borderline Personality Disorder; Obsessive–Compulsive Disorder; Personality and Health; Personality Assessment; Personality Psychology; Personality Theory and Psychopathology
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H. Saß Copyright # 2001 Elsevier Science Ltd. All rights reserved.
Personality Psychology Personality psychology is the scientific study of the whole person. The goal of personality inquiry is to provide a scientifically credible account of human individuality. Such an account considers aspects of human nature (how a person is like all other persons), individual differences between people (how a person is like some other persons), and individual uniqueness
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International Encyclopedia of the Social & Behavioral Sciences
ISBN: 0-08-043076-7
Personality Disorders 1. General Considerations Until the 1980s, both the scientific and the therapeutic aspect of personality disorders constituted a rather underdeveloped field despite their great significance for clinic and practice. Since the introduction of separate Axis II personality registration used in DSMIII (APA 1980) and the subsequent editions, DSM-IIIR and DSM-IV (APA 1987, 1994), research and publication worldwide have been considerably stepped up, leading to the inception of professional journals and scientific societies devoted solely to the field of personality disorders. As of the beginning of the twenty-first century there is a veritable deluge of theoretical concepts and therapeutic methods. More than in any other area of psychiatry, one still sees many inaccurate terms and concepts, and hard data on nosology, etiology, and pathogenesis of the various personality disorders remain rare. To be sure, there is a wealth of isolated pieces of etiological and pathogenetic knowledge on factors influencing the formation and progress of accentuated personality traits, but a comprehensive theoretical or empirical model remains as elusive as ever. We can therefore only address certain points and make some qualified references, as the exceedingly complex nature of the subject still does not allow any more definite statements. ‘Personality disorder’ is a value-free term which encompasses all those deviations from a normal personality development which require treatment. There are, necessarily, fluid borders to mental health on the one hand and mental disorder on the other. Concepts with meaning similar or identical to personality disorder are psychopathy, abnormal personality, psychopathic development, psychopathic or dissocial personality, sociopathy, etc. In Sect. 3, the author will give an overview of the historical roots of
these concepts while also addressing recent diagnostic and therapeutic developments.
2. Terms and Definitions The most comprehensive term in this field must surely be ‘personality.’ One of the most complex terms in our language, it can be defined in a variety of ways. Popularly, personality is often used as an ethicalpedagogical value judgment to mean character or temper, as when referring to someone as a strong personality or a person of character. Moral judgments are likewise made, as when we say that all human beings are persons, but we do not mean that everyone is a personality, which is characterized by a conscious and sustained exercise of thought and will. The current psychological and psychiatric definition of personality is: the sum of all mental and behavioural characteristics which make each of us a unique individual. On the other hand, a personality disorder occurs if, due to degree and\or a particular combination of psychopathologically relevant features in any of these areas, there is considerable suffering and\or lasting impairment of social adaptiveness (Saß 1987). According to DSM-IV, only when personality traits are inflexible and maladaptive and cause either significant functional impairment or subjective distress do they constitute personality disorders (Table 1).
3. A History of the Concepts of Abnormal Personality The concept of psychopathy arises from a confluence of views entertained by the French, the German, and the Anglo-American psychiatric traditions. Sociocultural factors caused these conceptions of psychopathy to develop more or less independently well into the twentieth century. The following section deals with all three traditions.
Table 1 General diagnostic criteria for personality disorder A. A lasting pattern of inner experiences and behavior which deviates markedly from the expectations of the culture the individual lives in. This pattern is manifested in two or more of the following areas: 1. cognition (i.e., ways of perceiving and interpreting oneself, others, and events) 2. emotiveness (i.e., range, intensity, stability, and appropriateness of emotional response) 3. interpersonal functioning 4. impulse control B. The pattern is inflexible and pervasive across a broad range of personal and social situations. C. The pattern leads to clinically significant distress or impairment in social, occupational, or other important areas. D. The pattern is stable and longlasting, and its onset can be traced back to adolescence or early adulthood. E. The pattern is not better accounted for as a manifestation or consequence of another mental disorder. F. The pattern is not due to direct physiological effects of a substance (e.g., drug or medication) or a general medical condition (e.g., head trauma).
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Personality Disorders 3.1 French Concepts Pinel’s (1809) concept of manie sans deT lire includes instances of ‘deranged personality’ and can be looked upon as the beginning of the scientific study of personality disorder as a nosological entity. In the eighteenth century, all mental diseases were regarded as fundamental disturbances of the intellect. Pinel was one of the first to point out that in some disorders, the emotions were primarily involved. Nevertheless, the early nineteenth-century definitions of madness remained centered mostly around the intellect. Indeed, to this day, psychiatric phenomenology neglects the disorders of affect. Esquirol (1838) developed the concept of monomania, a diagnostic category based on the partial, primary–and independent–involvement of the intellectual, emotional, and\or volitional functions of the mind, including states where a single behavioral disturbance became the sole diagnostic criterion for the condition (e.g., pyromania or kleptomania). Not surprisingly, monomania was one of the sources of the concept of psychopathy. Since its inception, the concept of monomania has been criticized on clinical and medicolegal grounds both in France and abroad. Morel’s (1857) idea of degeneration was a pseudobiological account strongly tinged with the idea of original sin. He proposed that: (a) degenerative alterations are pathological deviations from the normal; (b) mental illness is mostly hereditary; and (c) degeneration is both quantitative and qualitative, i.e., new disorders may appear. According to Morel’s model, all types of mental and neurological disorders can be traced back to one common hereditary origin. His idea of progressive and polymorphic degeneration was accepted as an explanation of mental illness.
3.2 Anglo-American Concepts Prichard (1835) defined moral insanity as ‘madness consisting of a morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions and natural impulses without any remarkable disorder or defect of the interest or the reasoning faculties, and particularly without any illusion or hallucinations.’ During the early nineteenth century, the word ‘moral’ had many uses, in the psychological sense chiefly to denote the affective and the conative (rather than the purely intellectual) functions. The British concept of psychopathy was shaped by D. K. Henderson (1939), who saw ‘psychopathic states’ as a condition of ‘constitutional abnormality.’ In contrast to other (especially German) psychiatrists, he thought of constitution as deriving from both heredity and environment. There were three psychopathic states, the predominantly aggressive, the inadequate, and the creative. The former two were 11302
characterized by antisocial traits and soon became part of the Anglo-American concept of personality disorder. Rush (1812) was the first Anglo-American psychiatrist to study individuals whose disturbances were primarily characterized by irresponsibility and aggressiveness; who showed, as he put it, a ‘moral alienation of the mind.’ He believed that these reprehensible acts were the manifestations of mental disease, that they were unmotivated and driven by ‘a kind of involuntary power.’ Partridge (1930) defined the concept of psychopathic personality as a persistent maladjustment which cannot be corrected by ordinary methods of education or by punishment. From Partridge on, the emphasis has been on description, and etiological speculation has taken the back seat. To this day, a view of psychopathy as sociopathy dominates AngloAmerican psychiatry. A parallel concept, that of the antisocial personality disorder, appeared in DSM-III (APA 1980) and was kept in DSM-III-R (APA 1987) and DSM-IV (APA 1994).
3.3 German Concepts In Germany, the concept of psychopathy embraces most forms of abnormal personality. The current German definition can be traced back to Koch, whose monograph Psychopathische Minderwertigkeiten [Psychopathic Inferiorities] (1891–93) was as decisive in shaping the concept of abnormal personality in Germany as Pinel’s work was in France, Rush’s in the USA, and Prichard’s in Great Britain. German ideas of psychopathy also influenced French and AngloAmerican views, especially after the 1930s, when many German-speaking psychiatrists and psychoanalysts emigrated to these countries. Kraepelin’s concept of psychopathy, influenced by the French theory of degeneration, formed the basis of Kurt Schneider’s typology, and via the latter, of today’s German doctrine of psychopathy. In successive editions of his textbook, Kraepelin elaborated on his concept of ‘psychopathic states’ as abnormal personality. He employed the term ‘psychopathic personalities’ in a predominantly social sense, including also innate delinquents, unstable liars, swindlers, and pseudo-querulous individuals. During this period, there also appeared various ‘systematic’ typologies to draw ‘psychopathic’ categories from prototypic personality theories. Foremost amongst these is Kretschmer’s konstitutionstypologisches Modell (1919). He suggested a specific correlation between body type and personality. Kretschmer (1921) and Ewald (1924) also introduced the concept of Reaktionstypologiento account for specific styles of dealing with experience. Systematic typologies lost influence after the publication of Schneider’s monograph in 1923.
Personality Disorders Kurt Schneider is known especially for his famous monograph Die psychopathischen PersoW nlichkeiten [The Psychopathic Personalities] (1923). He used a ‘typological approach’ to personality types and tried to avoid value judgments by not including antisocial forms of behavior. Schneider defines abnormal personalities as statistical deviations from an estimated average norm, although the concept of norm is poorly formulated in his work. In his model, eminently creative and intelligent individuals are also abnormal; hence, not all abnormal personalities could be said to have psychiatric implications. Schneider defined ‘psychopathic personalities [as] those abnormal personalities that suffer from their abnormality or whose abnormality causes society to suffer.’ It is very important to stress that Schneider did not consider psychopathy a form of mental illness, which by definition must be associated with a brain lesion or a recognized disease process. In this, he opposed Kretschmer and Bleuler, who believed that psychosis and psychopathy were just different degrees on the same spectrum of derangement. Schneider’s doctrine influenced all subsequent typologies, and current classification systems include essential parts of his concept of psychopathy. The appendix to DSM-IV even includes the ‘depressive type’ to encourage further research on this subject.
4. Epidemiology, Course of Illness, and Prognosis According to German and American studies, 3–10 percent of the general population meet the diagnostic criteria of a personality disorder. Compared to numbers in earlier manuals, these are rather high. However, simply meeting these criteria need not imply that the individuals in question are so dysfunctional and impaired as to require treatment. Prevalence rates are much higher among unselected psychiatric patients. After the first classification systems appeared, clinical studies found surprisingly high frequencies for personality disorders—50–80 percent—while more recent studies reported prevalence rates of 40–60 percent on the average. Forensicpsychiatric random samples yielded prevalence rates of up to 80 percent. In a large-scale international WHO study (Loranger et al. 1994), 39.5 percent of 716 psychiatric patients examined showed at least one personality disorder according to ICD-10, individual prevalence rates falling between 15.2 percent (anxious personality disorder) and 1.8 percent (schizoid personality disorder). Clinical experience has shown that increasing age and decreasing vitality tend to attenuate ‘sharp’ personality traits, especially those which seriously impair social functioning, such as inconstancy, antisocial behavior, and impulsiveness. Other traits can become sharper with advancing age, above all obstinacy and rigidity.
The prognosis depends on the particular type of personality disorder, on any eventual comorbidity, and on the degree of severity. Further prognostic factors are psychostructural maturity as well as the level of psychological and social functioning. Prognostically favorable characteristics are motivation, trust in others, flexibility, and insight into one’s own role in difficulties with interpersonal contact. Cases are complicated by concomitant illness, especially addiction and affective disorders. Thus, the mortality rate for patients with personality disorders and substance abuse is three times that of patients with a single personality disorder (Bohus et al. 1999). Generally speaking, the risk of suicide is three times higher for individuals with a personality disorder than for the general population, with borderline, narcissistic, and antisocial personality disorders showing the highest incidence. These groups also show the highest degree of psychosocial impairment, with deviant actions, decreased capacity for work, and deficient skills at establishing dependable interpersonal relations.
5. Diagnostic Problems In view of the complexity of the concept of personality, it becomes clear that difficulties exist in distinguishing between a normal range of varying personality traits (as many as 1800 features have been identified which might aid in characterizing possible personality traits) and personality disorders which might be of psychiatric relevance. Towards the end of the twentieth century there has been a trend towards reducing the myriad personality traits to 3, 5, or 7 essential dimensions from which the individual variations can be derived (Table 2). Interestingly, the factor structure of behavior and its abnormalities seems to be essentially the same in the general population and in clinical groups of behaviourally abnormal patients. The differences lie mainly in the degree and the particular combination of the various dimensions, not in a fundamental difference of personality traits. Categorical classifications are based on somatic models where the various diseases can be clearly separated from each other; personality disorders, however, show fluid borders, both between the various types and towards normality. Dimensional personality models, developed especially for scientific research, measure degree—or severity—by means of trait factors and thus assign it a position corresponding to its extent along various dimensional axes. It must be kept in mind that there is no inherent qualitative difference in personality traits between the general population and clinical groups of patients with personality disorders, only a difference in degree or severity, or eventually in a particular combination of traits. By means of factor analyses, these personality models 11303
Personality Disorders Table 2 Factor models of dimensional personality description 3-factor personality models
5-factor personality models
7-factor personality model
Eysenck (1977) neuroticism extroversion psychoticism
Costa and McCrae (1990) extroversion neuroticism agreeability conscientiousness
Cloninger (1994) harm avoidance novelty seeking reward dependence persistence
Millon (1981) joy\pain self\other-centeredness activity\passivity
openness to new experiences
self-directedness cooperativeness self-transcendence
von Zerssen (1988) extroversion neuroticism aggressivity conscientiousness openness (devoutness)
Widiger et al. (1994) free-floating anxiety\eccentric behavior assertiveness\dominance social integration DSM-IV (1994) eccentricity dramatic affect fear Table 3 Classification of personality disorders DSM-IV paranoid schizoid schizotypical antisocial borderline histrionic narcissistic avoidant obsessive-compulsive not otherwise specified
ICD-10 paranoid schizoid — dissocial impulsive histrionic — anxious obsessive-compulsive not otherwise specified and others
reduce the myriad personality traits to a few essential personality dimensions, independent of culture, from which the individual variants may then be derived. However, given the clinical usefulness of the categorical approach, and hence the widespread hesitancy in abandoning it, recent efforts have tended more towards a synthesis of the categorical and dimensional elements. The classification systems used today, which increasingly determine personality diagnosis, are the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), published by the American Psychiatric Association (APA 1994), and the International Classification of Diseases, 10th Edition (ICD10), published by the World Health Organization (WHO 1992). Both are used for making diagnoses, thus forcing clinicians, practitioners, and researchers 11304
alike to opt for one of the two systems. While the two systems resemble each other in many aspects, there are others where they completely disagree. Table 3 gives an overview of the most important discrepancies (see Differential Diagnosis in Psychiatry).
6. Therapy of Personality Disorders Following a thorough anamnesis, there are two main options: psychotherapy and therapy with psychopharmaceuticals. In detail:
6.1 Thorough Initial Examination The general procedure in treating personality disorders follows the usual rules of psychiatry. It is important that a thorough initial examination be done, with an exact medical and psychiatric anamnesis. Due to the lacking self-dystonia, the patient’s self-perception may be lower than in cases showing acute psychopathological symptoms. Hence, anamnesis by significant others can also be helpful in assessing social conflict when dealing with personality disorders.
6.2 Psychotherapy of Personality Disorders In the psychotherapy of personality disorders, the choice of the therapeutic procedure will depend on the particular form of personality disorder, its severity, as well as any concomitant mental disorders. Currently accepted forms of therapy include: cognitive\
Personality Disorders behavioral therapeutic and supportive techniques, depth psychology, disorder-oriented and interdisciplinary therapies with treatments for specific problem areas of a personality, pedagogic or psychogogic therapies, sociotherapy, and dialogue sessions for couples or families. An important element of every therapy is that disorder-related behavior and interaction abnormalities also be dealt with in the patient– therapist relation, so that a big step in the therapy will consist in opening up new self-awareness and possibilities of change to the patient via the therapeutic interaction itself. Psychotherapy of personality disorders usually requires a long time, since it involves a gradual reshaping of long-lasting characteristics in the areas of experiencing, feeling, and social behavior. Short-term crisis intervention can also be helpful if the problematic personality traits bring situations to a head and cause social conflicts. Building up a regular, trusting relation is of great importance. The frequency usually chosen is one to two hours per week. Aside from discussing current life conflicts, exploring past issues is also important as it can outline the development of the personality traits which are at the root of the trouble. Group therapy is well suited for many personalities (provided they are not seriously deranged) since observing other patients allows learning by example. The positive feedback or criticism from the other group members can reinforce desirable behavior and put undesirable behavior in perspective (see Cognitie and Interpersonal Therapy: Psychiatric Aspects). 6.3 Pharmacotherapy The second important therapy for personality disorders, one which in recent years has been increasingly developed, consists in the use of psychopharmaceuticals. It rests on the assumption that personality disorders can also have a biological cause which may be either constitutional or due to functional anomalies which were acquired later. The aim is to reduce the vulnerability to affective and cognitive dysfunctions neurochemically and to modify certain behavioral reaction patterns, the target symptoms or syndromes being: (a) the characteristics of the personality disorder (e.g., cognitive deficits, impulsive behavior, strong mood swings); (b) complications due to the personality disorder (e.g., suicidal tendencies, aggressivity towards others, deficient social skills); and (c) the axis I disorders associated with these (e.g., depressive or anxiety syndromes, compulsion, eating disorders). The pharmacological treatment of personality disorders is by no means an alternative to psychotherapy. Rather, it is used in support and preparation for psychotherapy, as well as for crisis intervention (especially with suicidal tendencies).
Due to the dangers of side effects and habituation or dependence associated with it, long-term pharmaceutical therapy of personality disorders must always be viewed critically. Likewise, the therapist must be aware of the danger that the patient may start believing in external control or attribute therapeutic success solely to the action of the psychopharmaceuticals. Moreover, there are special counterindications: alcohol and medicine abuse, social unreliability, bad compliance (incoming to therapy or in taking the medication). Due to the danger of late dyskinesias following long-term use, neuroleptics should be employed judiciously and substances of low or medium potency be considered. With benzodiazepines there is a particularly high risk of addiction, which is why they are generally not indicated for the treatent of personality disorders. Medication can also be tricky with some patients, who may harbor unrealistical expectations or fear to lose control. Due to these difficulties, such individuals may have to be admitted as inpatients before psychopharmaceutical therapy can be initiated (see Psychotherapy and Pharmacotherapy, Combined ).
7. The Most Important Personality Disorders According to DSM-IV This section offers classification of personality disorders, followed by an overview of the most important forms of abnormal personalities in DSM-IV. Please consult the manual for a complete list of the diagnostic criteria for the following personality disorders. The differential diagnosis refers solely to the Axis-I disorders (because of limited space). 7.1 Paranoid Personality Disorder According to DSM-IV, persons with a paranoid personality disorder show a pattern of distrust and suspicion, reading malevolence into the motives of others without sufficient basis for that supposition. They often doubt the loyalty of their friends, partners, or associates and are reluctant to confide in others for fear that the information might be used against them. Persons with a paranoid personality disorder quickly react to perceived insults with excessive force, counterattacks, and\or long-lasting enmity. Mistakes are usually blamed on others. Persons with this disorder usually have recurrent suspicions regarding the fidelity of their spouse or partner. These persons are easily insulted, emotionally rigid, and persevering while at the same time appearing humorless and restrictive in their expression of warm emotions. 7.2 Schizoid Personality Disorder The chief characteristics of the schizoid personality disorder are an inability to develop close emotional 11305
Personality Disorders attachments to others, seclusiveness, and a reduced capacity for emotional experience and expression in interpersonal settings. Schizoid personalities neither desire nor enjoy close relationships, have little, if any, interest in sexual experiences, and do not have friends or confidants. Persons with a schizoid personality disorder are shy, show emotional coldness and detachment, and are seemingly indifferent to praise or criticism. They take pleasure in few activities and distinctly prefer solitary ones. They may function adequately at work, especially if their job requires little social contact.
7.3 Schizotypal Personality Disorder The schizotypal personality disorder is characterized by strong deficits in establishing interpersonal contact. Persons with schizotypal personality disorder show a pronounced fear of social situations and actively avoid them. They do not have close friends or confidants. Their interpersonal deficits are marked by acute discomfort with close relationships, constricted affect, cognitive and perceptual distortions, and eccentricities of behavior, as in their choice of dress and movement. Persons with this disorder often develop magical thinking and a belief in the occult, and sometimes ideas of reference or paranoid ideation may influence their behavior. Regarding language, there are unclear, strange, or stereotyped expressions and incorrect use of words, though not to the point of associative loosening and incoherence. Phenomenological, biological, genetic, and outcome data (e.g., the Danish adoption studies) show a relation between schizotypal personality disorder and schizophrenia. Therefore, it is often considered a schizophrenia-spectrum disorder.
7.4 Antisocial Personality Disorder The main characteristic of the antisocial personality disorder is a permanent and deep-seated tendency to violate and abuse the rights of others occuring from the age 15 years on. These persons show little introspection and self-criticism, lack empathy, show coldness, egotism, an exaggerated sense of entitlement, a paradoxical idea of adaptation, and weak or faulty social norms. Their behavior is marked by impulsiveness, unreliability, weak commitment, and absence of guilt feelings. They are practically beyond therapy and prognosis is generally unfavorable.
7.5 Borderline Personality Disorder The borderline personality disorder shows a pattern of interpersonal and affective instability which often 11306
leads to sudden, short-lived bursts of extreme mood swings. The affective outbursts usually take place under conditions which are perceived as threatening, such as real or imagined abandonment or rejection. Especially characteristic for borderline personality disorder is an alternating lifelong pattern of impulsively inflicting harm on oneself or others, including self-inflicted wounds, bulimic binge-and-purge attacks, periods of excessive alcohol consumption, or fights. Repetitive suicide threats and attempts are common. Unlike antisocial personalities, most patients try to restrain or suppress their impulses, although these attempts often fail. This leads to unpredictable swings between a tense holding back of affective impulses on the one hand and sudden outbursts on the other. Predominant emotions are dysphoria, anxiety, anger, and chronic feelings of emptiness. Borderline personality disorder patients are furthermore characterized by a highly unstable image and perception of themselves, which can also include aspects of gender identity, deficient orientation and plans for the future, as well as indiscriminate choice of social groups or partners. In their unstable and intense interpersonal relationships they often alternate between extremes of idealization and devaluation (splitting). A last and important area are the transient, stress-related dissociative or (pseudo)psychotic symptoms or paranoid ideas (see Borderline Personality Disorder).
7.6 Histrionic Personality Disorder The main characteristics of this personality disorder are a strong need to be at the center of attention and to gain recognition. Persons with histrionic personality disorder show a pattern of excessive emotionality with self-dramatization, theatricality, and coquetry that may be reflected in their style of speech, which is impressionistic and lacking in detail. There is a tendency for affective instability and superficiality, displaying rapidly shifting emotions. Most patients are largely suggestible and unable to maintain a steadfast pursuit of goals or value orientation. They are thus inconstant, especially in relationships. Persons with histrionic personality disorder often interact with others in an inappropriate, sexually seductive or provocative manner, using their physical appearance to draw attention to themselves. Relationships are often considered to be more intimate than they actually are. Also clinically relevant, though uncommon, are the sometimes drastic ‘pseudohysterical’ cases showing aggravation, conversion, dramaticism, and improper behavior. Manic states may be accompanied by exaggerated expression of emotion and impressionistic behavior,
Personality Disorders but can be distinguished from histrionic personality disorder by the temporary nature of these symptoms and, of course, the presence of other specific\typical symptoms of mania.
7.7 Narcissistic Personality Disorder According to DSM-IV, individuals with a narcissistic personality disorder have an exaggerated sense of self-importance, are preoccupied with fantasies of grandiosity or superiority, and require excessive admiration. They believe that they are ‘special’ and can only be understood by other special people. Patients with narcissistic personality disorder tend to exploit others involuntarily, thinking that their own qualities and abilities entitle them to special treatment. There is a lack of empathy which becomes obvious in the unwillingness to identify with the feelings and needs of others. Further symptoms are a basically fragile self-esteem and feelings of envy and distrust towards others. With a clearly increased self-awareness and egotism, social discomfort and fear of negative opinions predominate. A particular problem is a tendency for depressive crises and resolute suicidality following an imagined insult.
might result in a loss of support or approval. This leads to submissive behavior, sometimes to the point of being self-effacing and obsequious. In a relationship, these patients experience a constant fear of loss and abandonment, and urgently seek out somebody for support and care when a close relationship ends. They further show a cognitive distortion known as catastrophizing, which is a fearful and exaggerated estimate of the worst possible consequences of the relation ending.
7.10 Obsessie-compulsie Personality Disorder
The avoidant-insecure personality disorder is characterized by a pervasive pattern of low self-esteem and hypersensivity to negative evaluation. Despite their strong wish for affection, persons with avoidantinsecure personality disorder avoid social relations, being insecure, shy, tense, and anxious. Their feelings of inferiority and inadequacy in social contact lead to a severe restriction of their social skills and roles, causing them to be reluctant to take personal risks or to engage in any new activities because they may prove embarrassing. Patients with avoidant personality disorder often show restraint with intimate relationships out of a strong fear of shame.
The main characteristics of the obsessive-compulsive personality disorder are conscientiousness, perfectionism, conformism, and devotedness to work, which can be overvalued to the point of adversely affecting professional productivity and interpersonal relationships. They dislike teamwork or delegating tasks unless the others conform exactly to their way of thinking or acting. These persons show a severity and rigidity both with themselves and with others which often interferes with social functioning. They are overconscientious, inflexible, and rule-minded about matters of morality or ethics. Obsessive-compulsive personalities are unable to separate the important from the unimportant (e.g., they cannot bring themselves to throw away old, worthless objects even when these have no sentimental value) and they have an inability to make decisions. Where money is concerned, they are miserly both with themselves and with others. Of great importance are the interactions between the obsessive-compulsive personality disorder and depression. On the one hand, obsessive-compulsive personality traits can intensify during depression or first become disturbing, as in the form of depressive insecurity or difficulties in making decisions; on the other hand, obsessive-compulsive behavior can lead to difficulties, and hence to reactive depression, where obsessive-compulsive personality traits and depressive symptoms are closely interwoven.
7.9 Dependent Personality Disorder
7.11 Personality Disorders not Otherwise Specified
The dependent personality disorder is characterized by an overpowering feeling of not being able to conduct one’s own life. With a self-image of weakness and helplessness, patients will seek support from others in all situations, especially from their partners. Persons with a dependent personality disorder need others to assume responsibility in most major areas of their life. They have difficulties doing things on their own or making everyday decisions without advice from others, and fear that expressing disagreement
This category applies to personality disorders which are not designated by a DSM-IV diagnosis, but which cause clinically significant distress or impairment. It may also be used when the features of more than one Axis II disorder are present but the full criteria for any one disorder are not met. It also includes the depressive and passive-aggressive (negativistic) personality disorder, which are actually found in the appendix to DSM-IV, being currently under research to determine whether they should be included in DSM-V or not.
7.8 Aoidant Personality Disorder
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8. Concluding Remarks Concluding, it should be noted that that all typologically arranged classifications of personality disorders are merely conventions. By giving a good description of the reality of life, they may acquire a certain plausibility, self-evidence, and clinical usefulness. A nosological diagnosis and therapy of personality disorders can only be expected for special forms, and even then only as long as it can be shown that they were caused by illnesses. Most personality disorders, however, lie at the fringe of mental health. Instead of pathological processes, one has to deal with difficult developments in life due to a strained constitution and biography. First and foremost, these people need psychotherapeutic and psychogogic support. Far more than in mental illness, the manifestations in personality disorders are in great part shaped by such phenomena as will, decision-making, self-control, temper, intentionality, bearing, and character. Even more than mental illness, personality disorders require the biological and the psychopathological planes to be complemented by an anthropological dimension. See also: Borderline Personality Disorder; Obsessive–Compulsive Disorder; Personality and Health; Personality Assessment; Personality Psychology; Personality Theory and Psychopathology
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H. Saß Copyright # 2001 Elsevier Science Ltd. All rights reserved.
Personality Psychology Personality psychology is the scientific study of the whole person. The goal of personality inquiry is to provide a scientifically credible account of human individuality. Such an account considers aspects of human nature (how a person is like all other persons), individual differences between people (how a person is like some other persons), and individual uniqueness
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ISBN: 0-08-043076-7