1. The personality disorders (p. 235) Personality disorders involve longstanding, inflexible, and maladaptive behavior patterns that produce personal and social difficulties, personal distress, or problems in functioning in society. They account for about 5 to 15 percent of admissions to hospitals and outpatient clinics; lifetime prevalence for all of them is 10 to 13 percent. Men are more likely than women to be diagnosed with some of the personality disorders, whereas women are more likely to be diagnosed with others. There are reasons to suggest that the gender distribution may be due to bias in diagnosing. Diagnosis is made on Axis II of the DSM, but diagnosis is difficult because symptoms represent extremes of normal personality traits, are rarely stable across situations, and may overlap with other disorders. Further, clinicians often render diagnoses inconsistent with DSM criteria. To be considered disorders personality patterns must cause significant impairment in functioning or subjective distress, a constellation of characteristics must be found, the personality pattern must characterize the persons current and long-term functioning, and the pattern must not be limited to episodes of illness. Further, there may be questions about the universality of these disorders and the cultural validity of DSM-IV-TR personality disorders.
2. Etiological and treatment considerations for personality disorders (p. 237) There is insufficient empirical research pertaining to the personality disorders. Researchers have found the five-factor model (FFM) may be a good way to describe personality and personality disorders. The five factors are neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. Personality disorders may be exaggerations of these traits. Heredity partially explains the development of personality styles, but family environment is also crucial. As varied as the theories of cause may be, so are the treatment approaches. Many people with personality disorders resist treatment, and there is little research on success rates for the full range of disorders. DSM-IV-TR lists ten personality disorders in three clusters: odd or eccentric behaviors; dramatic, emotional, or erratic behaviors; and anxious or fearful behaviors.
3. Disorders characterized by odd or eccentric behaviors (p. 238) Paranoid personality disorder is characterized by suspiciousness, hypersensitivity, and reluctance to trust others. DSM-IV-TR estimates the prevalence of paranoid personality disorder as between 0.5 and 2.5 percent. Psychodynamic explanations emphasize the role of projection in the disorder, Schizoid personality disorder is marked by aloofness and voluntary social isolation. To avoid conflicts and emotional involvements, these people withdraw from others or comply superficially with requests from others. The relationship between this disorder and schizophrenia is not clear. Schizotypal personality disorder involves odd thoughts and actions, such as speech oddities or beliefs in personal magical powers, and poor interpersonal relationships. It occurs in approximately 3 percent of the population. Odd though their behaviors are, individuals with this disorder are not as impaired as people with schizophrenia. There is some evidence of genetic links between the two disorders.
4. Disorders characterized by dramatic, emotional, or erratic behaviors (p. 243) Histrionic personality disorder is marked by self-dramatization, exaggerated emotional expression, and attention-seeking behaviors. It affects 1 to 3 percent of the population. Biological factors, such as autonomic or emotional excitability, and environmental factors, such as parental reinforcement of attention-seeking behaviors, may influence the development of histrionic personality disorder. Narcissistic personality disorder involves an exaggerated sense of self-importance, exploitative attitude, and lack of empathy. People with this disorder may use denial to ward off feelings of inferiority. Prevalence is about 1 percent. Antisocial personality disorder involves exploitation of others, irresponsibility, and guiltlessness, and is far more common in men than women. Borderline personality disorder is characterized by extreme fluctuations in mood: friendly one day, hostile the next. People with this disorder also lack identity, feel lost and empty; they engage in self-destructive behaviors. The core aspects seem to be difficulty in regulating emotions, and intense, unstable relationships. This disorder is the most commonly diagnosed personality disorder and is estimated to occur in 2 percent of the population, with females three times more likely to receive the diagnosis than men. The disorder has been conceptualized from a psychodynamic perspective (object splittingeither people are completely good or completely bad), a social learning viewpoint (conflict between attachment to others and avoidance of such engagement), and a cognitive approach (distorted attributions and assumptions). There is much more theory than research evidence.
5. Disorders characterized by anxious or fearful behaviors (p. 247) Individuals with avoidant personality disorder desire interpersonal contact but fear social rejection; they avoid situations that might lead to criticism. Their primary defense mechanism is fantasy, and their social skills are weak. Prevalence is about 1 percent of the population, with no gender differences and there seems to be disagreement about whether it is a separate diagnosis from social phobia or an extension of that disorder. People with dependent personality disorder are characterized by an extreme lack of self-confidence, reliance on others for decisions, and an ingrained assumption that they are inadequate and must be cared for by others. Prevalence of the disorder is about 2.5 percent. Obsessive-compulsive personality disorder is marked by excessive perfectionism, devotion to details, rigidity, and indecisiveness. Unlike obsessive-compulsive disorder, there are no recurrent unwanted thoughts or ritualistic actions. Prevalence is about 1 percent, with twice as many males as females having the disorder.
6. Antisocial personality disorder (p. 250) Other terms for this disorder are sociopathic and psychopathic personality. Cleckleys (1976) classic description of antisocial personality disorder includes superficial charm, shallow emotions and lack of guilt, unplanned actions, failure to learn from experiences, absence of anxiety, and irresponsibility. DSM-IV-TR criteria do not include lack of anxiety, shallow emotions, failure to learn, and superficial charm. They do include being at least 18 years old, having a history of breaking laws since age 15, aggressiveness, impulsivity, and lack of remorse. Research by Hare et al. using their Psychopathic Checklist-Revised (PCL-R), suggests three factors: arrogant and deceitful interpersonal style, deficient affective experience, and impulsive and irresponsible behavioral style. A subscale of the PCL-R is a good predictor of violence. Cleckleys traits seem to be retained as psychopathic criminals age, the DSM-IV-TR characteristics seem to decline with age. The prevalence in the United States is about 2 percent, with three times more men than women being diagnosed. Although there are socioeconomic differences, there are no racial differences in prevalence. Criminals are not necessarily antisocial personalities; they often have a sense of loyalty to others and feelings of guilt, which are missing in antisocial personalities. Primary psychopaths feel no guilt over antisocial behaviors, secondary psychopaths do.
7. Explanations of antisocial personality disorder (p. 252) Psychoanalytic theory stresses a lack of parental identification and consequent superego deficiency. Family and socialization theory stresses parental reject ' ion and modeling of antisocial behavior by fathers. Poor parental supervision predicts delinquency better than poverty or divorce. Genetic influences are supported by evidence of MZ twin concordance and greater likelihood of the disorder in the adoptees of antisocial biological parents. Central nervous system theory maintains that antisocial personalities have abnormal EEGs. Autonomic nervous system theory stresses antisocial personalities low anxiety level and thrill seeking to counteract general underarousal. Lykken and Farley suggest that psychopaths and heroes have traits of fearlessness or thrill seeking in common (they are called Big Ts). Little ts prefer certainty and low conflict. Antisocial personalities are also influenced by the kind and certainty of punishment (monetary loss is effective; shock and verbal are not). Psychopaths may also have an emotional imagery deficit: they have trouble forming associations between perceptual memory and responding.
8. Treatment of antisocial personality disorder (p. 259) Owing to their lack of anxiety, antisocial personalities are poorly motivated to change. Behavior modification and cognitive therapies have been somewhat helpful, but effective treatments for antisocial personality are rare. The focus might be placed on youths, who are more amenable to treatment.
9. Disorders of impulse control (p. 260) Impulse control disorders are unrelated to personality disorders and are included in this chapter for the sake of convenience. These disorders involve an inability to resist the temptation to perform some act, a feeling of tension before the act, and a sense of excitement, release, and sometimes guilt afterward. Intermittent explosive disorder is marked by brief episodes of losing control, leading to destruction of property or assaults on other people. Kleptomania involves stealing, even when the article is not needed. It appears to be more common in women than men. Pathological gambling involves an inability to resist impulses to gamble and afflicts 1 to 3 percent of American adults. Cognitive-behavioral approaches focus on the erroneous beliefs gamblers have about their ability to influence outcomes that are governed by chance. Pyromaniacs repeatedly and deliberately set fires without the motive of revenge. Children who are fire-setters are more often boys than girls and have problems with impulsivity and hostility. Trichotillomania is the inability to refrain from pulling out ones hair. It is probably more common in women than men; about 1 percent of college students have a past or current history of the disorder.
10. Etiology and treatment of impulse control disorders (p. 265) Little research has been done on the causes of these disorders. In some ways, impulse control disorders are similar to obsessive compulsive, substance abuse, and sexual disorders. Psychodynamic theory stresses sexual symbolism; behavioral theory focuses on classical conditioning, reinforcement, and modeling; and biological theory points out greater thrill seeking in pathological gamblers. Lesieur (1989) notes two schools of thought: impulse control problems range on a continuum, or they are disease-like (one either has the disorder or not). Behavioral and cognitive treatments have had some success, as have insight therapies and self-help groups such as Gamblers Anonymous.