The Practice of Clinical Psychology Worksheet


Learning Objectives

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After reading this chapter, you should be able to:

• Name and briefly describe the criteria used to differentiate normal from abnormal manifes- tations of behavior, thought, and affect.

• Identify the most common diagnostic system used in the United States and some of the prevalence rates for personality disorders.

• Name and define the DSM-5 personality dis- orders found in clusters A, B, and C.

• Discuss the different prevalence rates for the personality disorders, especially with respect to sex differences.

• Identify some of the alternative models for categorizing personality disorders, such as those proposed by the International Classifi- cation of Diseases, Millon, and the Five Factor Model.

• Name and briefly describe some measures of personality commonly used in clinical set- tings, particularly the MMPI–2.

Personality and Psychopathology 10

Chapter Outline Introduction

10.1 Defining Personality Disorders • Criteria to Define Abnormal Functioning • Criteria for Defining Problematic Functioning

in Terms of Personality • Conceptualizing Personality Disorders

10.2 Types of Personality Disorders • Cluster A Personality Disorders • Cluster B Personality Disorders • Cluster C Personality Disorders • Other Specified Personality Disorder • The Prevalence of Personality Disorders • Alternative Organizational Models for the

Personality Disorders • Questioning the Legitimacy of Mental Illness

• Explain why we need measures of response tendencies when assessing personality in clinical settings.

• Name some common validity scales used to assess over- and under-reporting tendencies.

• Read a case study and interpret some basic personality data in order to diagnose the patient, and provide a theo- retical account of their etiology based on one or more of the theories presented in this text.

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Introduction Try to recall the last time you took an exam. How many pencils did you bring with you? If you didn’t bring any, you might be considered unprepared. If you brought one, you might still be considered to be acting carelessly, given that the point might break. Perhaps you brought one extra, just in case. But what if you brought three, four, or five backup pencils? Would this suggest that you were acting in an obsessive manner, possibly demonstrating symptoms of obsessive-compulsive personality disorder? These are subtle distinctions, and it’s hard to decide at what point behavior—even a simple, mundane behavior, such as bringing pencils to a test—goes from normal to abnormal, or nonpathological to problematic.

This example illustrates the complexity of differentiating subtle variations of behavior, ranging from “normal” personality functioning to personality disorders. Three extra pencils (or any particular number of pencils) doesn’t necessarily mean anything diagnostically, but it might, especially if you spent too much of your exam preparation time collecting and sharpening pencils or if you spent much of the time taking the exam worrying about the durability of your pencils and whether you brought enough.

So far we’ve explored how personality functions. In this chapter, we turn our attention to the symptoms and development of personality dysfunction. The his- tory of personality psychology developed hand in hand with clinical psychology. Therefore, it is somewhat artificial to consider these two areas as distinct. Indeed, throughout this text, there have been both implicit and explicit references to psy- chopathology (e.g., depression, anxiety, personality disorders, etc.). In this chap- ter, we will more directly deal with personality disorders, the criteria by which they are defined and diagnosed, and assessment tools commonly used to assess per- sonality disorders. We will conclude the chapter with two case studies that bring these issues together with the explanatory accounts forwarded in earlier chapters.

As we explore the current thinking regarding personality disorders, it behooves us to remember our discussion about defining “normal” from Chapter One. Much of this chapter deals with abnormal personality as it is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychi- atric Association (APA), and while many of the behaviors discussed in this chapter are clearly problematic, it is important to remember that “normal” is a relative, culturally defined construct. And when it comes to defining what is normal or abnormal in personality, our culture has collectively decided to let the American Psychiatric Association decide.

10.3 Assessing Personality Disorders • The Minnesota Multiphasic Personality

Inventory (MMPI–2) • Personality Assessment Inventory

(PAI-) • The Millon Clinical Multiaxial Inven-

tory-III (MCMI-III/) • Common Features of Each Assessment

10.4 Case Illustrations • Case 1: Bob G. • Case 2: Samantha K.



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10.1 Defining Personality Disorders

Personality disorders share many of the same defining features with the concept of personal-ity; both, for example, have a stable pattern of behavior, affect, and cognition that charac-terize the individual. But to be considered a personality disorder there must also be a clear indication that a person’s behavior, affect, or cognition is problematic in some way—maladaptive or rigid, for example—and compromises the individual’s level of functioning. Personality disorders can be differentiated from clinical disorders that do not involve personality (e.g., alcohol depen- dence, schizophrenia, depression, anxiety, etc.), in that the former are typically more longstanding and pervasive, and they typically manifest in more subtle ways.

One of the biggest challenges to identifying and diagnosing any disorder is establishing a set of criteria that can help differentiate normal manifestations of behavior, affect, and cognition from what might be labeled as abnormal or even pathological manifestations. Over the years, a number of criteria have emerged by consensus, and some of those are briefly discussed in this section. Note that these criteria are broadly applied to abnormal behavior, and there are separate factors that will make them applicable to personality.

Criteria to Define Abnormal Functioning Four basic criteria are considered relevant to differentiating abnormal from normal functioning:

1. statistical deviance, 2. dysfunction in daily living, 3. the experience of distress, and 4. danger to self or others.

Each criterion is important in defining abnormal functioning, but none are nec- essary or sufficient to determine that a disorder is present. As an example, it is true that behavior that is markedly differ- ent (statistically deviant) from what most people do is more likely to be defined as abnormal, but some rare behaviors are not disorders, and in fact can be quite adaptive. For example, consider the life and behavior of Mother Teresa, which could be an extreme case of altruism, or that of Bill Gates, which could be an extreme case of financial and technologi- cal success. Neither of these would be considered maladaptive, but they are cer- tainly deviant from a statistical standpoint.

It is also the case that, despite these criteria, debate has continued with respect to what specifically should or should not be considered a disorder. Consider homosexuality, which prior to 1980 was considered a psychiatric disorder by the World Health Organization (WHO) and was also included in the Diagnostic and Statistical Manual of Mental Disorders, 2nd Edition (DSM-II; APA, 1968), but since that time has not been considered a disorder. A wide range of factors influence what we consider disordered, and the criteria—and interpretations of the criteria—will change over time.

Trevor Smith/iStockphoto/Thinkstock

What do we consider disordered behavior? When is abnormal behavior pathological?

10.1 Defining Personality Disorders

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CHAPTER 10 10.1 Defining Personality Disorders

Statistical Deviance

Statistical deviance refers to the infrequency of a behavior or trait in the general population, with the assumption that a lower frequency is typically associated with abnormal behavior. Statistical deviance is determined by the context, including the temporal context and the social/cultural context. Thus, what is considered typical today may have been labeled atypical in the past, and vice versa.

Consider for example, the incidence of women engaging in roles traditionally considered mascu- line, such as playing competitive sports, which was very rare a century ago, but today is not only common, but is also considered healthy. Likewise, behavioral standards and normative experi- ences vary tremendously around the world. For example, Windigo psychosis refers to a condition sometimes observed in Native American (especially Algonquin) Indians where the afflicted indi- vidual believes that he has been possessed by a spirit that results in a desire to consume human flesh (cannibalism). This disorder is rarely observed in other cultures. Or consider a disorder like anorexia nervosa and its incidence in Western civilization, with rates of occurrence of approxi- mately 0.5% overall, but with higher rates among high school and college-aged females at almost 6% (Makino, Tsuboi, & Dennerstein, 2004). This disorder, however, is virtually non-existent in non- Western cultures, with rates of approximately 0.0063%, even in females (Kuboki, Nomura, Ide, Suematsu, & Araki, 1996). Of course, there is no specific value that defines statistical deviance, and therefore this criterion is considered on a continuum.

Dysfunction in Daily Living

Simply being statistically unusual is not enough to consider a behavior disordered because rare behaviors and traits can be adaptive—and common behaviors and traits, such as heavy alcohol consumption among college students, are not necessarily adaptive. Thus, an important addi- tional feature is the extent to which the behavior or trait leads to problematic functioning, or dysfunction, in areas such as work, school, and relationships. For example, if someone is very task-driven and highly competitive, and this results in their attaining considerable professional success, establishing friendships, and attracting intimate partners who like that trait, then it would be considered adaptive. However, if that same level of competitive drive results in the alienation of intimate others, the inability to cooperate with colleagues, and, therefore, less career success, then the behavior would be more likely labeled as abnormal and problematic.

The Experience of Distress

Behaviors and traits can also result in the individual or those around them reacting with distress, and this criterion can help define abnormality. In fact, the individual’s own experience of distress has been a major predictor (e.g., Cepeda-Benito & Short, 1998; Kimerling & Calhoun, 1994; Mond et al., 2009; see also Vogel & Wei, 2005) of help-seeking behavior across a wide range of condi- tions. From a practical standpoint, psychological distress increases the likelihood that a contact/ interaction will occur with a mental health professional and that a diagnosis will be made.

In addition to the individual’s own experience of it, distress can affect others, and this will simi- larly increase the potential for the individual being encouraged (or even coerced) into treatment. In this way, this criterion addresses the circumstance of people who behave abnormally but have very little self-awareness. In this instance, the psychological distress is likely to be experienced by those who interact with the individual. This criterion also interacts closely with the criterion of dysfunction, as the experience of distress leads to dysfunction.

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CHAPTER 10 10.1 Defining Personality Disorders

Danger to Self or Others

Some instances of behaviors and traits are a danger—risky or harmful—either to the individual or to others. Consider suicidal behavior, which can be conceptualized as either an active (e.g., trying to take one’s own life) or passive (e.g., failure to engage in safer actions or avoid high-risk circumstances) threat to the self. Self-injurious behavior, which is distinct from a suicide attempt, would also be captured by this category of self-harm. Regardless of the specific example, this cri- terion emphasizes what might be considered the ultimate dysfunction, as it threatens existence. Moreover, such threats are also likely to involve distress by the individual and others. Thus, even though the criteria can be theoretically distinguished, from a practical standpoint, they are highly interrelated.

Criteria for Defining Problematic Functioning in Terms of Personality In addition to defining a behavior or trait along a continuum from normal to abnormal, it is also important to highlight the factors that help categorize it as a problem specific to the domain of personality. Disorders of personality are somewhat unique in that they involve behaviors or traits that are pervasive and longstanding. By pervasive we mean that the problematic behavior or trait emerges in virtually all aspects of the individual’s life (this would be similar to Allport’s term, car- dinal traits, as described in Chapter 8). By longstanding, we mean that the problematic behavior or trait has been present for a significant portion of the individual’s life. As we shall see when presenting the diagnostic criteria, personality disorders must be present since at least late ado- lescence or early adulthood, and therefore personality disorders should generally not be assigned until adulthood.

Despite the requirement that there be some durability to the personality disorder over the life- time, some research suggests that personality disorders may not be stable in their presentation, especially when there are overlying mood disorders, such as anxiety and depression (e.g., Ottos- son, Grann, & Kullgren, 2000). Studies have also found somewhat modest temporal stability for several measures of personality disorders (as indicated by the test-retest reliability coefficients; e.g., Trull, 1993), and it is unclear if this means that it is the measures that are unstable or the personality disorders themselves. Indeed, longitudinal studies have generally questioned whether personality disorders are, in fact, stable over time (Cohen, Crawford, Johnson, & Kasen, 2005; Skodol et al., 2005; Zanarini, Frankenburg, Hennen, Reich, & Silk, 2005), and this may have some important consequences for the construct itself (i.e., how we define personality disorders).

Although this chapter will focus on the disorders of personality, it is important to acknowledge that personality functioning is a critical aspect of understanding how other psychiatric disorders mani- fest in the individual and how they can best be treated. For example, a diagnosis of post-traumatic stress disorder (PTSD) may present very differently for a highly extraverted, conscientious, and neurotic individual relative to one scoring low on these traits (factors); both intervention strate- gies and treatment outcomes may likewise be affected by these traits (e.g., Bock, Bukh, Vinberg, Gether, & Kessing, 2010; Canuto et al., 2009; Ogrodniczuk, Piper, Joyce, McCallum, & Rosie, 2003).

Conceptualizing Personality Disorders Beginning with the diagnostic system published in 1980 (DSM-III; APA), there has been an interest in considering personality disorders as extreme versions of normal traits. In this approach, the dif- ference between clinical and nonclinical manifestations of personality would be quantitative, not

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CHAPTER 10 10.1 Defining Personality Disorders

qualitative. That is, personality disorders and normal personality functioning would be defined along the same continuum. In contrast, the more prevailing historical trend was to consider clini- cal (disordered) presentations of personality and nonclinical (normal) presentations of personality as qualitatively distinct, with medical terms used to define the former and traits to describe the latter. Using this approach, the two manifestations of personality are considered categorically dis- tinct. This highlights the division between at least two camps: those that believe that personality disorders are quantitatively different from normal personality functioning (i.e., they are simply extreme examples of the same traits) and those who believe that there are important qualitative distinctions that require the use of different constructs in clinical and nonclinical settings (see Clark, 2007; Strack & Lorr, 1994; Widiger & Samuel, 2005). The categorical model that emphasizes the qualitative distinctions continues to be a central feature of the newest incarnation of the Diag- nostic and Statistical Manual (DSM-5; APA, 2013).

A third, hybrid approach assumes that the quantitative differences, when combined in certain ways, can result in qualitative differences as well. There is some support for the latter position, as researchers have found that the traits that co-occur in nonclinical populations differ from the most common co-occurring traits in clinical settings (Livesley & Jang, 2005).

Yet another way to address this conceptual issue is to consider the distinction between abnormal personality and disordered personality. Most researchers would agree that abnormal personality is simply a variant of normal personality (i.e., a statistical oddity) that can be defined as an extreme score (too little or too much) on the basic personality traits (see also Eysenck, 1987; Wiggins & Pincus, 1989). In contrast, a personality disorder implies deficits in functioning and maladaptive behavior (or in the very least, the absence of adaptive behavior). Thus, in referring to the criteria noted earlier in this chapter, statistical deviance allows for a designation of abnormal, while some of the remaining criteria, most notably the presence of dysfunction, results in a qualitatively dif- ferent label (a disorder). Indeed, statistical deviance by itself is neither necessary nor sufficient to meet criteria for a disorder.

Although the qualitative versus quantitative distinction may seem like nothing more than a the- oretical debate, there are in fact some important implications. For example, if one adopts the qualitative model, then it would be necessary to develop separate measures for use in clinical and nonclinical settings (this is in fact the most common practice today). In contrast, the quantitative model would not require separate measures to be developed, only separate norms (i.e., to quan- tify the typical scores in clinical settings).

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CHAPTER 10 10.2 Types of Personality Disorders

10.2 Types of Personality Disorders

In 2013, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was published by the American Psychiatric Association (2013). Previous versions of the DSM adopted a multi-axial system to categorize disorders. Axis I identified the clinical disorders and conditions that might be the focus of clinical attention. Axis II included the personality disorders, learning dis- orders, and mental retardation. Axes III through V covered medical disorders, psychosocial prob- lems (e.g., homelessness, job loss, etc.), and a global (overall) rating of individuals’ functioning, respectively. Traditionally, there has been considerable diagnostic overlap and interdependence between the five axes, and in particular Axes I and II.

The DSM-5 adopts a very different approach by completely dropping the multi-axial system, and combining what was formerly categorized as Axes I, II, and III into a single diagnostic system, owing largely to the considerable overlap among the axes and the artificial nature of separating these dis- orders. This now aligns the DSM more closely with the most widely used diagnostic system around the world: the World Health Organization’s (WHO) International Classification of Diseases (ICD). The disorders of the DSM-5 are now organized based on their relatedness to each other, focusing on such factors as symptom overlap and similar underlying vulnerabilities. The DSM-5’s documen- tation of diagnoses does retain separate notations for psychosocial and contextual factors, as well as disability (formerly Axes IV and V, respectively), and none of the 10 personality disorders defined in the previous DSM-IV have changed with respect to their specific criteria in DSM-5.

According to the DSM-5 (APA, 2013), personality disorders must also present in at least two of the following four areas:

1. cognition (i.e., thinking; referring specifically to perceptions of the self, others, and events)

2. affect (i.e., emotional experiences, referring specifically to impact on affective range, lability, intensity, and appropriateness)

3. interpersonal functioning (i.e., relationships) 4. impulse control (i.e., the ability to, essentially, delay gratifying one’s needs and wants)

By requiring that at least two of the above-mentioned areas be affected, this assures that person- ality disorders will be pervasive in their impact on the individual’s life, and this is in keeping with the definition of personality.

Up to this point in the chapter, the more general requirements of personality disorders have been reviewed. Now we turn our attention to the specific diagnostic criteria for each disorder. Each of the personality disorders and their diagnostic criteria will be presented here, as forwarded in the DSM-5. Importantly, the presence of the previously noted features (e.g., distress, dysfunction, pervasiveness, etc.) is necessary for the diagnosis of a personality disorder in general, whereas the following criteria are necessary for the diagnosis of a specific disorder.

The personality disorder criteria are presented in three groupings, referred to as clusters. There is more symptom overlap within clusters rather than between the clusters.

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CHAPTER 10 10.2 Types of Personality Disorders

Cluster A Personality Disorders The cluster A personality disorders all involve odd or eccentric behavior, resulting in decreased socialization experiences and often increased isolation. Such behavior will most closely match the presentation seen with other clinical disorders with psychotic symptoms, such as schizophrenia or mood disorders with psychotic features. To qualify for the diagnosis of a personality disorder, the symptoms cannot be better explained by one of the clinical disorders.

Paranoid Personality Disorder

The primary presenting features of paranoid personality disorder is a persistent and universal distrust and suspiciousness of others. These individuals interpret the intentions of others as hos- tile and demeaning in nature, and as a result they often take umbrage to these perceived slights and respond with anger and provocation. Importantly, the suspiciousness is without justification and may be very subtle (if present at all), even though the general themes may be common (e.g., fidelity of an intimate partner, loyalties of others, persecution from a government agency, etc.). Thus, the symptomatic nature of the paranoid presentation is made most obvious by its recurrent nature.

Because of these beliefs, close relationships will be difficult to maintain, both because of the per- ception of attack and threat from others and because of the counterattacks that invariably occur. As a result, they often engage in social isolation and self-sufficiency, they may present as emo- tionally volatile, and they typically blame others for their shortcomings. According to the DSM-5, stress may exacerbate paranoia, and this personality disorder may be a precursor to a more severe psychotic presentation (i.e., schizophrenia). Prevalence rates have ranged from 2.3% to 4.3%, with the disorder being more commonly diagnosed in males (DSM-5; APA, 2013).

Schizoid Personality Disorder

The primary presenting feature for schizoid personality disorder is flat affect and disengagement from social interactions. Due at least in part to their lack of emotional experience, these individu- als have few interests and goals in life, and they do not desire or derive pleasure from close rela- tionships. As a result, these individuals present as indifferent and detached; they tend to choose to engage in isolated activities. They are unlikely to have friendships or close connections (e.g., they rarely date or marry), and aside from first-degree relatives, they may have no one in whom they might confide.

As was the case for paranoid personality disorder, the schizoid individual may experience height- ened symptoms during times of stress, and this disorder may be a precursor to a delusional disor- der or schizophrenia. Prevalence rates range from 3.1% to 4.9%, and this disorder is slightly more common in males (DSM-5; APA, 2013).

Schizotypal Personality Disorder

The diagnostic category for schizotypal personality disorder includes a wide range of symptoms that parallel what is often seen with schizophrenia, though symptoms tend to be less acute but more pervasive. Symptoms include referential thinking (i.e., mistakenly believing that the actions of others or events have special meaning or significance for the individual); magical thinking, which includes superstitious beliefs as well as belief in telepathy or clairvoyance; odd or unusual percep- tions; and unusual thinking or speech. Individuals with this diagnosis also have either restricted or

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CHAPTER 10 10.2 Types of Personality Disorders

inappropriate affective responses, and their behavior can be characterized as peculiar. Schizotypal personality disorder also tends to result in social isolation, with few if any close relationships, and the presence of social anxiety that is unaffected by the familiarity of those with whom they inter- act. Paranoia may be present, but it is not the primary or dominant symptom, as with paranoid personality disorder. Likewise, restricted affect and social withdrawal are also present but are less prominent relative to schizoid personality disorder.

As with the other cluster A personality disorders, schizophrenia and other psychotic disorders may manifest later in life, though this occurs in a relatively small percentage of those affected. Between 30% and 50% of those with schizotypal personality disorder have a co-occurring major depressive disorder. The prevalence rates for the cluster A personality disorders range from 3.9% to 4.6% in the United States, but the rates are much lower in other parts of the world (e.g., less than 1% in Norway). This disorder also appears to be slightly more common in males, and this is considered one of the more stable personality disorders, in that symptoms tend to present in a consistent manner throughout one’s life (APA, 2013).

Differentiating schizophrenia from the personality disorders of schizotypal, schizoid, and paranoid is complex, and misdiagnoses can occur. Research suggests that one of the more effective ways of differentiating schizophrenia from the personality disorders is that the former tends to have more of what are referred to as the positive symptoms (e.g., active hallucinations and delusions), whereas such symptoms are more subtle or even absent with the cluster A personality disorders. Instead, it appears to be symptoms such as social and physical anhedonia that characterize the personality disorders (e.g., Clementz, Grove, Katsanis, & lacono, 1991; Kendler, Thacker, & Walsh, 1996).

Cluster B Personality Disorders The cluster B personality disorders involve dramatic or emotional behavior, and although relationships will be pres- ent, there will be conflict, instability, and exploitation. Moreover, unlike the cluster A personality disorders, those in this cluster typically present with con- siderable affect and affective dysregula- tion. This cluster most closely resembles the mood disorders, although a cluster B personality disorder diagnosis should not be applied if the behavior is better accounted for by a mood disorder.

Antisocial Personality Disorder

This diagnosis is explicitly not permit- ted until the individual is aged 18 or older, and a conduct disorder diagno- sis is common prior to the age of 15. Antisocial personality disorder also differs from other personality disorders in that it tends to remit, or at least become less prominent, on its own, thereby suggesting that this is part of its normal course (i.e., with more pronounced presentation earlier in life).

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Antisocial personality disorder is much more common in this context, with rates as high as 70 percent of incarcerated men.

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CHAPTER 10 10.2 Types of Personality Disorders

The most prominent feature of this disorder is the universal and longstanding practice of complete disregard for social norms, with the individual typically engaging in a long history of illegal behav- ior. In fact, these individuals often come to clinical attention by way of the police (i.e., they rarely present for voluntary assessment or treatment of antisocial traits). These individuals routinely vio- late the rights of others, with little regard, remorse, concern, or empathy. They are callous, cynical, aggressive (e.g., fights, assaults, etc.), irritable, impulsive, reckless, and irresponsible. They pres- ent as opinionated and even arrogant, with a superficial charm and glib demeanor.

Because deceitfulness (lying) is a common feature of this personality disorder, there is often a history of taking advantage of others for personal (typically material) gain. The prominence of deceitfulness can be problematic from a diagnostic standpoint, as the clinician often relies on the individual’s self-report to arrive at a diagnosis. Thus, it is often necessary to rely more on objective information, such as arrest records and legal history, to arrive at an accurate diagnosis.

Antisocial personality disorder may be comorbid (co-occur) with mood disorders, substance abuse disorders, and impulse control disorders. According to the DSM-5 (APA, 2013), prevalence rates range from 0.2% to 3.3%, though rates can exceed 70% among males in legal and forensic set- tings and substance abuse clinics. The disorder is significantly more common in males relative to females (approximately three times greater in males; Eaton et al., 2012), though there are some concerns that this difference is due to an overemphasis on the symptoms of aggression. Spe- cifically, a recent study suggests rates of 1.9% for females and 5.5% in males (Eaton et al., 2012). Socioeconomic status also appears to be a risk factor, with higher rates among those who are economically depressed.

Borderline Personality Disorder

The trajectory for borderline personality disorder appears to result in decreasing symptoms as the individual ages, with greater stability beginning during the individual’s third and fourth decades of life. The most noteworthy symptoms include instability of affect and relationships, with the individual making dramatic attempts to avoid perceived abandonment by others. Those with bor- derline personality disorder often vacillate between the idealization of others and the complete devaluing of others, thereby leading to unstable relationships. Feelings of emptiness, anger, and problems with intense anger control are common, along with instability of the individual’s self- image. Impulsive and self-damaging behavior is common, sometimes marked by suicidal behavior or threats. The suicidal behavior may be best described as suicidal gestures, as they can often be described as high-visibility acts (i.e., making them known to others) with low lethality, thereby suggesting that the primary purpose of such behavior is to manipulate others and avoid abandon- ment. These individuals also have a pattern of disengaging from goal-directed behavior shortly before accomplishing a goal, and, as a result, they tend to be underachievers.

At times of stress, psychotic symptoms can occur, and mood disorders are also comorbid with borderline personality disorder. Histories of physical and sexual abuse, along with neglect, are commonly observed in the families of origin. Prevalence rates range from 1.6% to 5.9%, with the higher end of that range seen in primary care settings. Upwards of 10% prevalence rates are observed in outpatient mental health settings and up to 20% of those in inpatient psychiatric facilities. This disorder is largely diagnosed in females (approximately 75% of cases are female) (DSM-5; APA, 2013).

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CHAPTER 10 10.2 Types of Personality Disorders

Histrionic Personality Disorder

Prominent features of histrionic personality disorder include a dramatic and exaggerated emo- tional presentation that is almost theatrical in nature. These individuals often inappropriately sexualize situations, presenting as seductive and provocative, even when such behavior is clearly inappropriate (i.e., either the situation is inappropriate or the target is inappropriate). These indi- viduals strive to be the center of attention and often use their physical appearance to draw atten- tion to themselves. Depression or intense emotional reactions can occur when they are not the center of attention. Histrionic personality disorder involves rapidly shifting and shallow emotions (e.g., uncontrollable sobbing and temper tantrums), and speech is often shallow and impression- istic. They may depict themselves as victims in relationships with others.

Histrionic personality disorder is comorbid with somatization and mood disorders. Prevalence rates are estimated to be approximately 1.8% in the general population, and females appear to be more commonly diagnosed than males (DSM-5; APA, 2013).

Narcissistic Personality Disorder

The most prominent feature for narcissistic personality disorder is a grandiose self-presentation, with an attendant need to be admired. These individuals will often exaggerate their achievements (which are often quite ordinary) and thus expect to be recognized as superior to others. Narcis- sistic personality disorder involves excessive self-absorption, with fantasies of power and success and even intellectual prowess and beauty. They present as entitled, expecting favorable treatment from others. This also leads to interpersonal exploitation and a lack of empathy (i.e., unwilling or unable to recognize the viewpoint of others). Interestingly, despite presenting as superior, their self-esteem tends to be very fragile (hence the need for excessive admiration), and they can react quite strongly to perceived criticism.

This disorder co-occurs with mood disorders, anorexia nervosa, and substance abuse disorders (especially cocaine). Depending on the stringency of the criteria use, prevalence rates for narcis- sistic personality disorder can range from 0% to 62% in the general community, and males com- prise 50–75% of the diagnosed cases. This indicates that this disorder has one of the largest ranges in prevalence (DSM-5; APA, 2013).

Cluster C Personality Disorders Cluster C personality disorders are marked by fear and anxiety. Interpersonal relationships occur, but may be limited. Each of these disorders has a parallel clinical disorder that shares similar fea- tures but is nevertheless distinct.

Avoidant Personality Disorder

Individuals with avoidant personality disorder are socially inhibited and are fearful of, and hyper- sensitive to, negative evaluations from others. For these reasons, these individuals avoid interper- sonal interactions, fearing that they will be criticized and rejected. Thus, they may only interact with others if they are assured or certain of being liked and accepted (i.e., they require consider- able nurturance and support). Those with avoidant personality disorder consider themselves as inept, unappealing, inadequate, and inferior. They often exaggerate the potential for and conse- quences of interpersonal failure, choosing instead to remain isolated and safe.

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CHAPTER 10 10.2 Types of Personality Disorders

This personality disorder has considerable overlap with social phobia, agoraphobia, and other mood and anxiety disorders. This diagnosis can also co-occur with dependent personality disor- der, because they identify a small number of close trusted friends to help them navigate daily life. Prevalence rates are approximately 2.4% in the general population (DSM-5; APA, 2013).

Dependent Personality Disorder

Individuals with dependent personality disorder exhibit a pervasive need to be cared for by oth- ers. They are overly reliant on close friends or family and constantly fear losing that support net- work. They are extremely reluctant to make decisions for themselves, even minor decisions (e.g., what clothing to wear, what movie to see, what restaurant to select, etc.), and are reluctant to take any personal responsibility for their actions. They constantly seek the advice and guidance of oth- ers, and they require considerable reassurance. Because of their dependence on others, they are reluctant to express any disagreement; they fear losing the support of others. Even acts that may lead to greater independence are met with fears of losing social support, thereby undermining the desire to be more independent. These individuals are also willing to engage in self-sacrifice to maintain a relationship and may be willing to endure demeaning and humiliating circumstances. This sometimes results in their tolerating emotional, verbal, physical, or sexual abuse at the hands of those upon whom they depend.

This diagnosis is generally not recommended for use in children or adolescents. Mood disorders most often co-occur with dependent personality disorder, and typically there is a higher rate of occurrence in females. Prevalence rates are approximately 0.5% in the population (DSM-5; APA, 2013).

Obsessive-Compulsive Personality Disorder

Individuals with obsessive-compulsive personality disorder are overly preoccupied with details and trivial rules; they are stubborn; and they follow rigid moral standards, often forcing others to do so as well. Although they consider themselves to be perfectionists, their perceived perfection- ism actually interferes with the completion of tasks and the accomplishment of goals (or, in the very least, the missing of deadlines) because of their meticulous preoccupation with details and standards. They will refuse help even when they are behind schedule and are unwilling to delegate responsibilities to others because of concerns that others will not complete the task in a manner consistent with their own standards. If they do allow others to help, they will provide detailed instructions and are unwilling to compromise on how things should be done (i.e., there is only one way to accomplish any given task). Relationships are often compromised because they cannot see the perspective of others, and they lack awareness of the frustration they cause in others with their overly meticulous and rigid manner.

They are very poor allocators of time, sometimes spending more time planning an activity than actually executing it. For example, a student with obsessive-compulsive personality disorder might spend more time developing a study schedule and plan than actually studying for the test; he or she might not even get to the point of studying.

These individuals often adopt extreme cautiousness in spending both for themselves and others, and they may find it difficult to discard even worthless objects. Those with obsessive-compulsive personality disorder often feel they are too busy to take any time off or engage in any pleasurable activities like vacations. Excessive time is often spent on household chores, such as cleaning.

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CHAPTER 10 10.2 Types of Personality Disorders

Anxiety disorders often co-occur with obsessive-compulsive personality disorder, including obsessive-compulsive disorder (the latter involves repeatedly having an obsessive thought and then repeatedly engaging in ritualistic behavior to decrease the anxiety associated with that thought). Obsessive-compulsive personality disorder tends to show little variability over one’s lifetime. Prevalence rates in the general population range from 2.1 to 7.9%, and the disorder is diagnosed in males about twice as often as females (DSM-5; APA, 2013).

Other Specified Personality Disorder When individuals do not fit into any of the aforementioned categories, but they still have person- ality patterns that result in deviance, dysfunction, distress, and/or danger, then they may qualify for other specified personality disorder. In such instances, it is also possible to list the associated features, some of which could correspond to the other diagnostic categories (e.g., antisocial fea- tures) while others might not (e.g., passive-aggressive features). This diagnosis is also given when mixed personality features are present.

The Prevalence of Personality Disorders Personality disorders do not reflect acute problems or changes in functioning because, much like personality itself, they are stable and almost lifelong in their presentation. Thus, researchers esti- mate that those with personality disorders may be under-represented in clinical settings; thereby leading to an underestimation of their occurrence in the general population.

One of the largest (N = 5,692) and most recent attempts at determining the prevalence of person- ality disorders in the United States was published in 2007 and used DSM-IV criteria. The data are still relevant because there have been few functional changes in the criteria for the personality disorders between the DSM-5 and the previous version. Researchers concluded that the incidence of personality disorders in the general population was approximately 1 in 11 (9.1%). Research also finds that obsessive-compulsive personality disorder is one of the most common, with narcissistic and borderline personality disorders being the next most common (Lenzenweger, Lane, Loranger, & Kessler, 2007).

Relative to other countries, the United States appears to have a consistent and stable pattern of occur- rence, whereas greater variability is seen elsewhere. Specifically, outside the United States, published rates range from approximately 6% to 13%, but the average of these figures is commensurate with U.S. rates (Sansone & Sansone, 2011). It also appears to be the case that personality disorders are at least as common among those who identify as ethnic minorities (e.g., Blacks and Latinos) as among those who identify as White in America (e.g., Crawford, Rushwaya, Bajaj, Tyrer, & Yang, 2012).

Not surprisingly, researchers examining psychiatric samples have found high rates of occurrence and comorbidity (co-occurrence of different disorders). For example, in one such study, 23% of admitted psychiatric patients were found to have a personality disorder (Mors & Sørensen, 1994). Moreover, the researchers found that of those diagnosed with schizophrenia, 44% also had a personality disor- der (PD), while 20% of those with mood disorders also had a PD (Mors & Sørensen, 1994). In general, it appears that meeting criteria for one personality disorder makes it more likely that the individual will meet criteria for a second personality disorder, and those with a personality disorder are more likely to also have a diagnosed clinical (formerly Axis I) disorder.

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CHAPTER 10 10.2 Types of Personality Disorders

There are several possible explanations for the high comorbidity with personal- ity disorders, including the fact that the diagnostic criteria overlap to a certain degree, that having one diagnosis simply increases the possibility that one will be diagnosed for any other disorder, and that problems of one kind increase the probability that one will manifest other types of problems. The issue of comor- bidity is especially important when con- sidering where the data are collected. That is, when studying clinical samples (those seeking treatment) it is reason- able to assume that comorbidity will be higher because multiple problems are precisely why these individuals are seek- ing treatment.

Personality Disorders as Primarily Adult Disorders

Although one might be tempted to assign a personality disorder (e.g., narcissistic personality disorder) to an adolescent girl who appears egocentric in her thinking, or antisocial personality disorder to a young, undisciplined boy, it is important to note that personality disorders are sup- posed to have a history of at least one year and have begun to manifest since late adolescence or early adulthood. In fact, the DSM-5 explicitly states that some PDs, like antisocial personality disorder, should not be diagnosed prior to the age of 18. Instead, other diagnoses would be more appropriate. As an example, a conduct disorder would be a more appropriate diagnosis for a per- sistently disobedient child, whereas similar behavior as an adult would be more appropriately labeled antisocial in nature. Similarly, an identity disorder might be a more appropriate diagnosis for a teenager, whereas the same behaviors (identity disturbance) would be better characterized as borderline personality disorder as an adult. Finally, it is noted that behaviors that manifest in childhood and even adolescence may not continue to manifest into adulthood, even those that are thought to reflect highly stable characteristics. Consider the research showing that a signifi- cant portion of adolescents who are diagnosed with antisocial traits (e.g., psychopaths), do not exhibit this behavior when they are later assessed as adults (e.g., Lynam, Caspi, Moffitt, Loeber, & Stouthamer-Loeber, 2007; Salekin, Rosenbaum, Lee, & Lester, 2009).

Alternative Organizational Models for the Personality Disorders The DSM nosological (referring to the science of diagnostic classification) structure is the domi- nant model used in the United States to organize psychiatric disorders, including the personality disorders (as noted in the previous section). Other organizational systems exist; some of the alter- native models are here briefly reviewed.


Although a child may exhibit disobedient behavior, a conduct disorder diagnosis is more appropriate than an antisocial personality disorder diagnosis.

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CHAPTER 10 10.2 Types of Personality Disorders

The International Classification of Diseases, 11th Revision (ICD-11)

The World Health Organization (WHO) publishes the ICD and reports that the final version of the International Classification of Diseases, 11th Revision (ICD-11) will be officially endorsed in 2015, though a draft of the proposal was made available in 2012. The current version, the ICD-10, was published in 1992 by WHO. Regardless of the specific version, this health classification system is used around the world to facilitate diagnoses.

The ICD system assesses the severity of personality disorders using the following five levels:

1. normal personality 2. personality dysfunction 3. personality disorder 4. complex personality disorder 5. severe personality disorder

There are five personality disorder dimensions of the ICD system: asocial/schizoid, dissocial, obsessional/anankastic, anxious-dependency, and emotionally unstable. According to the ICD-11 draft, the last dimension will be incorporated into the anxious-dependency dimensions, such that anxious-dependency can be either anxious-dependency or emotional instability. Another signifi- cant change proposed for the ICD-11 is that the clinician will determine whether the disorder is present, rather than determining severity.

This system is quite different from the DSM-5, in that the ICD’s five categories are considerably fewer than the DSM-5’s ten categories, and the ICD rates the severity of the disorder, whereas the DSM only allows one to indicate whether it is present.

Millon’s Model for Classifying Personality Disorders

Millon devised a model to define both normal and clinical manifestations of different personality traits (i.e., a continuum approach), he tied his diagnoses to a theoretical (evolutionary) model (the DSM is atheoretical; that is, the categories are not based on any underlying theory), and he tied the diagnostic categories to a specific measure (the DSM is not tied to any assessment tool). Mil- lon’s model, which can be derived from the Millon Clinical Multiaxial Inventory-III (MCMI-III/; see the next section of this chapter which examines the MCMI-III/ along with other assessments of personality disorders), includes a total of 15 traits. Those defined under the clinical heading essen- tially parallel the DSM-5 disorders; the first 10 match the DSM, whereas the last 5 are additional categories (see Table 10.1).

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CHAPTER 10 10.2 Types of Personality Disorders

Table 10.1: Millon’s personality disorder classifications and corresponding normal traits

Normal Clinical

Retiring Schizoid

Eccentric Schizotypal

Suspicious Paranoid

Sociable Histrionic

Confident Narcissistic

Nonconforming Antisocial

Capricious Borderline

Conscientious Compulsive

Shy Avoidant

Cooperative Dependent

Exuberant Hypomanic*

Skeptical Negativistic*

Aggrieved Masochistic*

Pessimistic Melancholic*

Assertive Sadistic*

*Additional category that does not match the DSM Source: Adapted from Millon, T. (2011). The disorders of personality: Introducing a DSM/ICD spectrum from normal to abnormal (3rd ed.). Hoboken, NJ.: John Wiley & Sons Inc.

Millon believed that most individuals would not present with a “pure” personality prototype, but would instead present with a mixed picture of several of the personality variants. For exam- ple, Millon suggested that the schizoid personality had four subtypes: (1) remote (i.e., avoidant, schizotypal features), (2) languid (i.e., melancholic features), (3) affectless (i.e., compulsive fea- tures), and (4) depersonalized (i.e., schizotypal features) (see Millon & Davis, 1996b).

The Five Factor Model for Classifying Personality Disorders

Researchers have also suggested that the Five Factor Model (FFM; introduced in Chapter 8) can also serve to organize personality disorders. The advantage of using this model is that it allows for continuity between clinical and nonclinical manifestations of personality disorders, and it is based on a more empirically sound and tested model for organizing traits (Widiger, 2005). This is in sharp contrast to the DSM structure, which has always struggled to establish construct validity (e.g., Livesley, 2001).

In two independent reviews of the literature (Saulsman & Page, 2004; Widiger & Costa, 2002), researchers have found that the disorders of personality fit very well into the Five Factor Model of personality. Moreover, even lexical studies of the descriptive terms used for the personality disorders (e.g., Coker, Samuel, & Widiger, 2002) suggest considerable overlap between the DSM nomenclature and the Five Factor Model (see also Widiger, 2005; Widiger, Trull, Clarkin, Sander- son, & Costa, 2002).

As an example, schizotypal PD is defined by high neuroticism, low extraversion, and high openness to new experience (see Widiger et al., 2002, Table 6.1). The same researchers found that histrionic PD is defined by high scores on neuroticism, extraversion, agreeableness, and openness to new

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CHAPTER 10 10.2 Types of Personality Disorders

experience. Obsessive-compulsive PD is defined by high scores on extraversion and conscientious- ness, and low scores on agreeableness and openness to new experience.


Obviously, the models defining personality disorders that have been put forth vary considerably in their structure and basic assumptions. Moreover, research comparing several of the models defining personality disorders reviewed here suggests that Millon’s configuration tends to have the least support, followed by the DSM which has moderate support. The strongest support has emerged for the Five Factor Model, or similar, empirically derived variants (O’Connor & Dyce, 1998). Of course, the Five Factor Model has yet to be employed in clinical practice. Therefore, although it is strong with respect to its basic scientific roots, research is needed to see how effec- tively it can translate to applied clinical settings.

Questioning the Legitimacy of Mental Illness The basic thesis of this chapter is that psychiatric illnesses such as personality disorders are legit- imate—that they can be defined and organized into a coherent structure, assessed, and even treated. However, there have been some theorists who have taken a very different position on the matter. Although we have just presented the various criteria for the DSM personality disorders, we will now consider an anti-establishment perspective.

Thomas Szasz was a psychiatrist who was one of the most vocal anti-psychiatry voices in the field. Szasz argued that psychiatric illnesses (which would include personality disorders) are essentially fabricated (e.g., Szasz, 1960, 2011a). Specifically, Szasz contrasted mental illness with medical con- ditions like cancer and argued that the medical model should not be applied equally to mental illness. Szasz argued that, unlike physical illnesses, there is no way to definitively determine if mental illness is present in any given individual, as there is no test or objective method that allows one to find a disease from the DSM or any other classification.

Instead, Szasz argues that mental ill- ness defines unusual behavior but that what we define as a mental illness is a social construct, reflecting the prevail- ing views of the professionals governing the field. Szasz argues that the decision about what to include in the DSM is arbitrary; one version has homosexual- ity as a disorder, while the next version removes homosexuality but adds pre- menstrual syndrome. Szasz argues that true diseases do not move in and out of favor; they should be more objectively observable.

Szasz was also a strong proponent of giv- ing people control over their lives rather than imposing a diagnosis and, worst of all, an involuntary treatment. Thus, Szasz wouldn’t argue with someone who

.Getty Images/Dynamic Graphics/Creatas/Thinkstock

Previous versions of the DSM considered homosexuality to be a disorder. Szasz argues that this and all other DSM “disorders” simply reflect social and cultural standards, not diseases.

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CHAPTER 10 10.3 Assessing Personality Disorders

wanted to change for self-improvement. His concern was with the imposition of treatment (i.e., involuntary commitments), especially given the arbitrary nature of mental illness.

In his 1988 book, Cruel Compassion, Szasz argued that we justify our attempts to control and change others by considering the behavior as compassion, when in reality it is cruelty to impose unwanted treatment on others. In fact, he argued, we are being selfish, because the true justi- fication for our behavior is to either (1) change those who remain in society (i.e., those we have to interact with) with medications, surgeries (e.g., lobotomies), or therapy, or (2) relegate those who do not change to psychiatric hospitals so we do not have to interact with them. Because the field of psychiatry essentially substituted the term disease (mental illness) for bad or undesirable behavior, this now legitimizes treatment (Szasz, 1988; see also Szasz, 2011b).

Szasz was not alone in his criticism of the DSM. For example, despite the American Psychiatric Association’s endorsement of the DSM-5, the current director of the National Institute of Mental Health (NIMH), Dr. Thomas Insel, has expressed concerns over the lack of validity of the DSM-5 and its overreliance on symptoms to diagnose disorders.

Of course, Szasz’s perspective does not reflect the majority view, but there are some important arguments that should be considered, including the fact that the determination of what consti- tutes a disorder is essentially a process of consensus and is subject to change. Thus, we should be cautious of attributing too much importance to any specific diagnostic criteria such as the DSM. Moreover, if we accept that diagnostic categories are less than definitive, then we must be espe- cially cautious about imposing treatments on the individual, as those treatments are based on the assumption that the underlying problem to be changed is real.

Szasz’s critics countered that he was an extremist in his position, and like the very field he was critiquing, he overstated reality. For example, even though label- ing behavior as a “mental illness” may overstate reality, so too does a complete denial that there is any problem (see Phillips et al., 2012, for a complete discussion of these issues, especially as they apply to the DSM-5).

10.3 Assessing Personality Disorders

Several measures have been developed and validated to broadly assess psychiatric disorders, including personality disorders. We will here review three of the more commonly studied, modern-day measures. The Minnesota Multiphasic Personality Inventory (MMPI®-2) As noted in Chapter 1, this instrument is often considered the gold standard in the assessment of psychopathology because it is one of the most frequently used instruments, and it is arguably the most widely researched measure (Graham, 2006).

Beyond the Text: Classic Writings

In this 2001 paper, Thomas Szasz attempts to discredit the legitimization of psychiatric disorders. Read it at http://

Reference: Szasz, T. (2001). The therapeutic state: The tyranny of pharmacracy. The Independent Review, V(4), 485–521.

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CHAPTER 10 10.3 Assessing Personality Disorders

The instrument was developed by comparing samples of those who had a particular psychiatric diagnosis to control groups with no psychiatric diagnosis (the Minnesota normals) with respect to their responses on a large number of items. The items that were consistently answered in a dif- ferent way by the criterion group (those diagnosed) and the control groups formed the basis of the initial scales. These scales were then cross-validated (replicated in other criterion and control groups) and the items that survived comprised the original MMPI-. It was revised in 1989, result- ing in a 567-item true/false inventory (the MMPI–2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989).

The MMPI–2 has validity measures to assess the respondent’s test-taking approach (i.e., under- or over-reporting), basic scales to assess several clinical syndromes, and supplemental scales that assess such areas as general adjustment, ego strength, how one handles the expression of anger and hostility, and substance abuse measures, to name a few. The 10 basic scales from the MMPI–2 are summarized in Table 10.2.

Table 10.2: Ten basic scales and descriptors from the MMPI–2

Scale Abbreviation—Name Description

1 Hs – Hypochondriasis somatic complaints, constricted by symptoms

2 D – Depression dysphoria, shy, irritable, guilt ridden

3 Hy – Hysteria sudden anxiety, naïve, self-centered, infantile

4 Pd – Psychopathic deviate poor judgment, antisocial, irresponsible, hostile

5 Mf – Masculinity–Femininity *traditional masculine or feminine traits

6 Pa – Paranoia ideas of reference, angry, resentful, suspicious

7 Pt – Psychasthenia ruminating, anxiety, fearful, apprehensive

8 Sc – Schizophrenia disordered thinking, delusional, bizarre, alienated

9 Ma – Hypomania expansive, grandiose, euphoric, overly extended

0 Si – Social Introversion withdrawn, aloof, insecure, low self-confidence

* This scale is scored separately by gender. High scores for each gender denote a gender stereotype consistent presentation. Source: Adapted from Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaemmer, B. (1989). Minnesota Multiphasic Personality Inventory-2 (MMPI-2): Manual for administration and scoring. Minneapolis: University of Minnesota Press.

One of the unique features of the MMPI–2 is that it is not closely aligned with any theoretical perspective, given that the selection of items was based almost exclusively on the statistical dif- ferentiation of groups. In fact, this technique for scale development was sometimes referred to as a “black box” or empirical approach to item selection because of the lack of clear theory-driven decisions.

Three more recent updates to the MMPI–2 are noteworthy. The first was a significant psycho- metric revision that resulted in the addition of the Restructured Clinical (RC) Scales (Tellegen et al., 2003). These scales were designed to be more psychometrically sound than the original MMPI–2 clinical scales and they attempt to control for a response tendency (demoralization) that results in considerable overlap among the scales.

The second change occurred in 2008 with the publication of the MMPI–2-RF (Restructure Form; Ben-Porath & Tellegen, 2008), which was based on the RC scale revision. This new measure, which provided further psychometric improvements over the MMPI–2, is briefer than the previous

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CHAPTER 10 10.3 Assessing Personality Disorders

versions (338 true/false items), thereby simplifying the resources needed to administer and inter- pret the measure.

Finally, it should be noted that new MMPI–2 scales, the Personality Psychopathology Five (PSY-5)—Aggressiveness (AGGR), Psychoticism (PSYC), Disconstraint (DISC), Negative Emotionality/Neuroticism (NEGE), and Introversion/ Low Positive Emotionality (INTR)—were also introduced to parallel the dominant theoretical framework in personality psychology, the Five Factor Model (discussed at length in Chapter 8). However, these new PSY-5 scales were thought to have relevance in both clinical and nonclinical settings and are not intended as a substitute or proxy for the big five (Harkness, McNulty, Ben-Porath, & Graham, 2002). The PSY-5 scales differ from the five factors identified in nonclinical populations, in that the former were meant to determine the extent to which personality disorders might manifest and be recogniz- able in clinical populations (see Harkness et al., 2002). They also differ from the other MMPI–2 scales by adding significantly to the prediction of personality disorders (Wygant, Sellbom, Graham, & Schenk, 2006).

Personality Assessment Inventory (PAI®) The PAI- is a 344-item measure that assesses 22 non-overlapping scales that were intended to broadly assess psychiatric disorders, and like the MMPI- scales, it also includes validity indexes (Morey, 2007). Its 11 clinical scales are grouped within the neurotic and psychotic spectrum, and a third grouping is referred to as behavioral disorders or problems of impulse control. Other scales assess such constructs as complications and motivation for treatment, harm potential, and interpersonal relations, to name a few. Two specific clusters of personality disorder traits are also assessed: borderline and antisocial.

The PAI- has normative data from patients, students, and the population at large, and reliability and validity figures are adequate for both clinical and nonclinical settings.

Recent research also suggests that the PAI- is correlated with several life-event variables in mean- ingful ways, providing further validation for this relatively new measure (Slavin-Mulford et al., 2012). Moreover, recent studies have attempted to validate the PAI- for use in various settings, including forensic populations (e.g., Newberry & Shuker, 2012) and neuropsychological settings (Aikman & Souheaver, 2008).

The Millon Clinical Multiaxial Inventory-III (MCMI-III™) The MCMI-III/ provides a standardized assessment of psychopathology matched to the Axis I and II disorders of the DSM-IV. The current 175-item version was published in 1994 and was most recently updated in 2009 (Millon, Millon, Davis, & Grossman). Although explicitly intended for use in clinical populations, this measure has also been used in nonclinical settings to predict clinical outcomes. The measure has validity indicators and 10 measures of clinical syndromes; seven of those denote moderate conditions and three denote severe conditions.

The MCMI-III/ also includes 14 personality disorder scales that are subdivided into 11 basic scales assessing schizoid, avoidant, depressive, dependent, histrionic, narcissistic, antisocial, sadistic, compulsive, masochistic, and negativistic (with the latter also referred to as passive-aggressive) and 3 severe personality pathologies assessing schizotypal, borderline, and paranoid features.

Despite the theoretical appeal and innovativeness of the MCMI/ tests, there have been some concerns due to the modest, and in some cases poor, empirical support for some of the scales on

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the inventory (e.g., Retzlaff, 1996; Saulsman, 2011). This has led some in the field to suggest that the MCMI-II/ and MCMI-III/ have failed to meet the basic standards of admissibility for a test in a court of law (known as the Daubert standard), especially when considering the valid assessment of personality disorders (Rogers, Salekin, & Sewell, 1999). Moreover, researchers have suggested that there are problems with the base rate data in the MCMI/ that is used to facilitate diagnoses, and as a result some revisions have been suggested (Grove & Vrieze, 2009). It has also been noted that although the original MCMI/ had reasonable validity, the MCMI-III/ has not received the same empirical scrutiny; therefore, it is less clear whether the newest version is valid (see Craig & Olson, 2005, Craig, 2008).

Common Features of Each Assessment Although the measures presented here adopt distinct assumptions and have many unique scales, there are nevertheless overlapping features. All are self-report inventories with symptom-specific items that require the respondent to respond using some kind of a scale (either true/false or Lik- ert). In all cases, scores are then compared to normative samples for interpretation, and the inter- pretation takes into account the test-taking approach of the respondent (i.e., the validity scale profile). Another common feature is that the measures essentially tap the same broad groupings of psychopathology. For example, in a recent study, researchers factor analyzed (grouped) item responses of psychiatric inpatients, those with substance abuse disorders, and even those drawn from forensic settings. For both the MMPI–2-RF and the MCMI-III/, the measures captured the extent to which the disorders are (1) internalizing, (2) externalizing, (3) reflective of paranoia/ thought disturbance, and (4) pathologically introverted (van der Heijden, Egger, Rossi, & Derk- sen, 2012). Thus, irrespective of the measure, there appears to be some fundamental overlap with respect to the constructs being assessed (i.e., the disorders themselves are a constant, and the various measures essentially reflect that). This suggests that the more noteworthy difference between the various measures may involve the validity scales, rather than the scales assessing psychopathology.

Validity scales are typically embedded within the inventories and assess the extent to which the respondent may have approached the test in a manner other than an honest and forthright one. This is particularly important because these measures are often administered in settings where the individual has much to gain or lose based on the outcome of the assessment. For example, in psychiatric settings, the respondent may want to receive services and may, therefore, exaggerate symptoms or problematic personality functioning to gain access to services. Or they may want to avoid an involuntary hospitalization, thereby resulting in a minimization tendency. Thus, the use of validity scales to gauge the respondent’s test-taking approach is critical to interpreting the test.

The MMPI–2 has the most comprehensive set of validity indicators, including multiple measures of defensiveness (defensiveness and lie scales), a measure of superlative responding (answering as you think a well-adjusted person might respond), multiple measures of exaggeration (items infrequently endorsed either in the general population or in clinical settings), infrequent somatic symptoms, measures of inconsistent responding, and a measure to assess for the tendency to primarily give true or false responses. Of course, having the most validity measures does not nec- essarily equate with having the best validity indicators, and this is the focus of the next research feature.

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CHAPTER 10 10.4 Case Illustrations

10.4 Case Illustrations

In this section, we provide some case examples to illustrate the personality disorders, the mea-sures used to assess them, and how the theoretical models are applied to explain their occur-rence. In some instances, multiple theoretical perspectives will be applied to illustrate how the same data can be explained from different perspectives—and, in some instances, with equal plausibility.

Case 1: Bob G. Bob G., a 32-year-old, single Caucasian male, presented for a psychiatric interview at the behest of his supervisor, who had received numerous complaints from the residents of a building where Bob is employed. The complaints essentially involve Bob being nonresponsive to requests and attempts to interact (i.e., Bob goes out of his way to isolate himself from the residents, to the point of undermining some of his duties). Bob had previously worked the night shift and had had many fewer interactions with the residents, but because of a new rotating schedule, he was now required to work the day shift sometimes.

Family background indicates that Bob has minimal interactions with his family of origin. His father is now deceased, but had been diagnosed with schizophrenia. His mother is in out-of-state assisted living. Bob also has a sister who provided collateral information, saying that Bob has always been a social isolate and somewhat odd. He was also described by his sister as smart, and he did reason- ably well in school.

Bob reported that his best friend was a former college roommate, whom he had not seen since his freshman year, when they shared a dormitory room for one semester. He characterized their relationship as mostly “focused on work,” and stated that they typically “gave each other space” so that they could accomplish their schoolwork.

Bob is single and has not had any dates or expressed any interest in dating. He does describe him- self as heterosexual, but when asked about his relationships with women, he simply noted that he has some fellow security officers who work on other floors who are female. Bob also noted that he perspires easily and heavily, and therefore he tends to keep to himself so as not to offend others (especially women) with the smell. (Note: No odor was detected during the interview.) This is one of the reasons he does not like to socialize with others. He also described himself as someone who is “serious” and “all business.” Thus, he does not like to waste time with idle chatter. He reported few socialization experiences outside the work setting. In fact, even in the work setting, he did not appear to know many people; when he described having lunch with colleagues he described it as “uncomfortable” and noted that he typically eats in the cafeteria with others, but does not speak to them. Bob noted that he can usually tell what others are thinking, and so there is little need to actually speak to them.

He denied the use of any alcohol or drugs and denied any legal history. He also denied any formal psychiatric history. As noted, family psychiatric history only involves his father, who was diagnosed with schizophrenia.

With respect to behavioral observations, Bob presented as somewhat awkward socially, he rarely made eye contact, and his gaze often moved about the room. He sat with his hands clenched and only spoke when asked a question, but he was cooperative. He was dressed in his security guard uniform, which was kempt. Although Bob denied the experience of hallucinations, he did appear

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CHAPTER 10 10.4 Case Illustrations

to become overly engrossed in common stimuli in the interview room (e.g., staring at the walls and the desk for prolonged periods of time). He occasionally engaged in some odd hand gestures, where he seemed to be blocking out stimulation that was not apparent to the interviewer. Verbal- izations were nonlinear (tangential and circumstantial) and difficult to follow at times. He would begin to answer a question, but then become engrossed in another topic. For example, when asked about his intense focus on the blue painted wall, he reported being lost in thought, contem- plating the complexities of the depths of our oceans, and the undiscovered and even magical qual- ities of that part of the world. Affective expression was generally flat throughout the interview.

One other odd verbalization is also worth highlighting. Bob stated that he became aware of the current complaints from work because he “sensed” that others might be upset with him and believed that it was not uncommon for others to be speaking about him behind his back. He also expressed concern that the various executives who have offices where he works are likewise talk- ing about him and may even be considering terminating his position because of Bob’s decision not to attend church on Sundays. When asked directly if the executives would know about Bob’s non-work-related behavior, he acknowledged that they would not likely know about this, but that if they did, they would strongly disapprove. Despite these concerns, Bob was unsure as to why he needed this evaluation, stating that he is doing fine and has not noticed any changes in his behavior.

Data From Standardized Measures

Bob completed the MMPI–2. The validity profile indicated a mildly defensive response set, as Bob either minimized his problems or demonstrated poor insight with respect to his difficul- ties. Nevertheless, the basic scales are interpretable. Several of the clinical scales were elevated, including scales 8, 6, and 0, indicating disordered thinking, eccentric behaviors, poor contact with reality, withdrawal, alienation, suspiciousness, the tendency to displace blame on others, mis- taken beliefs, introversion, social withdrawal, and aloofness. No other basic scales were elevated.

With respect to the PSY-5 scales, Bob was elevated on Psychoticism (PSYC), indicating discon- nection from reality and odd beliefs and perceptions, and Introversion/Low Positive Emotionality (INTR), indicating few positive emotions and social withdrawal.

Critical Thinking Questions:

• Referring to the DSM-5 criteria presented earlier in this chapter, which personality disorder (if any) best fits Bob? What might be the pros and cons of administering the following measures to assess Bob: (a) The MCMI-III/? (b) The Rorschach using the Exner scoring system? Consider one of the theoretical perspectives presented in this text, and try to explain the etiology for Bob’s behavior and presentation (i.e., how did he become the way he is now?).

Diagnosing Bob

Bob’s presentation in the clinical interview and MMPI–2 test scores suggest a personality disor- der, most likely schizotypal PD. Importantly, there appear to be problems in functioning, as Bob has been having problems at work and relationships are largely absent. His behavior is different from that of most others, and he may cause those around him to experience distress, even though

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CHAPTER 10 10.4 Case Illustrations

he does not. Moreover, data from the clinical interview indicate that Bob’s behavior has been constant through much of his life, and it appears to manifest in all areas of his life. Thus, if there is a problem, it is likely to be one of personality.

Data to suggest schizotypal PD include the presence of odd beliefs, such as being able to “sense” things (i.e., magical or delusional thinking), and also possible paranoid ideation, as indicated by his concerns regarding the executives talking about him and planning to fire him for not attending church (something his employers would not know about, let alone have an interest in). There may have been some evidence of hallucinations, including smelling an odor that was not detectable and seeing things in the walls that preoccupied his thoughts and engendered odd hand gestures. Bob’s affect was flat, he presented as asocial, and he appeared aloof and alienated, with few, if any, social contacts. Bob’s profile of scores on the MMPI–2 highlights many of these same themes (i.e., disordered thinking, odd perceptions, alienation, and aloof presentation), thereby providing further corroboration for the diagnosis.

Theoretical Approaches to Bob’s Case

A number of different theoretical accounts can be forwarded based on the theoretical models reviewed in previous chapters. For example, from the neurobiological perspective, it is noted that Bob’s father was diagnosed with schizophrenia, thereby suggesting that Bob would have an increased genetic risk for a similar disorder, such as a cluster A personality disorder. Research also suggests that the traits seen in the cluster A personality disorders can be the result of physiologi- cal hard wiring, whereby one is less responsive to environmental stimuli and learning experiences (e.g., Raine, 1988).

Bob also evidenced some mild but pervasive delusional ideation, with some evidence of paranoia. Freud believed that paranoia resulted from a combination of two defense mechanisms that are unconsciously engaged in order to address homosexual thoughts and feelings (note that Bob has no dating history and no interest in any type of relationship with women). Freud might argue that Bob deals with unacceptable homosexual ideation by first using reaction formation, such that the thought “I, a man, love other men,” becomes the opposite, in the form of “I, a man, hate other men.” Freud argued that this, too, was an unacceptable thought, so projection is used, thereby changing “I, a man, hate other men” to “Other men hate me.”

The behavioral model might suggest that Bob was not properly reinforced for “normal” behavior early in life, and therefore he engaged in increasingly bizarre behavior for reinforcement (possibly attention). It might also be argued that many of Bob’s beliefs, such as his “decision” to avoid oth- ers (especially women) because of his odor, is a preferred interpretation of reality, as the alter- native is that others have little or no interest in him, and this is a far less favorable (reinforcing) interpretation (cf. Roberts, 1991).

The cognitive perspective has also weighed in on odd or delusional thinking, as researchers have demonstrated the presence of reasoning biases in those with delusional ideation. For example, deluded schizophrenics were found to request less information relative to non-deluded psychi- atric patients before reaching a decision, and despite having less information, they expressed greater certainty in their decisions (Huq, Garety, & Hemsley, 1988; see also Garety, Hemsley, & Wessely, 1991). Thus, it would be predicted that Bob would require less evidence to come to his conclusion that the executives were conspiring to fire him for non-work–related behavior, and the cognitive model would predict that he would have greater certainty in this delusional narrative (see also McGuire, Junginger, Adams, Burright, & Donovick, 2001).

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CHAPTER 10 10.4 Case Illustrations

Case 2: Samantha K. Samantha K. is a 26-year-old mother of one who was recently arrested by police for prostitution. However, because police thought she was acting in an atypical manner, they brought her to the regional psychiatric hospital for evaluation. Samantha was arrested in Atlanta, but she resides in Baltimore. She reported having traveled to Atlanta to visit friends when her 5-year-old son, who was staying with an ex-boyfriend in Baltimore, became ill with pneumonia and had to be hospital- ized. Samantha stated that the reason she had turned to solicitation was so that she could earn enough money to immediately travel back to Baltimore and pay for her son’s medical services. She was quite convinced that her actions were fully justified, and she said she would do it again if placed in the same position (“I don’t regret anything I’ve done, and you would have done the same thing if you were in those circumstances”).

Although she denied any significant legal history, records indicate a series of arrests for petty theft and marijuana possessions charges, dating back to when Samantha was 14. Despite the large number of charges, few resulted in convictions. In those instances where she was convicted, Samantha had lengthy explanations to justify her actions, and she typically put the blame on either the circumstances or the actions of others.

Samantha has no psychiatric history. She completed high school, and although she scored reason- ably high on aptitude tests, her grades were average and she did not continue education after high school. Samantha has held a number of service-related jobs, such as hostessing at restaurants and sales in clothing stores, but she has rarely held a job for more than a few months; she moves on when she gets bored with the position. She has also been fired twice for suspicion of stealing on the job, but no charges were pressed.

Samantha’s parents divorced when she was 4 years old, after many years of verbal and physi- cal assaults. Samantha stayed with her mother and had little to no contact with her father. She described her mother as having many different boyfriends, but no stable relationships. Because her mother worked, she reported “essentially raising myself.” Samantha is somewhat estranged from her family, who also reside in Baltimore. According to several members of her family, Saman- tha will call a couple of times per year, but it is usually to request money or a favor. These requests involve lengthy justifications and sometimes even business schemes that have never come to frui- tion. Because she owes many people money, many acquaintances and family members have cut off ties with Samantha.

Samantha is an attractive woman, who presents as somewhat charming at first. However, her interpersonal style comes across as manipulative, and it’s not always clear if she is telling the truth. She appears relatively calm and collected interpersonally, but will sometimes verbalize aggression. The clinical interview was complicated by the fact that Samantha repeatedly changed topics after several questions on any one topic. She also perseverated on her son’s health, but despite saying she was concerned about her son, she did not appear concerned (at least her out- ward appearance did not indicate it).

When asked about her son and the rationale for leaving him behind in Baltimore, Samantha explained that she wanted to give her son some quality time with her ex-boyfriend; however, it was unclear as to why her son would benefit from or even desire this contact, given that Samantha dated her ex-boyfriend prior to her son’s birth (i.e., her son didn’t know Samantha’s ex-boyfriend prior to this trip).

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CHAPTER 10 10.4 Case Illustrations

Data From Standardized Measures

Samantha completed the MMPI–2. The validity profile indicated that she was highly defensive; she demonstrated a tendency to under-report and minimize problems. The observed defensiveness can undermine the interpretation of the clinical scales, as low scores do not necessarily denote the absence of psychopathology, but may instead be the result of excessive under-reporting. However, any significant elevations that do emerge can be interpreted.

One clinical scale was elevated: scale 4. Elevations on this scale are often associated with poor judgment, irresponsible behavior and attitudes, hostility, and the displacement of blame onto others.

Two of the five personality subscales from the MMPI–2 were also elevated, most notably the AGGR scale, which refers to the use of aggression, hostility, and intimidation to facilitate goal attainment. The second elevation was on DISC, which suggests the presence of risk taking and impulsivity and little regard for following rules. Finally, the MMPI–2 supplemental scale assessing over-controlled hostility was also elevated, suggesting that although Samantha usually responds appropriately to provocation, she is likely to sometimes evidence an exaggerated anger response, even in the absence of provocation.

The NEO-PI was also completed, but this measure resulted in no significant elevations, aside from Samantha’s endorsement of items indicating that she is very friendly (agreeableness) and dutiful (conscientiousness). The scores on this face-valid measure appeared to reflect a more socially desirable response set, but there are no formal validity measures on the NEO™-PI.

Critical Thinking Questions

• Referring to the DSM-5 criteria presented earlier in this chapter, which personality disorder (if any) best fits Samantha? What might be the pros and cons of administering the following measures to assess Samantha: (a) The MMPI–2? (b) The NEO/-PI? Consider one of the theoretical perspectives presented in this text, and try to explain the etiology for Samantha’s behavior and presentation (i.e., how did she become the way she is now?).

Diagnosing Samantha

Samantha’s test scores and her presentation in the clinical interview converge on a diagnosis of antisocial personality disorder. A recurrent theme in the evaluation was her less-than-genuine presentation. She under-reported her problems, was defensive on the standardized measures, and even provided misleading information regarding her criminal history. Even the fact that she has a lengthy criminal history is indicative of this diagnosis. Samantha also did not evidence any remorse for her actions, opting instead to blame the circumstances on others; she even stated that she would act in the same way if given the opportunity to do so again.

Samantha has superficial relationships and she tends to take advantage of others. She presents as aggressive and even hostile at times, though she can be quite charming when trying to get what she wants. Samantha’s actions also suggest that she is impulsive and has been an underachiever for most of her life.

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CHAPTER 10 10.4 Case Illustrations

Given Samantha’s less-than-genuine presentation and defensiveness on the MMPI–2, it is not surprising that she only endorsed more favorable characteristics on the face-valid NEO/-PI. The MMPI–2 scores converge with many of the above descriptions, with elevations on scale 4, as well as other scales assessing problems managing aggression and impulsivity. Importantly, even though Samantha does not feel distress, she appears to be creating distress in those around her. There is also clear evidence of dysfunction, with a poor work history, legal and drug problems, and few stable relationships.

Theoretical Approaches to Samantha’s Case

The physician Philippe Pinel introduced the concept “manie sans délire” to refer to individuals who appeared to think clearly, but who would nevertheless behave in a manner that would sug- gest disturbance. Similarly, the physician James Prichard coined the term “moral insanity” to char- acterize mental illness where emotional experiences are disturbed, but intellectual capacities are intact. These terms arguably provide some of the earliest writings relating to the modern-day concept of antisocial PD (see also Berrios, 1996).

More recently, antisocial tendencies have been referred to using the terms sociopath and psycho- path, and this highlights two distinct etiologies for the associated behaviors, a behavioral (or social learning) account and a physiological account.

The term sociopath implies problematic learning, which can include parental neglect (i.e., failure to reinforce appropriate behavior and punish inappropriate behavior) and/or poor parenting (i.e., reinforcing inappropriate behavior and punishing appropriate behavior). Thus, from this account, Samantha’s unstable home, and the report that she raised herself, would be consistent with prob- lematic learning experiences early in life, resulting in the antisocial tendencies. Sociopathy also involves problematic factors outside the family-of-origin, such as poverty and the presence of delinquent peers. Samantha came from a single-parent home, and given her current shortcomings with respect to finances, we can assume that she has and continues to struggle financially. The case history also indicates involvement with the law and extensive experience with drugs begin- ning at an early age, thus delinquent peers were also likely.

The above-described factors could also be accounted for by social learning theory, whereby Samantha observed and subsequently modeled her mother’s numerous superficial relationships and aggressive behavior toward her ex-husband. Similarly, her delinquent peers would have served as targets to model, and their substance abuse and other criminal behavior would eventu- ally lead to Samantha demonstrating these same behaviors.

The term psychopath has also been linked to antisocial personality disorder, but here the implica- tion is the presumed physiological underpinnings of the disorder. That is, in contrast to the above models, which emphasize environmental factors, the psychopathy model focuses on inherited genetic factors.

Psychopaths are thought to have innate, temperamental features that predispose them to be impulsive decision-makers, risk takers, and individuals who do not profit from learning experi- ences (e.g., Cleckley, 1982; Hare, 1978; Lykken, 1957; Raine, 1987; see also Lykken, 1995, and Raine, 1993, for reviews). For example, mild electric shocks (positive punishments) appear to be less effective at eliminating behaviors for psychopaths, and this problematic learning may be especially prominent when there are no delays in responding (i.e., impulsive responding). Some

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CHAPTER 10Summary

research suggests that the cause of these and other related problems are the result of a dys- function in the prefrontal cortex, which is the region of the brain governing decision-making, responsiveness to rewards and punishments, and impulsivity (see Crews & Boettiger, 2009). This extensive literature suggests that psychopaths are essentially wired differently than others, mak- ing them less responsive to reinforcers and punishers, which then inhibits proper learning and the internalization of moral standards. Researchers have also forwarded more complex physiological accounts, though even these models are in keeping with the traditional literature, while also impli- cating motivated behavior through classic approach-avoidance models presented earlier in this text (see Arnett, 1997). From this perspective, it is somewhat irrelevant whether Samantha had opportunities to learn or model appropriate behavior, as it would be assumed that she would not profit from these experiences to develop proper, internalized moral standards. Thus, Samantha would feel justified in her behavior even when it breaks the law or is contrary to moral standards.


Personality disorders have traditionally been studied separate from normal personality, and, as a result, researchers have developed distinct systems of categorization and unique mea-sures to assess them. The dominant model for identifying personality disorders in the United States is represented by the DSM-5, which identifies 10 personality disorders (schizoid, schizo- typal, paranoid, histrionic, narcissistic, antisocial, borderline, obsessive-compulsive, avoidant, and dependent), along with the specific symptoms associated with each diagnosis. In addition to the diagnosis-specific criteria, the identification of a personality disorder requires that there be a number of other, more general, criteria, such as the presence of dysfunction, distress, danger, and deviance from social/cultural standards. These criteria are neither necessary nor sufficient, but the more criteria that are present, the more likely the observed traits will constitute a personality disorder. The prevalence rates vary considerably for the personality disorders, and there are also marked differences based on gender.

Although widely used, the DSM-5 and its predecessors are not the only classification system, and many researchers argue that a more parsimonious and accurate approach would be one in which the models used to characterize normal personality functioning (e.g., the Five Factor Model) are applied to the personality disorders. This approach would then signal a quantitative rather than a qualitative distinction between normal and disordered personality. Other critics of the DSM have argued that it is not simply the diagnostic system that is a problem; rather, they question the very existence of the psychiatric disorders themselves.

Some of the most commonly used measures of personality and other psychiatric disorders include the MMPI–2, the PAI-, and the MCMI-III/. These measures are uniquely qualified to assess disorders because they also have validity scales that assess the respondent’s test-taking approach. This is important because in clinical settings there are often external contingencies that can increase the incidence of over- or under-reporting biases, and these have to be understood in order to interpret the data. Using information from these tests (and others), along with the patient’s case history, allows the clinician to diagnose the individual. Moreover, the theories pre- sented in earlier chapters can then be used to conceptualize the patient and how their pathology developed.

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CHAPTER 10Key Terms

Key Terms

abnormal personality A variant of normal personality that can be defined as an extreme of the basic personality traits.

antisocial personality disorder A personal- ity disorder characterized by universal and longstanding practice of complete disregard for social norms and often a history of illegal behavior.

avoidant personality disorder A personality disorder characterized by social inhibition and fear and hypersensitivity to negative evalua- tions from others.

borderline personality disorder A personality disorder characterized by instability of affect and relationships, with the individual making dramatic attempts to avoid perceived abandon- ment by others.

cluster A personality disorders Personality dis- orders that involve odd or eccentric behavior, resulting in decreased socialization and often increased isolation.

cluster B personality disorders Personality disorders that involve dramatic or emotional behavior and conflict, instability, and exploita- tion in relationships.

cluster C personality disorders Personality disorders that involve fear, anxiety, and limited interpersonal relationships.

comorbidity The co-occurrence of different disorders.

danger When certain behaviors or traits are risky or harmful to either the individual or to others.

Daubert standard The basic criteria of admis- sibility for a test in a court of law.

dependent personality disorder A personality disorder characterized by a pervasive need to be cared for by others.

deviance The statistical infrequency of a behavior in the general population; a lower frequency is typically associated with abnormal behavior.

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) The most recent manual of the APA (2103), which has eliminated the multi-axial system of categoriz- ing diagnoses (used in previous DSM editions) and aligned itself more closely with the World Health Organization’s (WHO) International Clas- sification of Diseases (ICD).

distress Negative feelings or reactions felt by an individual or those around them as a result of certain behaviors or traits.

dysfunction The extent to which a behavior or trait leads to problematic functioning in daily living.

histrionic personality disorder A personality disorder characterized by dramatic and exag- gerated emotional presentation that is almost theatrical in nature.

International Classification of Diseases, 11th Revision (ICD-11) The version of the World Health Organization’s (WHO) International Clas- sification of Diseases that will be released in 2015. The ICD is used worldwide for diagnoses.

longstanding When a problematic behavior or trait has been present for a significant portion of an individual’s life.

narcissistic personality disorder A personal- ity disorder characterized by grandiose self- presentation and a need to be admired.

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CHAPTER 10Key Terms

obsessive-compulsive personality disorder A personality disorder characterized by preoccu- pation with details and trivial rules, stubborn- ness, and rigid moral standards.

other specified personality disorder A diagno- sis that can be given to individuals who do not fit into the cluster personality categories but still exhibit personality patterns that result in deviance, dysfunction, distress, and/or danger.

paranoid personality disorder A personality disorder characterized by persistent and univer- sal distrust and suspiciousness of others.

personality disorder A deficit in functioning and maladaptive behavior or, in the very least, the absence of adaptive behavior; also known as a disordered personality.

pervasive When a problematic behavior or trait emerges in virtually all aspects of an indi- vidual’s life.

psychopath A term for a person with anti- social tendencies of a physiological etiology; that is, the behaviors emerge because of inher- ited genetic factors.

schizoid personality disorder A personality disorder characterized by flat affect and disen- gagement from social interactions.

schizotypal personality disorder A personal- ity disorder characterized by a wide range of symptoms that parallel those seen in schizo- phrenia, though less acute and more pervasive.

sociopath A term for a person with antisocial tendencies of a behavioral etiology; that is, the behaviors emerge because of problematic learning, which can include parental neglect (i.e., failure to reinforce appropriate behavior and punish inappropriate behavior); poor par- enting (i.e., reinforcing inappropriate behavior and punishing appropriate behavior); poverty; and delinquent peers. Can also be indicative of a social-learning etiology; that is, the behaviors emerge as the individual models others’ anti- social behaviors.

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