Personality
disorders
this summary is based on the book Personality Disorders by Paul M. G. Emmelkampand
Katharina Meyerbröker, 2nd edition, recommended scientific articles and notes taken during
classes
(additional explanations, diagrams, pictures, and annotations were added, too, to make learning easier; some
paragraphs were copied directly from the book when they were easy to understand and didn’t require
explanations)
,Laura C. / 2023-2024
Lecture 1
Description of personality disorders/ DSM/ the Alternative model
personality= enduring aspects of individual differences in our usual tendencies to think,
feel, react, and behave in different situations; personality is stable and by which
people distinguish us from others and react to us. While we experience our
personality as stable across time, we are able to adapt and learn and evolve our
experiences to be successful in what life is demanding from us within the variety of
the different facets of our personality
abnormal personality/ personality pathology = the inability of persons to react flexibly and
appropriate to life’s challenges; maladaptive traits that are overly rigid and/or
extreme lead to disruption in the development and maintenance of mutual
interpersonal relationships and self-development
personality disorder= an enduring pattern of inner experiences and specific behaviours that
deviates to a significant extent from the expectations of the individuals culture; PD’s
are:
o pervasive: affects several domains of life
o persistent: it starts around early adulthood
o pathological: the behaviour/ thoughts/ emotions of a person with PD are divergent
from the norm
46-60% of clinical patients have a PD; 10-12% of the population suffers from PDs
personality disorders versus clinical syndromes
- in clinical syndromes, symptoms are perceived as foreign to the individuals (ego-
dystonic) and are considered something they “have”; people find their lives
disrupted- they can no longer function as they used to because of fear of panic (e.g.
panic disorder), or unusual lack of interest and energy (e.g. depression)
- personality disorders are rooted in how individuals have matured into their adult
personalities, often characterized by traits; unlike clinical syndromes, personality
disorders are typically ego-syntonic, meaning individuals see them as part of
themselves => the key features of personality disorders include disturbed
relationships in both personal and professional life and disruptions in the inner
experience of oneself
Classification systems
- PDs are usually classified according to the Diagnostic and Statistical Manual of
Mental Disorders (DSM) or the International Classification System of Diseases (ICD)
- personality disorder according to DSM 5: “an enduring pattern of inner experience
and behaviour that deviates markedly from the expectations of the individual’s
culture”
PS general criteria according to DSM 5:
criterion a: this pattern is manifested in two (or more) of the following areas: cognition,
affectivity, interpersonal functioning, and impulse control
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criterion b: the pattern is inflexible and pervasive across a broad range of personal and
social situations
criterion c: the pattern results in notable distress or hinders functioning in crucial aspects of
social, occupational, or other significant areas
criterion d: the pattern is stable and of long duration, and its onset can be traced back at
least to adolescence or early adulthood
criterion e: the pattern is not better explained as being a manifestation or consequence of
another mental disorder
criterion f: the observed pattern cannot be attributed to the direct physiological effects of a
substance (e.g., drugs) or a broader medical condition
- criterion e and f are exclusion criteria
DSM-5 classification
- the personality disorders are categorized into three clusters: cluster A, B and C
→ Cluster A: the “odd” cluster:
paranoid personality disorder
schizoid personality disorder
schizotypal personality disorder
→ Cluster B: the “dramatic” cluster:
antisocial personality disorder
borderline personality disorder
histrionic personality disorder
narcissistic personality disorder
→ Cluster C: the “anxious” cluster:
avoidant personality disorder
dependent personality disorder
obsessive-compulsive personality disorder
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Functional impairment and distress
- both the DSM-5 and ICD-11 classify personality disorders (PDs) based on two key
criteria:
functional impairment
subjective distress
however, the degree to which these criteria are met varies between different PDs;
e.g.,: borderline personality disorder (BPD) is a PD where both functional impairment
and subjective distress are often severe; in contrast, schizotypal personality disorder
(STPD) is less likely to involve subjective distress, while narcissistic personality
disorder (NPD) may not always manifest as obvious functional impairment
Phenomenology of the personality disorders
Cluster A: the “odd” cluster
paranoid personality disorder
schizoid personality disorder
schizotypal personality disorder
- “odd” and “eccentric” represent the core qualities and characteristics of these
personality disorders
Paranoid personality disorder
- patients’ characteristics:
profound mistrust and suspiciousness regarding the motives of other persons
hypervigilant to hidden meanings and threats, in a contentious, hostile way
secretive and hypersensitive to insults
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- 4/7 criteria need to be met to satisfy the formal diagnosis:
A. A pervasive distrust and suspiciousness of others such that their motives are
interpreted as malevolent, beginning by early adulthood and present in a variety of
contexts, as indicated by four (or more) of the following:
1. suspects, without sufficient basis, that others are exploiting, harming, or deceiving
him or her
2. is preoccupied with unjustified doubts about the loyalty or trustworthiness of
friends and associates
3. is reluctant to confide in others because of unwarranted fear that the information
will be used maliciously against him or her
4. reads hidden demeaning or threatening meanings into benign remarks or events
5. persistently bears grudges, i.e. is unforgiving of insults, injuries, or slights
6. perceives attacks on his or her character or reputation that are not apparent to
others and is quick to react angrily or to counterattack
7. has recurrent suspicions, without justification, regarding fidelity of spouse or
sexual partner
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or
depressive disorder with psychotic features, or another psychotic disorder and is not
attributable to the direct physiological effects of another medical condition.
e.g., Rita, a 45-year-old single mom, presents herself for treatment after experiencing a
burnout triggered by a car accident. She is feeling angry and depressed and experiences a
lack of energy. She suspects that, although her employer tries to work together with her on
reintegration, he is actually trying to get rid of her. Instead of collaboration she feels that
her boss wants to control her and prove her wrong in front of the team. When her employer
contacts her to collaborate in the process of reintegration at work she feels attacked in her
personal life and takes it as evidence that her employer wants to fire her. She does not get
any support because she holds that her friends and family are actually taking the side of her
employer. She does not tell them anymore how she feels and she has contacted an attorney
to assist her in the reintegration process at work. At the moment, this is increasingly
developing into a work conflict, which in turn confirms Rita’s distrust of her employer. She is
finding negotiating harder and harder. She does not contact family and friends because she
is disappointed that they are taking the side of her employer. She does not allow the
psychologist to contact the general practitioner because she does not trust the general
practitioner either, because he earlier tried to motivate her to go back to work.
Schizoid personality disorder
- patients characteristics:
lead a withdrawn, isolated life
are quietly distant, and prefer to be on their own, with minimal needs for relatedness
tend to be somewhat low in energy
their emotional life is rather flat and unexcitable
few close interpersonal relationships if any & emotionally detached in social situations
indifferent to criticism or praise
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- it is extremely rare for schizoid PD patients to seek treatment for these characteristic
behaviours- if they come in for treatment, it is because they developed a syndromal
disorder
- some research suggests genetic continuity of schizoid PD with schizophrenia;
persons with schizoid PD resemble individuals who have prodromal or residual
schizophrenia, but an important difference is that the schizoid PD does not include
the psychotic-like positive symptoms of schizophrenia
- 4/7 criteria need to be met to satisfy the formal diagnosis:
A. A pervasive pattern of detachment from social relationships and a restricted range of
expression of emotions in interpersonal settings, beginning by early adulthood and
present in a variety of contexts, as indicated by four (or more) of the following:
1. neither desires nor enjoys close relationships, including being part of a family
2. almost always chooses solitary activities
3. has little, if any, interest in having sexual experiences with another person
4. takes pleasure in few, if any, activities
5. lacks close friends or confidants other than first-degree relatives
6. appears indifferent to the praise or criticism of others
7. shows emotional coldness, detachment, or flattened affectivity
B. Does not occur exclusively during the course of schizophrenia, a bipolar
disorder, or depressive disorder with psychotic features, another psychotic
disorder, or autism spectrum disorder and is not attributable to the physiological
effects of another medical condition
e.g., Carol, a 37-year-old woman, who formally worked at a library archiving books, seeks
help from her general practitioner after she lost her job due to a reorganization. She does
not succeed in acquiring another job; every time – if she gets invited to interview – another
candidate gets the position. There is not much support in her surroundings – she has no
close friends and does not feel the urge to socialize with others. Moreover, she actually likes
to be on her own. At work, she felt neither anger nor satisfaction. During young adulthood,
she had two short relationships with men. These were not initiated by her and she actually
felt relieved when the men no longer contacted her. She did not feel the urge for bodily
contact or sexual intercourse. The second man she was with cooked delicious dinners for
her, but she never understood this as she feels no satisfaction or joy in tasting food. The
general practitioner is puzzled by the flat and not very responsive encounters with her.
Schizotypal personality disorder
- patient’s characteristics:
peculiarity and eccentricity in thought and behaviour
hold unusual, sometimes “magical”, idiosyncratic beliefs
what has no meaning to most persons may have very special meaning
- 5/9 criteria need to be met to satisfy the formal diagnosis:
A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort
with, and reduced capacity for, close relationships as well as by cognitive or
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perceptual distortions and eccentricities of behaviour, beginning by early adulthood
and present in a variety of contexts, as indicated by five (or more) of the following:
1. ideas of reference (excluding delusions of reference)
2. odd beliefs or magical thinking that influences behavior and is inconsistent with
subcultural norms (e.g. superstitiousness, belief in clairvoyance, telepathy, or
“sixth sense”; in children and adolescents, bizarre fantasies or preoccupations)
3. unusual perceptual experiences, including bodily illusions
4. odd thinking and speech (e.g. vague, circumstantial, metaphorical, over
elaborate, or stereotyped)
5. suspiciousness or paranoid ideation
6. inappropriate or constricted affect
7. behaviour or appearance that is odd, eccentric, or peculiar
8. lack of close friends or confidants other than first-degree relatives
9. excessive social anxiety that does not diminish with familiarity and tends to be
associated with paranoid fears rather than negative judgements about self
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or
depressive disorder with psychotic features, another psychotic disorder, or autism
spectrum disorder
e.g., Daniel is a 57-year-old man, who presents himself reluctantly to treatment for his
hoarding problems. He does not feel the urge to change anything in his lifestyle – it is more
that the township is putting demands on him for how he lives. He actually lives with three
big exotic parrots who he sees as his family. He thinks that you cannot trust other people
and becomes suspicious when other people start talking to him. He has only one friend he
met long ago when he was sitting in the park talking to his parrots. Earlier the township
retrieved another parrot from him during an inspection of his apartment. Daniel always
referred to the parrot as Mr Dixit and he believed he was able to communicate with him via
telepathic channels. During the absence of the parrot, he “felt” physical pain that he
experienced due to his parrot being trapped in a cage. He has named the other three
parrots as well and to comfort them living in a big city he always wears green clothes with
large prints of flowers and trees. When people see him they often turn around and stare.
This increases his fear of other people and anxiety that they will take away his parrots and
so he avoids any contact with other people. A few times people have thought that he
belonged to a theatre company, given his extravagant appearance.
Cluster B: the “dramatic” cluster
antisocial personality disorder
borderline personality disorder
histrionic personality disorder
narcissistic personality disorder
Antisocial personality disorder
- patients ‘characteristics:
disregard the rights of others and are prone to unethical behaviour
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irresponsible, and do not “learn” from previous mistakes
low frustration tolerance
quite aggressive and impulsive/ cunning and manipulative
remorse and guilt are absent for the negative consequences their behaviour may have
for others (some may derive pleasure from the suffering of others)
- antisocial PD is often associated with drug and alcohol problems and criminal
behaviour
- 3/7 criteria need to be met to satisfy the formal DSM-5 diagnosis:
A. A pervasive pattern of disregard for and violation of the rights of others,
occurring since age 15years, as indicated by three (or more) of the following:
1. failure to conform to social norms with respect to lawful behaviours as indicated
by repeatedly performing acts that are grounds for arrest
2. deceitfulness, as indicated by repeated lying, use of aliases, or conning others for
personal profit or pleasure
3. impulsivity or failure to plan ahead
4. irritability and aggressiveness, as indicated by repeated physical fights or assaults
5. reckless disregard for safety of self or others
6. consistent irresponsibility, as indicated by repeated failure to sustain consistent
work behaviour or honour financial obligations
7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
mistreated, or stolen from another
B. The individual is at least age 18 years
C. There is evidence of conduct disorder with onset before age 15 years
D. The occurrence of antisocial behaviour is not exclusively during the course of
schizophrenia or bipolar disorder
e.g., Steven is a 27-year-old single man, who seeks the psychologist to get a diagnosis which
could help him to get financial assistance from the state for debt restructuring. During
intake he tells that he worked at a store for a few years and that in the meantime he stole
$30,000 because he did not earn enough to live the life he wanted to. When the store
owner finally caught him, Steven got fired, but as he put it, “the owner of the store was too
stupid to charge me, so it is his own fault that he does not get the money back”.
Afterwards he worked in a jewellery store where expensive watches were sold. He says that
watches are his obsession – or as he formulates it, his “odd focus”. He says that he has
difficulties in recognizing people’s facial expressions and that he has difficulty in empathizing
with others. He thinks that he has a form of autism and therefore he consults the
psychologist so that he can confirm this diagnosis. The psychologist is reluctant, because
when he asks Steven if he would be fine with bringing his mother and his girlfriend for a
developmental anamnesis and a hetero-anamnesis, he becomes irritated and threatening
towards the psychologist. He says that his mother always does what he wants – so she will
of course come for an anamnesis – she always gives him money when he asks. Later on, he
says that his mother became afraid of him, because he behaves so unpredictably and
because he hits his girlfriend when she behaves disrespectfully.
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Borderline personality disorder
- patients ‘characteristics:
a pervasive pattern of instability across multiple domains, including affect, interpersonal
relationships, and self-image
extremely angry at one moment, despondent the next (these intense mood shifts are hard
to predict and most often short-lived)
in relationships, they may feel that their partner is “perfect” on any particular day, yet
totally worthless the next day
fears of abandonment often predominate
self-destructive impulsivity, which includes (but is not limited to) deliberate self-harm,
or (para)suicidal behaviours
sense of self is compromised (patients feel emptiness, or not knowing who they really
are)
- 5/9 criteria need to be met to satisfy the formal diagnosis:
A pervasive pattern of instability of interpersonal relationships, self-image, and affects,
and marked impulsivity beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) of the following:
1. frantic efforts to avoid real or imagined abandonment
2. a pattern of unstable and intense interpersonal relationships characterized by
alternating between extremes of idealization and devaluation
3. identity disturbance: markedly and persistently unstable self-image or sense of self
4. impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex,
substance abuse, reckless driving, binge eating).
5. recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
6. affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria,
irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
7. chronic feelings of emptiness
8. inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of
temper, constant anger, recurrent physical fights)
9. transient, stress-related paranoid ideation or severe dissociative symptoms
e.g., Brandon is a 37-year-old father of two daughters from different women, who presents
himself to the outpatient clinic with depressive symptoms. As long as he can remember his
life has been a roller coaster – or as he puts it: his life has been cursed. He refers to his
unhappy childhood, his unstable adolescence, and the turbulences of his adult life, living in
crisis and depression and climbing up from these to fall again. He remembers his parents as
being absent and cold and that he spent long periods at children’s homes where he got
bullied “for being such a wimp”.
Since adulthood, he finds it suspicious when people are nice to him and he experiences it as
disrespectful towards him if somebody does not agree with him; he interprets this as
looking for confrontation. If his two daughters of five- and eight-years old do not do what he
expects, he yells and swears at them and tells them that he hates them and that they
destroy his life. Additionally, he calls them egoistic and threatens that he will commit
suicide. Afterwards he often leaves the girls home alone and goes out to a bar.
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Brandon is very impulsive and cannot control his anger and feelings of hate. He thinks that
he knows exactly what others think or feel, but when somebody is quiet for a minute, he
interprets it as aggression, if somebody cares for him he interprets it as a lie, if somebody
makes a joke he feels attacked – and when somebody apologizes for something he thinks
they are being dishonest.
Histrionic personality disorder
- patients’ characteristics:
the lability and shallowness of their affect (key feature of this PD): may quickly change from
being very sad to very cheerful, and express both feelings equally dramatically
seek to be the centre of attention, and are unhappy when they are not
to attract attention they may be overly emotionally expressive or use their appearance (to
the risk of being inappropriate)
quite extroverted and tend to perceive their relationships as more special than others do
- 5/8 criteria need to be met to satisfy the formal diagnosis:
A pervasive pattern of excessive emotionality and attention seeking, beginning by early
adulthood and present in a variety of contexts, as indicated by five (or more) of the
following:
1. is uncomfortable in situations in which he/ she is not the centre of attention
2. interaction with others is often characterized by inappropriate sexually seductive or
provocative behavior
3. displays rapidly shifting and shallow expression of emotions
4. consistently uses physical appearance to draw attention to self
5. has a style of speech that is excessively impressionistic and lacking in detail
6. shows self-dramatization, theatricality, and exaggerated expression of emotion
7. is suggestible, i.e. easily influenced by others or circumstances
8. considers relationships to be more intimate than they actually are
e.g., Betty, a 25-year-old woman, is trying to finish her college education. She is an
attractive young woman. At events, when there are sufficient “important” people, she
knows how to draw attention to herself, presenting herself in revealing clothes. She always
knows how to become the centre of attention. Right now she is in crisis because she did not
meet the final deadline to finish her thesis. Totally unforeseen to her, her supervisor had
given her a fail, which meant that she had to postpone her traineeship for another year.
She felt that her supervisor had let her down because he did not react to her “advances”
during the final evaluation. She had tried to explain to him why it was a special situation in
her case – but he just did not respond to her “despair”. Afterwards, in her despair, she calls
her “boyfriend”, who she met the previous weekend after a concert. He was the lead singer
and they spent a night together “after she seduced him”. She has since told everybody that
she is going out with the lead singer.
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