Learning Unit 7

LECTURE 1
LEARNING GOALS

A student should be able to:

o Identify the characteristics of a personality disorder (PD) o Distinguish

between personality traits vs. personality disorders o To identify the
various etiologies of PD o To compare and distinguish the different PDs and
their characteristics, including: - Three clusters
- Diagnostic criteria and (associated) features
- Prevalence, development and course
- Risk and prognostic factors
- Culture- and gender-related diagnostic issues
- Differential diagnosis
o Apply knowledge of PDs and their characteristics to clinical examples

• DSM-5
• PERSONALITY DISORDERS

• Paranoid personality disorder = a pattern of distrust and suspiciousness such that others’
motives are interpreted as malevolent.
• Schizoid personality disorder = a pattern of detachment from social relationships and a
restricted range of emotional expression.
• Schizotypal personality disorder = a pattern of acute discomfort in close relationships,
cognitive or perceptual distortions, and eccentricities of behavior.
• Antisocial personality disorder = a pattern of disregard for, and violation of, the rights of
others.
• Borderline personality disorder = a pattern of instability in interpersonal relationships, self-
image, and affects, and marked impulsivity.
• Histrionic personality disorder = a pattern of excessive emotionality and attention seeking.
• Narcissistic personality disorder = a pattern of grandiosity, need for admiration, and lack of
empathy.
• Avoidant personality disorder = a pattern of social inhibition, feelings of inadequacy, and
hypersensitivity to negative evaluation.
• Dependent personality disorder = a pattern of submissive and clinging behavior related to an
excessive need to be taken care of.
• Obsessive-compulsive personality disorder = a pattern of preoccupation with orderliness,
perfectionism, and control.

CLUSTERS
 A. Paranoid, schizoid, and schizotypal personality disorders = individuals appear odd or
eccentric (5.7%)
B. Antisocial, borderline, histrionic, and narcissistic personality disorders = individuals
appear dramatic, emotional, or erratic (1.5%)
C. Avoidant, dependent, and obsessive-compulsive personality disorders = individuals
appear anxious or fearful (6.0%)
• Prevalence for any personality disorder = 9.1%
• U.S. adult’s prevalence = 15%

GENERAL PERSONALITY DISORDER

A. An enduring pattern of inner experience and behavior that deviates markedly from the
expectations of the individual’s culture. This pattern is manifested in two (or more) of the
following areas:
1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional
response).
3. Interpersonal functioning.
4. Impulse control.
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social
situations.
C. The enduring pattern leads to clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least to
adolescence or early adulthood.
E. The pattern is not better explained as a manifestation or consequence of another mental
disorder.
F. The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication) or another medical condition (e.g., head trauma).

DIAGNOSTIC FEATURES

• Personality traits = enduring patterns of perceiving, relating to, and thinking about the
environment and oneself that are exhibited in a wide range of social and personal contexts.
• The diagnosis of PDs requires an evaluation of the individual’s long-term patterns of
functioning, and the particular personality features must be evident by early adulthood.
• The personality traits that define these disorders must also be distinguished from
characteristics that emerge in response to specific situational stressors or more transient
mental states (e.g., bipolar, depressive, or anxiety disorders; substance intoxication).
• The clinician should assess the stability of personality traits over time and across different
situations. Assessment can also be complicated by the fact that the characteristics that define a
PD may not be considered problematic by the individual (i.e., the traits are often ego-
syntonic).
 DEVELOPMENT AND COURSE

• The features become recognizable during adolescence or early adult life.

• Enduring pattern of thinking, feeling, and behaving that is relatively stable over time.
• For a PD to be diagnosed in an individual younger than 18 years, the features must have been
present for at least 1 year, except antisocial personality disorder, which cannot be diagnosed in
individuals younger than 18 years.

GENDER-RELATED DIAGNOSTIC ISSUES

• Certain PDs (e.g., antisocial personality disorder) are diagnosed more frequently in males, and
others (e.g., borderline, histrionic, and dependent personality disorder) are diagnosed more
frequently in females.

DIFFERENTIAL DIAGNOSIS

• For the three PDs that may be related to the psychotic disorders (i.e., paranoid, schizoid, and
schizotypal), there is an exclusion criterion stating that the pattern of behavior must not have
occurred exclusively during the course of schizophrenia, a bipolar or depressive disorder with
psychotic features, or another psychotic disorder.
• The clinician must be cautious in diagnosing PDs during an episode of a depressive or anxiety
disorder.
• When personality changes emerge and persist after an individual has been exposed to extreme
stress, a diagnosis of posttraumatic stress disorder should be considered.
• When an individual has a substance use disorder, it’s important not to make a PD diagnosis
based solely on behavior that are consequences of substance intoxication or withdrawal, or
that are associated with activities in the service of sustaining substance use (e.g., antisocial
behavior).
• When enduring changes in personality arise as a result of the physiological effects of another
medical condition (e.g., brain tumor), a diagnosis of personality change due to another medical
condition should be considered.

CLUSTER A PERSONALITY DISORDERS

PARANOID PERSONALITY DISORDER

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
or 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
physiological effects of another medical condition.

DIAGNOSTIC FEATURES

• The essential feature of paranoid personality disorder is a pattern of pervasive distrust and
suspiciousness of others such that their motives are interpreted as malevolent.
• This pattern begins by early adulthood and is present in a variety of contexts.

ASSOCIATED FEATURES SUPPORTING DIAGNOSIS

• Difficult to get along with and having problems with close relationships.
• Because they are hypervigilant for potential threats, they may act in a guarded, secretive, or
devious manner and appear to be “cold” and lacking in tender feelings.
• Having an excessive need to be self-sufficient and a strong sense of autonomy.
• Having a high degree of control over those around them and often being rigid, critical of
others, and unable to collaborate, although they have great difficulty accepting criticism
themselves.
• They may blame others for their shortcomings.
• They may be litigious and frequently become involved in legal disputes.
• They may exhibit thinly hidden, unrealistic grandiose fantasies, are often attuned to issues of
power and rank, and tend to develop negative stereotypes of others, particularly those from
population groups distinct from their own

PREVALENCE

• 2.3% (based on probability subsample from Part II of the National Comorbidity Survey
Replication).
• 4.4% (based on National Epidemiologic Survey on Alcohol and Related Conditions).
 DEVELOPMENT AND COURSE

• May be first apparent in childhood and adolescence with solitariness, poor peer relationships,
social anxiety, underachievement in school, hypersensitivity, peculiar thoughts and language,
and idiosyncratic fantasies.
• More commonly diagnosed in males.

RISK AND PROGNOSTIC FACTORS

• Genetic and physiological: some evidence for an increased prevalence of paranoid personality
disorder in relatives of probands with schizophrenia and for a more specific familial
relationship with delusional disorder, persecutory type.
• Culture-related diagnostic issues: members of minority groups, immigrants, political and
economic refugees, or individuals of different ethnic backgrounds may display guarded or
defensive behaviors because of unfamiliarity (e.g., language barriers or lack of knowledge of
rules and regulations) or in response to the perceived neglect or indifference of the majority of
society.

DIFFERENTIAL DIAGNOSIS

• Paranoid PD can be distinguished from delusional disorder, persecutory type; schizophrenia;

and a bipolar or depressive disorder with psychotic features because these disorders are all
characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations).
• Paranoid PD must be distinguished from personality change due to another medical condition,
in which the traits that emerge are attributable to the direct effects of another medical
condition on the central nervous system.
• Paranoid PD must be distinguished from symptoms that may develop in association with
persistent substance use.
• Paranoid PD must be distinguished from paranoid traits associated with the development of
physical handicaps (e.g., a hearing impairment).

Personality disorder Similarities with paranoid PD Differences with paranoid PD

Schizotypal • Suspiciousness • Magical thinking (schizotypal)
• Interpersonal aloofness • Unusual perceptual experiences
• Paranoid ideation (schizotypal)
• Odd thinking and speech (schizotypal)
Schizoid • Perceived as strange, eccentric, cold, • Prominent paranoid ideation (paranoid)
and aloof
Borderline • React to minor stimuli with anger • Pervasive suspiciousness (paranoid)
Histrionic • React to minor stimuli with anger • Pervasive suspiciousness (paranoid)
Avoidant • Reluctant to confide in others • From fear of being embarrassed or
found inadequate (avoidant)
• From fear of others’ malicious intent
(paranoid)
 Antisocial • Antisocial behavior • Motivated by a desire for personal gain
or to exploit others (antisocial)
• Motivated by a desire for revenge
(paranoid)
Narcissistic • Suspiciousness • From fears of having their imperfections
• Social withdrawal or flaws revealed (narcissistic)
• Alienation

SCHIZOID PERSONALITY DISORDER

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.

DIAGNOSTIC FEATURES

• The essential feature of schizoid PD is a pervasive pattern of detachment from social

relationships and a restricted range of expression of emotions in interpersonal settings.

ASSOCIATED FEATURES SUPPORTING DIAGNOSIS

• May have particular difficulty expressing anger, even in response to direct provocation, which
contributes to the impression that they lack emotion.
• Their lives sometimes seem directionless, and they may appear to “drift” in their goals.
• Often react passively to adverse circumstances and have difficulty responding appropriately to
important life events.
• Have few friendships, date infrequently, and often do not marry.
• May do well when they work under conditions of social isolation.
• May experience very brief psychotic episodes.

PREVALENCE
• Uncommon in clinical settings.
• 4.9% (based on probability subsample from Part II of the National Comorbidity Survey
Replication).
• 3.1% (based on data from the 2001-2002 National Epidemiologic Survey on Alcohol and
Related Conditions).

DEVELOPMENT AND COURSE

• May be first apparent in childhood and adolescence with solitariness, poor peer relationships,
and underachievement in school, which mark these children or adolescents as different and
make them subject to teasing.

RISK AND PROGNOSTIC FACTORS

• Genetic and physiological: schizoid PD may have increased prevalence in the relatives of
individuals with schizophrenia or schizotypal PD.
• Culture-related diagnostic issues: individuals from a variety of cultural backgrounds sometimes
exhibit defensive behaviors and interpersonal styles that may be erroneously labeled as
“schizoid”, immigrants from other countries are sometimes mistakenly perceived as cold,
hostile, or indifferent.
• Gender-related diagnostic issues: schizoid PD is diagnosed slightly more in males and may
cause more impairment on them.

DIFFERENTIAL DIAGNOSIS

• Schizoid personality disorder can be distinguished from delusional disorder, schizophrenia,

and a bipolar or depressive disorder with psychotic features because these disorders are all
characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations).
• There may be great difficulty differentiating individuals with schizoid personality disorder from
those with milder forms of autism spectrum disorder, which may be differentiated by more
severely impaired social interaction and stereotyped behaviors and interests.

Personality disorder Similarities with schizoid PD Differences with schizoid PD

Schizotypal • • Lack of cognitive and perceptual

distortions (schizoid)
Paranoid • • Lack of suspiciousness and paranoid
ideation (schizoid)
Avoidant • Social isolation • Attributable to fear of being
embarrassed or found inadequate and
excessive anticipation of rejection
(avoidant)
• More pervasive detachment and limited
 desire for social intimacy (schizoid)
Obsessive-compulsive • Social detachment • Stemming from devotion to work and
discomfort with emotions
(obsessivecompulsive)
• Underlying capacity for intimacy
(obsessivecompulsive)
Loners (no PD) • Personality traits that might be • Only when these traits are inflexible and
considered maladaptive and cause significant
schizoid impairment or subjective distress do
they constitute schizoid
SCHIZOTYPAL PERSONALITY DISORDER

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 perceptual distortions and
eccentricities of behavior, 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, 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, overelaborate, or
stereotyped).
5. Suspiciousness or paranoid ideation.
6. Inappropriate or constricted affect.
7. Behavior 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 judgments 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.

DIAGNOSTIC FEATURES

• The essential feature of schizotypal personality disorder is 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 perceptual distortions and eccentricities of behavior.
• Ideas of reference = incorrect interpretations of casual incidents and external events as having
a particular and unusual meaning specifically for the person.
• Delusions of reference = the aforementioned beliefs are held with delusional conviction.

ASSOCIATED FEATURES SUPPORTING DIAGNOSIS

• Individuals with schizotypal personality disorder often seek treatment for the associated
symptoms of anxiety or depression rather than for the personality disorder features per se.
• Particularly in response to stress, individuals with this disorder may experience transient
psychotic episodes, although they usually are insufficient in duration to warrant an additional
diagnosis such as brief psychotic disorder or schizophreniform disorder.

PREVALENCE

• 0.6% (in Norwegian samples).

• 4.6% (in a U.S. community sample).
• The prevalence of schizotypal personality disorder in clinical populations seems to be
infrequent (0% - 1.9%), with a higher estimated prevalence in the general population (3.9%)
found in the National Epidemiologic Survey on Alcohol and Related Conditions.
DEVELOPMENT AND COURSE

• Schizotypal personality disorder has a relatively stable course, with only a small proportion of
individuals going on to develop schizophrenia or another psychotic disorder.
• May be first apparent in childhood and adolescence with solitariness, poor peer relationships,
social anxiety, underachievement in school, hypersensitivity, peculiar thoughts and language,
and bizarre fantasies.
• These children may appear “odd” or “eccentric” and attract teasing.

RISK AND PROGNOSTIC FACTORS

• Genetic and physiological: schizotypal personality disorder appears to aggregate familiarly and
is more prevalent among the firstdegree biological relatives of individuals with schizophrenia
than among the general population.
• Cultural-related diagnostic issues: pervasive culturally determined characteristics, particularly
those regarding religious beliefs and rituals, can appear to be schizotypal to the uninformed
outsider (e.g., voodoo, speaking in tongues, life beyond death, shamanism, mind reading, sixth
sense, evil eye, magical beliefs related to health and illness).
• Gender-related diagnostic issues: schizotypal personality disorder may be slightly more
common in males.

DIFFERENTIAL DIAGNOSIS

• Schizotypal personality disorder can be distinguished from delusional disorder, schizophrenia,

and a bipolar or depressive disorder with psychotic features because these disorders are all
characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations).
• There may be great difficulty differentiating children with schizotypal personality disorder from
the heterogeneous group of solitary, odd children whose behavior is characterized by marked
 social isolation, eccentricity, or peculiarities of language and whose diagnoses would probably
include milder forms of autism spectrum disorder or language communication disorders.
• Communication disorders may be differentiated by the primacy and severity of the disorder in
language and by the characteristic feature of impaired language found in a specialized
language assessment.
• Milder forms of autism spectrum disorder are differentiated by the even greater lack of social
awareness and emotional reciprocity and stereotyped behaviors and interests.
Personality Similarities with schizotypal Differences with schizotypal PD
disorder PD
Paranoid • Social detachment • Presence of cognitive or perceptual distortions and
• Restricted affect marked eccentricity or oddness (schizotypal)
Schizoid • Social detachment • Presence of cognitive or perceptual distortions and
• Restricted affect marked eccentricity or oddness (schizotypal)
Avoidant • Limited close relationships • Active desire for relationships is constrained by a fear of
rejection (avoidant)
• Lack of desire for relationships and persistent
detachment (schizotypal)
Narcissistic • Suspiciousness • Derive primarily from fears of having imperfections or
• Social withdrawal flaws revealed (narcissistic)
• Alienation
Borderline • Transient, psychotic-like • More closely relate to affective shifts in response to
symptoms stress and usually more dissociative (borderline)
• Social isolation
• Enduring psychotic-like symptoms that may worsen
under stress but are less likely to be invariably
associated with pronounced affective symptoms
(schizotypal)
• Social isolation is usually secondary to repeated
interpersonal failures due to angry outbursts and
frequent mood shifts (borderline)
• Social isolation as a result of a persistent lack of social
contacts and desire for intimacy (schizotypal)
• Don’t usually demonstrate the impulsive or
manipulative behaviors of individuals with borderline
(schizotypal)
Schizotypal • • May be reflective of transient emotional turmoil, rather
features than an enduring personality disorder
during
adolescence
(no PD)

CLUSTER B PERSONALITY DISORDERS

ANTISOCIAL PERSONALITY DISORDER

A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age
15 years, as indicated by three (or more) of the following:
 1. Failure to conform to social norms with respect to lawful behaviors, 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
behavior or honor 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 behavior is not exclusively during the course of schizophrenia or
bipolar disorder.

DIAGNOSTIC FEATURES

• The essential feature of antisocial disorder is a pervasive pattern of disregard for, and
violation of, the rights of others that begins in childhood or early adolescence and continues
into adulthood.
• This pattern has also been referred to as psychopathy, sociopathy, or dissocial personality
disorder.
• Because deceit and manipulation are central features of antisocial personality disorder, it may
be especially helpful to integrate information acquired from systematic clinical assessment
with information collected from collateral sources.
• Conduct disorder = a repetitive and persistent pattern of behavior in which the basic rights of
others or major age-appropriate societal norms or rules are violated.
- Fall into one of four categories: aggression to people and animals, destruction of
property, deceitfulness or theft, or serious violation of rules.

ASSOCIATED FEATURES SUPPORTING DIAGNOSIS

• Frequently lack empathy and tend to be callous, cynical, and contemptuous of the feelings,
rights, and sufferings of others.
• May have an inflated and arrogant self-appraisal (e.g., feel that ordinary work is beneath them
or lack a realistic concern about their current problems or their future) and may be excessively
opinionated, self-assured, or cocky.
• May display a glib, superficial charm and can be quite voluble and verbally facile (e.g., using
technical terms or jargon that might impress someone who is unfamiliar with the topic).
• Lack of empathy, inflated self-appraisal, and superficial charm are features that have been
commonly included in traditional conceptions of psychopathy that may be particularly
 distinguishing of the disorder and more predictive of recidivism in prison or forensic settings,
where criminal, delinquent, or aggressive acts are likely to be nonspecific.
• May also be irresponsible and exploitative in their sexual relationships.
• May have a history of many sexual partners and may never have sustained a monogamous
relationship.
• May be irresponsible as parents, as evidenced by malnutrition of a child, an illness in the child
resulting from a lack of minimal hygiene, a child’s dependence on neighbors or nonresident
relatives for food or shelter, a failure to arrange for a caretaker for a young child when the
individual is away from home, or repeated squandering of money required for household
necessities.
• May receive dishonorable discharges from the armed services, may fail to be self-supporting,
may become impoverished or even homeless, or may spend many years in penal institutions.
• More likely to die prematurely from violent means (e.g., suicide, accidents, homicides).
• May also experience dysphoria, including complaints of tension, inability to tolerate boredom,
and depressed mood.
• May have associated anxiety disorders, depressive disorders, substance use disorders, somatic
symptom disorder, gambling disorder, and other disorders of impulse control.
• Often have personality features that meet criteria for other personality disorders, particularly
borderline, histrionic, and narcissistic personality disorders.
• Increased likelihood if the individual experienced childhood onset of conduct disorder (before
age 10 years) and accompanying attention-deficit/hyperactivity disorder.
• Child abuse or neglect, unstable or erratic parenting, or inconsistent parental discipline may
increase the likelihood that conduct disorder will evolve into antisocial personality disorder.

PREVALENCE

• Twelve-month prevalence rates are between 0.2% and 3.3%.

• Highest prevalence (greater than 70%) among severe samples of males with alcohol use
disorder and from substance abuse clinics, prisons, or other forensic settings.
• Higher in samples affected by adverse socioeconomic (i.e., poverty) or sociocultural (i.e.,
migration) factors.

DEVELOPMENT AND COURSE

• Antisocial personality disorder has a chronic course but may become less evident or remit as the
individual grows older, particularly by the fourth decade of life.

RISK AND PROGNOSTIC FACTORS

• Genetic and physiological: APD is more common among the first-degree biological relatives of
those with the disorder than in the general population, the risk of biological relatives of
 females with the disorder tends to be higher than males, biological relatives of individuals with
this disorder are also at increased risk for somatic symptom disorder and substance use
disorders.
- Within a family that has a member with APD, males more often have APD and SUD,
whereas females more often have somatic symptom disorder
- Both adopted and biological children of parents with antisocial personality disorder
have an increased risk of developing antisocial personality disorder, somatic symptom
disorder, and substance use disorders.
• Cultural-related diagnostic issues: APD appears to be associated with low socioeconomic
status and urban settings and diagnosis may be misapplied to individuals in settings in which
seemingly antisocial behavior may be part of a protective survival strategy.
• Gender-related diagnostic issues: APD is much more common in males than in females.

DIFFERENTIAL DIAGNOSIS

• This diagnosis is not given to individuals younger than 18 years and is given only if there is a
history of some symptoms of conduct disorder before age 15 years.
• For individuals older than 18 years, a diagnosis of conduct disorder is given only if the criteria
for antisocial personality disorder are not met.
• When antisocial behavior in an adult is associated with a substance use disorder, the diagnosis
of antisocial personality disorder is not made unless the signs of antisocial personality disorder
were also present in childhood and have continued into adulthood.

Personality disorder Similarities with antisocial PD Differences with antisocial PD

Narcissistic • Tendency to be tough-minded, glib, • Does not include characteristics of
superficial, exploitative, and lack impulsivity, aggression, and deceit
empathy (narcissistic)
• May not be as needy of the admiration
and envy of others (antisocial)
• Usually lack the history of conduct
disorder in childhood or criminal
behavior in adulthood
(narcissistic)
Histrionic • Tendency to be impulsive, • More exaggerated in their emotions and
superficial, excitement seeking, not characteristically engaged in
reckless, seductive, and antisocial behaviors (histrionic)
manipulative • Manipulative to gain nurturance
(histrionic)
Borderline • • Manipulative to gain nurturance
(borderline)
• Manipulative to gain profit or some
material gratification (antisocial)
• Less emotionally unstable (antisocial)
• More aggressive (antisocial)
Paranoid • Antisocial behavior may be present • Usually motivated by a desire for
personal gain or to exploit others
 (antisocial)
• Attributable to a desire for revenge
(paranoid)

BORDERLINE PERSONALITY DISORDER

A. 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. (Note: Do not include suicidal
or self-mutilating behavior covered in Criterion 5.)
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). (Note: Do not include suicidal or
self-mutilating behavior covered in Criterion 5.)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
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.

ASSOCIATED FEATURES SUPPORTING DIAGNOSIS

• May have a pattern of undermining themselves at the moment a goal is about to be realized
(e.g., dropping out of school just before graduation; regressing severely after a discussion of
how well therapy is going; destroying a good relationship just when it is clear that the
relationship could last).
• Some develop psychotic-like symptoms (e.g., hallucinations, body-image distortions, ideas of
reference, hypnagogic phenomena) during times of stress.
• May feel more secure with transitional objects (i.e., a pet or inanimate possession) than in
interpersonal relationships.
• Premature death from suicide may occur.
• Physical handicaps may result from self-inflicted abuse behaviors or failed suicide attempts.
• Recurrent job losses, interrupted education, and separation or divorce are common.
• Physical and sexual abuse, neglect, hostile conflict, and early parental loss are more common in
the childhood histories.
 • Common co-occurring disorders include depressive and bipolar disorders, substance use
disorders, eating disorders (notably bulimia nervosa), posttraumatic stress disorder, and
attention-deficit/hyperactivity disorder.

PREVALENCE

• 1.6% median population prevalence but may be as high as 5.9%.

• About 6% in primary care settings.
• About 10% among individuals seen in outpatient mental health clinics.
• About 20% among psychiatric inpatients.
• Prevalence may decrease in older age groups.

DEVELOPMENT AND COURSE

• There is considerable variability in the course of BPD.

• The most common pattern is one of chronic instability in early adulthood, with episodes of
serious affective and impulsive discontrol and high levels of use of health and mental health
resources.
• Although the tendency toward intense emotions, impulsivity, and intensity in relationships is
often lifelong, individuals who engage in therapeutic intervention often show impairments
beginning sometime during the first year.
• During their 30s and 40s, the majority attains greater stability in their relationships and
vocational functioning.

RISK AND PROGNOSTIC FACTORS

• Genetic and physiological: BPD is about five times more common among first-degree relatives
of those with the disorder than in the general population.
• Gender-related diagnostic issues: diagnosed predominantly (about 75%) in females.

DIFFERENTIAL DIAGNOSIS

• BPD often co-occurs with depressive or bipolar disorders.

Personality disorder Similarities with borderline PD Differences with borderline PD

Histrionic • Attention seeking, manipulative • Self-destructiveness, angry disruptions in
behavior, and rapidly shifting close relationships, and chronic feelings
emotions of deep
emptiness and loneliness (borderline)
Schizotypal • Paranoid ideas or illusions • More transient, interpersonally reactive,
 and responsive to external structuring
(borderline)
Paranoid • Angry reaction to minor stimuli • Relative stability of self-image, as well as
the relative lack of self-destructiveness,
impulsivity, and abandonment concerns
(paranoid)
Narcissistic • Angry reaction to minor stimuli • Relative stability of self-image, as well as
the relative lack of self-destructiveness,
impulsivity, and abandonment concerns
(narcissistic)
Antisocial • Manipulative behavior • Manipulative to gain profit, power, or
some other material gratification
(antisocial)
• Goal directed towards gaining the
concern of caretakers (borderline)
Dependent • Fear of abandonment • Reacts to abandonment with feelings of
emotional emptiness, rage, and
demands
(borderline)
• React with increasing appeasement and
submissiveness and urgently seek a
replacement relationship to provide
caregiving and support (dependent)
• Pattern of unstable and intense
relationships (borderline)

HISTRIONIC PERSONALITY DISORDER

A. 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 or she is not the center 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.

ASSOCIATED FEATURES SUPPORTIGN DIAGNOSIS

• May have difficulty achieving emotional intimacy in romantic or sexual relationships.

• Without being aware of it, they often act out a role (e.g., “victim” or “princess”) in their
relationships to others.
• May seek to control their partner through emotional manipulation or seductiveness on one
level, while displaying a marked dependency on them at another level.
• Have often impaired relationships with same-sex friends because their sexually provocative
interpersonal style may seem a threat to their friends’ relationships.
• May also alienate friends with demands for constant attention.
• Often become depressed and upset when they are not the center of attention.
• May crave novelty, stimulation, and excitement and tend to become bored with their usual
routine.
• Often intolerant of, or frustrated by, situations that involve delayed gratification, and their
actions are often directed at obtaining immediate satisfaction.
• Interest may lag quickly in a job or project which was initiated with great enthusiasm.
• Increased risk for suicidal gestures and threats to get attention and coerce better caregiving.
• Higher rates of somatic symptom disorder, conversion disorder (functional neurological
symptom disorder), and major depressive disorder.
• Borderline, narcissistic, antisocial, and dependent personality disorders often co-occur.

PREVALENCE

• 1.84%
• More frequently diagnosed in females.

DIFFERENTIAL DIAGNOSIS

Personality disorder Similarities with histrionic PD Differences with histrionic PD

Borderline • Attention seeking, manipulative • Self-destructiveness, angry disruptions in
behavior, and rapidly shifting close relationships, and chronic feelings
emotions of deep emptiness and identity
disturbance
(borderline)
Antisocial • Tendency to be impulsive, • Tend to be more exaggerated in their
superficial, excitement seeking, emotions and do not characteristically
reckless, seductive, and engage in antisocial behaviors
manipulative (histrionic)
• Manipulative to gain nurturance
(histrionic)
• Manipulative to gain profit, power, or
some other material gratification
(antisocial)
Narcissistic • Crave attention from others • Usually want praise for their
“superiority”
(narcissistic)
• Exaggerate intimacy of their • Willing to be viewed as fragile or
relationships with other people dependent if this is instrumental in
getting attention
(histrionic)
 • More apt to emphasize the “VIP” status
or wealth of their friends (narcissistic)
Dependent • Excessively dependent on others for • Without the flamboyant, exaggerated,
praise and guidance emotional features (dependent)

NARCISSISTIC PERSONALITY DISORDER

A. A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of
empathy, beginning by early adulthood and present in a variety of contexts, as indicated by
five (or more) of the following:

1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents,

expects to be recognized as superior without commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal
love.
3. Believes that he or she is “special” and unique and can only be understood by, or
should associated with, other special or high-status people (or institutions).
4. Requires excessive admiration.
5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable
treatment or automatic compliance with his or her expectations).
6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own
ends).
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of
others.
8. Is often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.

ASSOCIATED FEATURES SUPPORTING DIAGNOSIS

• Vulnerability in self-esteem makes these individuals very sensitive to “injury” from criticism or
defeat, this may haunt them and leave them feeling humiliated, degraded, hollow, and empty,
and they may react with disdain, rage, or defiant counterattack (which often leads to social
withdrawal or an appearance of humility that may mask and protect the grandiosity).
• Interpersonal relationships are typically impaired because of problems derived from
entitlement, the need for admiration, and the relative disregard for the sensitivities of others.
• Though overweening ambition and confidence may lead to high achievement, performance
may be disrupted because of intolerance of criticism or defeat.
• Sometimes vocational functioning can be very low, reflecting an unwillingness to take a risk in
competitive or other situations in which defeat is possible.
• Sustained feelings of shame of humiliation and the attendant self-criticism may be associated
with social withdrawal, depressed mood, and persistent depressive disorder (dysthymia) or
major depressive disorder.
• Sustained periods of grandiosity may be associated with a hypomanic mood.
 • Narcissistic PD is also associated with anorexia nervosa and substance use disorders
(especially related to cocaine).
• Histrionic, borderline, antisocial, and paranoid PDs may be associated with narcissistic PD.

PREVALENCE

• Estimates range from 0% to 6.2% in community samples.

DEVELOPMENT AND COURSE

• Narcissistic traits may be particularly common in adolescents and do not necessarily indicate
that the individual will go on to have narcissistic personality disorder.
• May have special difficulties adjusting to the onset of physical and occupational limitations that
are inherent in the aging process.
• Of those diagnosed, 50-75% are male.

DIFFERENTIAL DIAGNOSIS

• Grandiosity may emerge as part of a manic or hypomanic episode, but the association with
mood change or functional impairments helps distinguish these episodes from narcissistic PD.

Personality disorder Similarities with narcissistic PD Differences with narcissistic PD

Histrionic • Interactive style is coquettish • Grandiosity (narcissistic)
(flirterig) • Excessive pride in achievements, a
• Require much attention relative lack of emotional display, and
disdain for others’ sensitivities
(narcissistic)
• Need attention to be admiring
(narcissistic)
Antisocial • Interactive style is callous • Grandiosity (narcissistic)
(ongevoelig) • Does not necessarily include
• Tendency to be tough-minded, glib, characteristics of impulsivity, aggression,
superficial, exploitative, and and deceit (narcissistic) • May not be as
unemphatic needy of the admiration and envy of
others (antisocial)
• Usually lack the history of conduct
disorder in childhood or criminal
behavior in adulthood
(narcissistic)
Borderline • Interactive style is needy • Grandiosity (narcissistic)
• Require much attention • Relative stability of self-image
(narcissistic)
• Relative lack of self-destructiveness,
impulsivity, and abandonment concerns
(narcissistic)
 • Need attention to be admiring
(narcissistic)
Obsessive-compulsive • May profess a commitment to • Self-criticism (obsessive-compulsive)
perfectionism and believe that • More likely to believe that they have
others cannot do things as well achieved perfection (narcissistic)
Schizotypal • Suspiciousness and social • Core feature (schizotypal)
withdrawal • Derive primarily from fears of having
imperfections or flaws revealed
(narcissistic)
Paranoid • Suspiciousness and social • Core feature (paranoid)
withdrawal • Derive primarily from fears of having
imperfections or flaws revealed
(narcissistic)

CLUSTER C PERSONALITY DISORDERS

AVOIDANT PERSONAILTY DISORDER

A. A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative

evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by
four (or more) of the following:

1. Avoids occupational activities that involves significant interpersonal contact because of

fear of criticism, disapproval, or rejection.
2. Is unwilling to get involved with people unless certain of being liked.
3. Shows restraint within intimate relationships because of the fear of being shamed or
ridiculed.
4. Is preoccupied with being criticized or rejected in social situations.
5. Is inhibited in new interpersonal situations because of feelings of inadequacy.
6. Views self as socially inept, personally unappealing, or inferior to others.
7. Is unusually reluctant to take personal risks or to engage in any new activities because
they may prove embarrassing.

ASSOCIATED FEATURES SUPPORTING DIAGNOSIS

• Often vigilantly appraise the movements and expressions of those with whom they come into
contact.
• Their fearful and tense demeanor may elicit ridicule and derision from others, which in turn
confirms their self-doubts.
• Are very anxious about the possibility that they will react to criticism with blushing or crying.
• Are described by others as being “shy”, “timid”, “lonely”, and “isolated”.
• The major problems occur in social and occupational functioning.
• The low self-esteem and hypersensitivity to rejection are associated with restricted
interpersonal contacts.
• May become relatively isolated and usually do not have a large social support network that can
help them weather crises.
• Desire affection and acceptance and may fantasize about idealized relationships with others.
• Co-occurring disorders include depressive, bipolar, and anxiety disorders, especially social
anxiety disorder (social phobia).
• Often diagnosed with dependent personality disorder, because individuals with avoidant
personality disorder become very attached to and dependent on those few other people with
whom they are friends.
• Tends to be diagnosed with borderline personality disorder and with the Cluster A personality
disorders.

PREVALENCE

• 2.4%
• Equally frequent in males and females.

DEVELOPMENT AND COURSE

• The avoidant behavior often starts in infancy or childhood with shyness, isolation, and fear of
strangers and new situations.
• Individuals who go on to develop avoidant personality disorder may become increasingly shy
and avoidant during adolescence and early adulthood, when social relationships with new
people become especially important.
• Some evidence that in adults it tends to become less evident or to remit with age.

DIFFERENTIAL DIAGNOSIS

• There appears to be a great deal of overlap between avoidant PD and social anxiety disorder
(social phobia), so much so that they may be alternative conceptualizations of the same or
similar conditions.

Personality disorder Similarities with avoidant PD Differences with avoidant PD

Dependent • Feelings of inadequacy, • Primary focus of concern is avoidance of
hypersensitivity to criticism, and a humiliation and rejection (avoidant)
need for reassurance • Focus on being taken care of
• Particularly likely to co-occur! (dependent)
Schizoid • Social isolation • Want to have relationships with others
and feel their loneliness deeply
(avoidant)
• May be content with and even prefer
their social isolation (schizoid)
Schizotypal • Social isolation • Want to have relationships with others
 and feel their loneliness deeply
(avoidant)
• May be content with and even prefer
their social isolation (schizotypal)
Paranoid • Reluctance to confide in others • Reluctance is attributable more to a fear
of being embarrassed or being found
inadequate (avoidant)
• Fear of others’ malicious intent
(paranoid)

DEPENDENT PERSONALITY DISORDER

A. A pervasive and excessive need to be taken care of that leads to submissive and clinging
behavior and fears of separation, beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) of the following:

1. Has difficulty making everyday decisions without an excessive amount of advice and
reassurance from others.
2. Needs others to assume responsibility for most major areas of his or her life.
3. Has difficulty expressing disagreement with others because of fear of loss of support
or approval. (Note: Do not
include realistic fears of retribution.)

4. Has difficulty initiating projects or doing things on his or her own (because of a lack of
self-confidence in judgment or abilities rather than a lack of motivation or energy).
5. Goes to excessive lengths to obtain nurturance and support from others, to the point
of volunteering to do things that are unpleasant.
6. Feels uncomfortable or helpless when alone because of exaggerated fears of being
unable to care for himself or herself.
7. Urgently seeks another relationship as a source of care and support when a close
relationship ends.
8. Is unrealistically preoccupied with fears of being left to take care of himself or herself.

ASSOCIATED FEATURES SUPPORTING DIAGNOSIS

• Are often characterized by pessimism and self-doubt, tend to belittle their abilities and assets,
and may constantly refer to themselves as “stupid”.
• They take criticism and disapproval as proof of their worthlessness and lose faith in
themselves.
• They may seek overprotection and dominance from others.
• Occupational functioning may be impaired if independent initiative is required.
• They may avoid positions of responsibility and become anxious when faced with decisions.
• Social relations tend to be limited to those few people on whom the individual is dependent.
• There may be an increased risk of depressive disorders, anxiety disorders, and adjustment
disorders.
• Often co-occurs with other personality disorders, especially borderline, avoidant, and
histrionic personality disorders.
• Chronic physical illness or separation anxiety disorder in childhood or adolescence may
predispose the individual to the development of this disorder.

PREVALENCE

• 0.49-0.6%
• Diagnosed more frequently in females, although some studies report similar prevalence rates
among males and females.

DEVELOPMENT AND COURSE

• This diagnosis should be used with great caution, if at all, in children and adolescents, for whom
dependent behavior may be developmentally appropriate.

DIFFERENTIAL DIAGNOSIS

Personality disorder Similarities with dependent PD Differences with dependent PD

Borderline • Fear of abandonment • React to abandonment with feelings of
emotional emptiness, rage, and
demands
(borderline)
• React with increasing appeasement and
submissiveness and urgently seeks a
replacement relationship (dependent)
• Typical pattern of unstable and intense
relationships (borderline)
Histrionic • Strong need for reassurance and • Self-efficacy and docile (volgzaam)
approval • May appear childlike and behavior (dependent)
clinging • Gregarious flamboyance with active
demands for attention (histrionic)
Avoidant • Feelings of inadequacy • Such a strong fear of humiliation that
• Hypersensitivity to criticism they withdraw until they are certain
• Need for reassurance they will be accepted (avoidant)
• Pattern of seeking and maintaining
connections to important others, rather
than avoiding and withdrawing from
relationships (dependent)

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

A. A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and
interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early
adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

1. Is preoccupied with details, rules, lists, order, organization, or schedules to the

extent that the major point of the activity is lost.
2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a
project because his or her own overly strict standards are not met).
3. Is excessively devoted to work and productivity to the exclusion of leisure activities
and friendships (not accounted for by obvious economic necessity).
4. Is over-conscientious, scrupulous, and inflexible about matters of morality, ethics, or
values (not accounted for by cultural or religious identification).
5. Is unable to discard worn-out or worthless objects even when they have no
sentimental value.
6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his
or her way of doing things.
7. Adopts a miserly spending style toward both self and others; money is viewed as
something to be hoarded for future catastrophes.
8. Shows rigidity and stubbornness.

ASSOCIATED FEATURES SUPPORTING DIAGNOSIS

• Decision making may become a time-consuming, often painful process.

• May have such difficulty deciding which tasks take priority or what is the best way of doing
some particular task that they may never get started on anything.
• Prone to become upset or angry in situations in which they are not able to maintain control of
their physical or interpersonal environment, although anger is typically not expressed directly.
• Usually express affection in a highly controlled or stilted fashion and may be very
uncomfortable in the presence of others who are emotionally expressive.
• Their everyday relationships have a formal and serious quality, and they may be stiff in
situations in which others would smile and be happy.
• They carefully hold themselves back until they are sure that whatever they say will be perfect.
• They may be preoccupied with logic and intellect, and intolerant of affective behavior in
others.
• They often have difficulty expressing tender feelings, rarely paying compliments.
• May experience occupational difficulties and distress, particularly when confronted with new
situations that demand flexibility and compromise.
• Individuals with anxiety disorders, including generalized anxiety disorder, social anxiety
disorder (social phobia), and specific phobias, and obsessive-compulsive disorder (OCD) have
an increased likelihood of having a personality disturbance that meets criteria for obsessive-
compulsive personality disorder.
• It appears that the majority of individuals with OCD do not have a pattern of behavior that
meets criteria for this personality disorder.
• Many of the features of obsessive-compulsive personality disorder overlap with “type A”
personality characteristics (e.g., preoccupation with work, competitiveness, time urgency), and
these features may be present in people at risk for myocardial infarction.
• There may be an association with depressive and bipolar disorders and eating disorders.

PREVALENCE

• One of the most prevalent PDs in the general population, with estimated prevalence ranging
from 2.1% go 7.9%.
• Diagnosed about twice as often among males.

DIFFERENTIAL DIAGNOSIS

• OCD is usually easily distinguished from OCPD by the presence of true obsessions and
compulsions in OCD.
• A diagnosis of hoarding disorder should be considered especially when hoarding is extreme
(e.g., accumulated stacks of worthless objects present a fire hazard and make it difficult for
others to walk through the house).

Personality disorder Similarities with OCPD Differences with OCPD

Narcissistic • Profess a commitment to • More likely to believe that they have achieved
perfectionism and believe perfection (narcissistic)
that others cannot do • Self-critical (OCPD)
things as well • Will indulge themselves (narcissistic)
• Lack generosity
Antisocial • Lack generosity • Will indulge themselves (narcissistic)
• Adopt a miserly spending style toward both self
and others
(OCPD)
Schizoid • Apparent formality and • Discomfort with emotions and excessive devotion
social detachment to work (OCPD)
• Fundamental lack of capacity for intimacy
(schizoid)

#1 NOTES
PERSONALITY DISORDERS

• An enduring pattern of inner experience and behavior (thinking, feeling and behavior) that
deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible,
has an onset in adolescence or early adulthood, is stable over time, and leads to distress or
impairment.
• Unique characteristics ¹ PD.
• Important that it cannot be better explained by another mental disorder, medical condition or
drugs.
• 3P’s = persistent (over time), pervasive (across different contexts), pathological (markedly
deviates from normal).

ETIOLOGY

• We don’t know a lot about where they come from.

• When we’re talking about etiology, we’re talking
about the diathesis-stress model ®
• There’s a lot of comorbidity, which suggests a role of
genes, but we don’t know a lot about that.

CLUSTERS OF PDS

A. 5% B. 1.5%

C. 6%

• Cluster B PDs are most well-known because of impact on society.

• Different extents to which people can suffer from these PDs.

CLUSTER A (ATYPICAL)

• Paranoid PD
- Suspiciousness
- More male
- Very guarded people
- We all have a certain degree of paranoia, which is healthy, but if you question
everyone it becomes pathological - Example: Stalin wasn’t able to trust anyone
and overanalyzed anything, super paranoid of every interaction
• Schizoid PD
- Detaching from social relationships
- Restricted range of emotional expressions
- More male
- Example: Dexter in the very first episodes, no desire in social relationships, lives very
limited, doesn’t need any social interaction, little connectedness
- More observant, not interested in intimacy and sexual relations
• Schizotypal PD
- Acute discomfort (not schizoid in no interest whatsoever), more atypical, eccentric -
Distortions in everyday life (not per se linked to stress)
- Odd, eccentric
 - Really misinterpret other people’s behaviors
- Off, unusual
- Example: Willy Wonk
- Over half has a history of a major depressive episode

CLUSTER B (BOOHOO! IN TERMS OF DRAMA)

• Antisocial PD
- Example: Joram van der Slot (Dutch serial killer)
- Disregard of and violation of other people’s rights
- “I just do my own thing, whatever I’m doing I don’t really care about rights and
boundaries and consequences” - Little empathy
- Problems with the law
- At least conduct disorder to start early on in childhood
- Self-appraisal, cocky, opiniated
- Not the same as psychopathy! Most psychopaths will meet the criteria though, but not
all people with antisocial PD are psychopaths
• Borderline PD
- Pattern of instability how they see themselves, how they feel, in social relationships -
Predominantly women
- Self-harm, impulsive, very difficult to be separated or rejected
- Chronic feelings of emptiness and overall instability
- Examples: Angelina Jolie, Amy Winehouse, Lindsay Lohan, Brittney Spears
• Histrionic PD
- “hysteria” or “hysterical neurosis”
- Excessive emotionality and attention seeking
- Overlap with borderline, but more about being the center of attention
- “victim” or “princess” whatever gets a lot of attention
- More sexually seductive behavior, because it’s an easy way to get attention
- Example: Regina George (Mean Girls), Kim Kardashian
• Narcissistic PD
- “anal”
- Grandiosity, need for admiration, lack of empathy
- “me, myself, and I”
- Snobbish, disdainful
- Examples: Kim Kardashian, Donald Trump, Kanye West
- More men

CLUSTER C (CONTROLLING FEAR)

• Avoidant PD
 - Example: Michael Jackson
- Social inhibition, try to refrain
- Feeling inadequate and sensitive
- Very worried
- Gender is quite equal
- Fear of being criticized or rejected
- Shy, timid, lonely, isolated
- Some overlap with schizoid
• Dependent PD
- Super submissive, clingy to others, excessive need to be taken care of
- Controlling fear by clinging to others
- Similar to avoidant: being afraid of criticism or rejection
- If they don’t cling to others, they don’t know what to do with their fear
• Obsessive-compulsive PD
- Example: Steve Jobs
- Preoccupation with orderliness, perfectionism, control, adherence to rules and
systems
- Wanting everything to be clean, ordered, structured
- Sometimes difficult to prioritize because everything seems important
- Linked to violence in the home
- NOT the same as OCD: OCD is about compulsions and behavior that are about dealing
with your own stress (I have to… because if I don’t…), OCPD is interpersonal because
they want other people to stick to the rules as well
Ø OCD = ego-dystonic (I don’t like it either but I have to)
Ø OCPD = ego-syntonic (I care about the rules because the rules are important to me
and they should be important to you too)

KEYWORDS

NEGATIVE

• Cluster A
- Paranoid: paranoid
- Schizoid: loners
- Schizotypal: eccentric
• Cluster B
- Antisocial: antisocial
- Borderline: drama queens
- Histrionic: attention seekers
- Narcissistic: me-myself-I
• Cluster C
- Avoidant: shy
 - Dependent: clingy
- Obsessive-compulsive: controlling

POSITIVE

• Cluster A
- Paranoid: careful, caring
- Schizoid: independent, autonomous
- Schizotypal: eccentric, unique
• Cluster B
- Antisocial: “own agenda” - Borderline: sensitive
- Histrionic: dramatic, flair
- Narcissistic: special, unique
• Cluster C
- Avoidant: shy
- Dependent: loyal, people-person
- Obsessive-compulsive: perfectionistic, conscientious