Download UNIT 9 PERSONALITY DISORDERS: CLUSTER B AND ... and more Lecture notes Psychiatry in PDF only on Docsity!
Disorders of Personality, Paraphilic and Substance- related Disorders
UNIT 9 PERSONALITY DISORDERS:
CLUSTER B AND CLUSTER C*
Structure
9.0 Introduction 9.1 Cluster B Personality Disorders 9.1.1 Histrionic Personality Disorder 9.1.1.1 Causal Factors 9.1.1.2 Treatment 9.1.2 Narcissistic Personality Disorder 9.1.2.1 Causal Factors 9.1.2.2 Treatment 9.1.3 Antisocial Personality Disorder 9.1.3.1 Causal Factors 9.1.3.2 Treatment 9.1.4 Borderline Personality Disorder 9.1.4.1 Causal Factors 9.1.4.2 Treatment 9.2 Cluster C Personality Disorders 9.2.1 Avoidant Personality Disorder 9.2.1.1 Causal Factors 9.2.1.2 Treatment 9.2.2 Dependent Personality Disorder 9.2.2.1 Causal Factors 9.2.2.2 Treatment 9.2.3 Obsessive-Compulsive Personality Disorder 9.2.3.1 Causal Factors 9.2.3.2 Treatment 9.3 Socio-cultural Causes of personality Disorders 9.4 Summary 9.5 Keywords 9.6 Review Questions 9.7 References and Further Reading 9.8 Web Resources
Learning Objectives After reading this Unit, you will be able to: Explain the characteristics of Cluster B; Identify the characteristics of Cluster C personality disorders; Discuss the clinical causes, and treatment of histrionic, narcissistic, antisocial and borderline personality disorders; and
*Ms. Vrushali Pathak, Assistant Professor of Psychology (Ad-hoc), Jesus and Mary College, University of Delhi, New Delhi
Personality Disorders: Cluster B and Cluster C
Describe the clinical features, causal factors and treatment of avoidant, dependent and obsessive-compulsive personality disorders.
9.0 INTRODUCTION
Personality disorders are related to one’s personality structure and is the ‘normal’ way of functioning by the person. Personality disorders are classified into Cluster A, Cluster B, and Cluster C. In the previous Unit, you learnt about Cluster A personality disorders, that included paranoid personality disorder, schizoid personality disorder and schizotypal personality disorder. Their causal factors and treatment were also be discussed. In this Unit, the clinical features, causal factors and treatment of Cluster B and Cluster C personality disorders will be explained.
9.1 CLUSTER B PERSONALITY DISORDERS
The prevailing symptoms of Cluster B are being dramatic, erratic or emotional. We will discuss histrionic, narcissistic, antisocial and borderline personality disorders in this section.
9.1.1 Histrionic Personality Disorder
Histrionic personality disorder is characterised by exaggerated expression of emotions such as hugging someone fiercely they have just met or crying uncontrollably during a sad movie (Skodol & Gunderson, 2008). Another characteristic feature of this disorder is excessive attention-seeking behavior. Their lively, charming, dramatic and extraverted behavior usually makes them center of attention and they may feel unappreciated if they are not being attended to by people. But, soon people around them get tired of this level of attention they seek for constantly which usually results in unstable and unsatisfying relationships. Their appearance and behavior are usually found to be very dramatic, theatrical and at times sexually provocative as well (Freeman, Freeman & Rosenfield, 2005). They also tend to be vain, uncomfortable and self-centered when not in limelight and very much concerned about their looks. They can also be impulsive and can have difficulty in delaying gratification. Speech is often very vague, lacking details and also impressionistic with a major concern of approval from others. Their cognitive style could be characterized by a tendency to view situations in an absolutistic manner (black and white) (Beck, Freeman, & Davis, 2007).
The prevalence of histrionic personality disorder in the general population has been estimated to be around 2 to 3 percent (Blashfield, Reynolds, & Stennett,
- and some studies also suggest of its prevalence more in women as compared to men (Lynam & Widiger, 2007). The reasons provided behind this gender difference has been very controversial as it is suggested that the criteria for histrionic personality disorder encompasses maladaptive variants of female- related traits mainly such as seductiveness, vanity, overdramatization and too much concern with one’s physical appearance (Widiger & Bornstein, 2001). However, there are certain characteristic traits of this disorder which are more commonly found in men such as excitement seeking behavior or low consciousness. Some recent researches have pointed towards the influence of some form of bias on the basis of gender in the diagnosis of histrionic personality disorder (Lynam & Widiger, 2007).
Personality Disorders: Cluster B and Cluster C
9.1.1.2 Treatment
Therapists have tried to deal with the attention seeking behavior of the people with histrionic personality. For instance, in one of the researches, using a behavioral paradigm the researchers rewarded the appropriate behavior and interaction of people with traits like histrionic personality and were fined for their attention seeking behavior. They found significant improvement after an 18-month follow-up (Kass et al., 1972). As they usually manipulate people through their charm or emotional tactics, a large part of the therapy goes in focusing at their interpersonal relationships (Beck et al., 2007). They are also taught more appropriate and acceptable ways to negotiate in order to get their demands fulfilled.
9.1.2 Narcissistic Personality Disorder
According to Greek mythology, there was a young hunter Narcissus who remained aloof and arrogant, holding many women in disdain who happened to fall for him. To punish Narcissus for his arrogance, the goddess of revenge, Nemesis, put a spell on him due to which when he next noticed his reflection in a pool of water, he was enamored by it; love overtook him. He became entirely absorbed by his beautiful image without realizing that it was actually himself. Psychoanalysts have used the term narcissist to describe those individuals who give a lot of importance to themselves and are preoccupied with receiving attention from others most of the times (Cloninger & Svakic, 2009).
Narcissistic personality disorder is characterized by exaggerated sense of self importance that the individual gives to one’s self. Another important feature is preoccupation with seeking attention, admiration and lack of empathy (Ronningstam, 2005, 2009, 2012). It can be of two types: grandiose and vulnerable. The defining features of the grandiose type of narcissism are aggression, dominance and grandiosity. Thus, they are known to overestimate their abilities and underestimate that of the others. They have a high sense of entitlement and believe that they deserve it all. They brag a lot about themselves and use constant self-references, in order to get recognition which, they usually claim for. They easily take offense and rarely forgive others (Exline, Baumesiter, Bushman, Campbell, & Finkel, 2004). Vulnerable narcissists have a fragile sense of self-esteem and they use arrogance and disdain to mask their shame and hypersensitivity towards criticism and rejection from outside (Cain, Pincus & Ansell 2008). They usually avoid relationships and intimacy due to their fear of rejection and criticism. They might look completely absorbed with their achievements and its fantasies but they do experience and nurse profound shame about their ambitions. Both the types seem to be associated with high levels of antagonism/ low agreeableness (low modesty, arrogance, superiority, feelings of grandiosity), low altruism, and tough mindedness (lack of empathy). In the case of grandiose narcissist, it is the close relatives and family who are more distressed about their behavior rather than the individual (narcissist) herself/himself. Vulnerable narcissists usually have a high level of negative affectivity (Miller, Widiger, & Campbell, 2010). Wink (1991) tried understanding how the spouses of people narcissism described them and came to the conclusion that they are “bossy, intolerant, cruel, argumentative, dishonest, opportunist, conceited, arrogant, and demanding” and those with high grandiosity were also additionally described as being “aggressive, outspoken, hard-headed, assertive and
Disorders of Personality, Paraphilic and Substance- related Disorders
determined”, whereas patients high on vulnerability were “worrying, emotional, defensive, anxious, bitter, tense and also complaining” (p. 595).
Another important aspect of individuals with narcissism is their inability to take other person’s perspective and if they do not receive validation as they wanted or desired, they may turn out to be retaliatory (Rasmussen, 2005). This disorder may be seen more in men as compared to women (Golomb, Abraham, & Rosenbaum, 1995). It is a relatively rare disorder especially in comparison to other personality disorders with an estimated occurrence of 1 percent in the population.
Box 9.2: DSM 5 criteria for Narcissistic Personality Disorder (APA, 2013)
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:
- Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
- Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
- Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or highstatus people (or institutions).
- Requires excessive admiration.
- Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
- Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
- Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
- Is often envious of others or believes that others are envious of him or her.
- Shows arrogant, haughty behaviors or attitudes.
9.1.2.1 Causal factors
There is a wealth of theories about narcissistic personality disorder but little empirical research in comparison. Kohut (1978) believed that it arises mainly from the failure of parenting wherein parents fail to model empathy in the early developmental stages of the child. Thus, the child (and later as an adult) gets tangled in the endless search for this ideal person who would meet the unfulfilled empathic needs.
It has also been found that grandiose narcissism is not generally associated with childhood abuse, neglect or poor parenting but perhaps with parental overvaluation. On the other hand, vulnerable narcissism is associated with
Disorders of Personality, Paraphilic and Substance- related Disorders
assessment tool. Six of which are included in his Revised Psychopathy Checklist (PCL-R): 1. Glibness/superficial charm, 2. Grandiose self-worth, 3. Need for stimulation, 4. Pathological lying, 5. Conning/manipulation, and 6. Lack of remorse (Neumann, Hare, & Newman, 2007, p. 103).
There are two dimensions of psychopathy- a) affective and interpersonal core, b) behavioral dimension. The affective and interpersonal core consists of traits such as lack of remorse, callousness, glibness, lack of empathy, charm etc. while the behavioral dimension focuses mainly on the behavior including impulsivity, socially deviant lifestyle, poor and irresponsible behavior, parasitic lifestyle etc. DSM mainly focused on the observable behaviors as opposed to personality traits so that the clinicians could reliably agree on the diagnosis. The basic logic behind this is that it is difficult to assess someone for a trait of manipulation but comparatively easier to see if the individual is engaged in certain behavior such as repeated fighting or stealing. Some of the characteristics of antisocial personality disorder are described in Box 9.3.
Box 9.3: Some Characteristic Features of People with Antisocial Personality Disorder Inadequate conscience development Can understand ethical values only at a verbal level. Intellectual development is normal but conscience development is stunted (Fowles & Dind, 2005). Affective and interpersonal dimension is positively related to verbal intelligence but antisocial dimension is negatively related to intelligence. May “act out” tensions and then worry them. Irresponsibility and Impulsive behavior Total disregard for needs, rights and well-being of others. High on thrill seeking, deviant and unconventional behavior. Rarely forego immediate pleasure for some future gain. Occurrence of alcohol, or any other substance dependence and abuse. Elevated rates of suicide attempts Rejection of authority Do not follow social norms and rules. Difficulty with educational and law enforcement authorities. Behave as if immune to the consequences of their action. Ability to impress and exploit others Very charming, win friends easily (Patrick, 2005). Good sense of humor and optimistic outlook. Frequent liar, may seem sorry when caught in the act but are not so. Good insight into other people’s needs and weakness. Find excuses readily for their conduct, usually projecting blame on others.
Personality Disorders: Inability to maintain good relationships Cluster B and Cluster C Ability to win liking of others initially but rarely keep close friends and relationships. Irresponsible, cynical, unsympathetic, egocentric, ungrateful and remorseless. Cannot understand love. Violence towards family members is common. Manipulative and exploitative in their sexual relations. Considered as a menace for family and society.
Results from long term follow-up researches show that many adults with psychopathy or antisocial personality disorder had conduct disorder as children (Robins, 1978; Salekin, 2006). It has been found that the chances of having adult antisocial personality disorder increase if the child has had a history of both conduct disorder and attention deficit/hyperactivity disorder (Moffit, Caspi, Rutter, & Silva, 2001). A major difference between the two is that lack of remorse is there in antisocial personality disorder but not in the criteria for conduct disorder.
Box 9.4: DSM 5 Criteria for Antisocial Personality Disorder (APA, 2013) 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:
- Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
- Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
- Impulsivity or failure to plan ahead.
- Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
- Reckless disregard for safety of self or others.
- Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
- 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.
9.1.3.1 Causal Factors
In a classic study done by Crowe (1974), children of criminal mothers who were later adopted by other families were compared with adopted children of normal
Personality Disorders: Cluster B and Cluster C
9.1.3.2 Treatment
One of the major issues in treating ASPD is that they are capable of manipulating even their therapists, thus, there are very few documented successful treatment cases of ASPD. Mostly, therapists agree with detaining or imprisoning them for their antisocial acts so that any future such acts can be avoided. Precaution is something that has been mainly encouraged here so that the high-risk children can be identified and treatment can be attempted on them before they enter adulthood. One of the common strategies used is to train parents of these children by teaching them how to identify these behavioral problems and using a reward- based system to encourage prosocial behavior. However, family dysfunction, poor socioeconomic status or even high conduct related issues with the child may risk the treatment or may result in dropout form the treatment (Kaminski, Valle, Filene, & Boyle, 2008). Drugs such as lithium and anticonvulsants that are used to treat bipolar disorder have been found to be successful to some extent in dealing with aggressive/impulsive behavior but the evidence is not solid to make concrete conclusions (Markovitz, 2001). Cognitive behavioral therapy mainly targets: social perspective taking, helping them in increasing self-control, increasing victim-awareness, teaching anger management skills, changing antisocial attitudes and even curing their drug addiction. It is important to note here that when dealing with ASPD, therapists are actually dealing with the complete lifestyle of an individual rather than a few subsets of behavior (Hare et al., 2012). It has also been found that their behavior can be managed when they are in the prison or the facilities where treatment is being administered but does not generalize once these people go back to the real outside world (Harris & Rice, 2006).
9.1.4 Borderline Personality Disorder
The term borderline was originally used to refer to the people who had a condition which could be termed as being between neurotic and psychotic -”borderline”. However, later this explanation was termed as schizotypal personality disorder which is biologically also related to schizophrenia. The current diagnosis of borderline personality disorder (BPD) is not biologically linked to schizophrenia.
The characteristic pattern of people with BPD is impulsivity and instability in self-image, moods and even in relationships. This affective instability is usually manifested by extreme and intense responses to any of the environmental triggers without thinking about any sort of long-term consequences. They can also go through rapid shifts in emotions from one to another (Paris, 2007). Their sense of self has been described as fragmented. They have highly unstable relationships perhaps due to their unstable self-image and affective instability usually ending in disappointment and anger. Though, it also important to note here that their fear of abandonment is also very strong and thus they try to avoid it as much as possible (Livesley, 2008). These people are also prone to get into self-destructive and erratic behavior. Suicide attempts can also be a part of the clinical picture, it could be manipulative and some may also end up completing the act. Self-injury or self- mutilation id a common feature amongst people with BPD but again it has to be understood with caution that everyone or anyone engaging in any kind of self-harm do not have BPD, such a behavior could be performed to relieve oneself of anxiety or as a result of dysphoria.
Disorders of Personality, Paraphilic and Substance- related Disorders
With these behavioral and affective symptoms, there are cognitive symptoms as well in the patients with BPD. There can be very short periods when they may have psychotic-like symptoms such as losing contact with reality, delusional experiences or even hallucinations (Paris, 2007). This particular personality disorder leads to significant social, occupational and academic functioning and is also seen to commonly co-occur with mood disorders, anxiety disorders, eating disorders and substance-use as well.
Box 9.5: DSM-5 Criteria for Borderline Personality Disorder (APA, 2013)
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:
Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
Identity disturbance: markedly and persistently unstable self-image or sense of self.
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)
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
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).
Chronic feelings of emptiness.
Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
Transient, stress-related paranoid ideation or severe dissociative symptoms.
9.1.4.1 Causal Factors
It has been found that genetic factors may play an important role in development of BPD. One of the major aspects supporting this view is that both affective instability and impulsivity that are prominent manifestations of people with BPD are partially heritable (Hooley et al., 2012). The genes involved in regulation of the neurotransmitter dopamine may also have a role to play in BPD (Hooley et al., 2012) along with lower serotonin levels. The low serotonin level might be a reason why they are not able to stop their impulsive behaviors. Structural brain abnormalities studies show that patients with BPD may have reductions in the
Disorders of Personality, Paraphilic and Substance- related Disorders
9.2 CLUSTER C PERSONALITY DISORDERS
Cluster C personality disorders comprises of three personality disorders-avoidant, dependent and obsessive-compulsive. The common characteristics are anxiety and fearfulness. To help understand the mentioned disorders, let us look at the clinical features, causal factors and treatment of each disorder.
9.2.1 Avoidant Personality Disorder
Extreme social inhibition and introversion are characteristic patterns of avoidant personality disorder. Due to this they have a pattern of limited social relationships and are reluctant in social interactions. They do not seek out for other people as they are scared of being criticized for rebuffed by them. However, this does not mean that they do not desire affection; they often feel lonely and bored. Millon & Martinez (1995) believed that it is important to distinguish between individuals who are asocial as they are apathetic, have flat affect, indifferent towards criticism and not interested in interpersonal relationships (diagnosis comparable to schizoid personality disorder) and those who are asocial because they fear rejection and thus are interpersonally anxious. The latter category is the one that fits the diagnosis of avoidant personality disorder (Millon & Martinez, 1995). Unlike people with schizoid personality disorder, they do not enjoy their aloofness. Due to their inability to relate to others they may have low self-esteem and may even be associated with depression (Sanislow et al., 2012).
Researchers have concluded that people with avoidant personality disorder show generalized shyness or nervousness and may also avoid novel situations and even emotions (this can also include avoiding positive emotions). They may also exhibit their inability in experiencing pleasure (Taylor et al., 2004). Another tricky distinction is between social phobia and avoidant personality disorder. Some investigators have concluded that avoidant personality could be simply a more severe manifestation of generalized social phobia (Carter & Wu, 2010).
Box 9.6: DSM-5 Criteria for Avoidant Personality Disorder (APA, 2013)
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:
- Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
- Is unwilling to get involved with people unless certain of being liked.
- Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
- Is preoccupied with being criticized or rejected in social situations.
- Is inhibited in new interpersonal situations because of feelings of inadequacy.
- Views self as socially inept, personally unappealing, or inferior to others.
- Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
Personality Disorders: Cluster B and Cluster C
9.2.1.1 Causal Factors
Avoidant Personality disorder may have its roots in an innate “inhibited” temperament due to which the newly born, infant and child may feel timid or even inhibited in a new or an ambiguous situation. Some of the studies also show that genetic vulnerability for avoidant personality disorder can also been seen in people with social phobia if not fully then at least partially (Reichborn- Kjennerud et al., 2007). Fear of rejection and negative evaluation has also been found to be moderately heritable along with traits such as introversion and neuroticism and all these are prominent in people with avoidant personality disorder. There is also a possibility that these biologically based inhibited temperaments may actually serve as a diathesis and when one faces experiences such as emotional abuse or rejection (as a child), it may eventually lead to avoidant personality disorder.
9.2.1.2 Treatment
The problems experienced by people with avoidant personality are similar to those with social phobias and that is why a similar set of techniques is used for both. Behavioral intervention techniques for social skill management and anxiety are very helpful here as well (Borge et al., 2010). It is important to note that the therapeutic alliance is an important predictor in avoidant personality disorder for the success of treatment (Strauss et al., 2006).
9.2.2 Dependent Personality Disorder
Dependent personality disorder is characterised by an individual’s extreme need to be taken care of, thus, pointing towards her/his submissive and also clingy behavior. They may show fear of being separated from others just being alone as they find themselves inept or incompetent. They may not get angry with others, or find fault in others due to their fear of being separated from others or losing their support. This is indicative of the fact that such people may remain in physically or psychologically abusive relationships. Thus, they usually carve their lives around other people giving lesser importance to their own needs and not having confidence in themselves they take decisions with the help of others. In terms of the five-factor model, dependent personality disorder is associated with prevalence of neuroticism and agreeableness (Lowe et al., 2009).
The prevalence of dependent personality disorder has been seen in women more than men. This not just due to the gender bias in the diagnosis but mainly because of the higher prevalence of traits such as neuroticism and agreeableness in women which are also characteristic features of dependent personality disorder (Lynam & Widiger, 2007). Some of the features of dependent personality disorder also overlap with that of histrionic, borderline and avoidant personality and a clear understanding of the three necessary is to make a diagnosis. The difference between avoidant and dependent personality has already been highlighted above. Similarly, both borderline and dependent personalities fear abandonment by people around them but their reactions to it can be different, for instance, people with borderline personality may react with feelings of emptiness and rage whereas people with dependent personality may initially become submissive and then may seek for new relationships.
Personality Disorders: Cluster B and Cluster C
9.2.3 Obsessive-Compulsive Personality Disorder
People with obsessive-compulsive personality disorder (OCPD) show an excessive concern with maintaining order and control. They exhibit perfectionist tendencies by paying attention to rules, orders and schedules. Their perfectionism can be dysfunctional to the extent that they may never finish their projects as they are too preoccupied with trivial details and thus, utilize their time poorly (Yovel et al., 2005). They might be too devoted to work to the extent that they may have difficulty in doing anything for leisure and entertainment. Others may view them as rigid or cold as they usually don’t delegate tasks to others.
It is important to note that unlike people with Obsessive-Compulsive Disorder (OCD) they do not have obsessions or follow compulsive rituals. Instead people with OCPD have lifestyle characteristics of high neuroticism, inflexibility, high conscientiousness and also perfectionism. It has also been found that only about 20 percent of the people with OCD have a comorbid diagnosis of OCPD (Albert et al., 2004). In fact, people with OCD are more likely to be diagnosed with either avoidant or dependent personality disorder (Wu et al., 2006).
Box 9.8: DSM-5 Criteria for Obsessive-Compulsive Personality Disorder (APA, 2013) 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:
- Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
- 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).
- Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
- Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
- Is unable to discard worn-out or worthless objects even when they have no sentimental value.
- Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
- Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
- Shows rigidity and stubbornness.
9.2.3.1 Causal Factors
As per the biological dimensional approach of Cloninger (1987), there are three personality dimensions that have been discussed- novelty seeking, harm avoidance and reward dependence. People with OCPD are seen to have lower levels of
Disorders of Personality, Paraphilic and Substance- related Disorders
novelty seeking and reward dependence but a higher level of harm avoidance. Some research has also confirmed that OCPD traits show a modest genetic influence (Calvo et al., 2009). Personality trait-based theories have discussed that people with OCPD are high on conscientiousness (Samuel & Widiger, 2011). This could also be a reason for their perfectionist tendencies, highly controlling behavior or extreme devotion towards work.
9.2.3.2 Treatment
Therapy usually focuses on their need for keeping everything in control and order. They are helped by teaching them relaxation and distraction techniques to keep the compulsive thoughts away. Cognitive Behaviour Therapy has been found to be effective with patients of OCPD (Svartberg et al., 2004).
9.3 SOCIOCULTURAL CAUSES OF
PERSONALITY DISORDERS
According to some of the researches, there is less variation in personality disorders across cultures than within cultures. This could be due to the fact that all the cultures share the basic five personality traits (Allik, 2005). Paris (2001) noted that certain personality disorders have increased in the American society in past few years, this could be due to the changing cultural priorities with time. For instance, narcissistic personality disorder has been found to be more prevalent in western societies and a probable reason for it could be the emphasis on personal success and ambition (Widiger & Bornstein, 2001). It has also been suggested that as emotional dysregulation and impulsive behavior has increased over the years (especially since World War II), it may have some association with the increased prevalence of borderline and ASPDs over a period of time for the same time frame. It may have its connections with breakdown of traditional family systems and various other social structures (Paris, 2001). Thorough research in this area is required before making any further claims.
Check Your Progress 3 Fill in the blanks
- __________ and ___________are characteristic patterns of avoidant personality disorder.
- _____________ exhibit perfectionist tendencies by paying attention to rules, orders and schedules.
- Genetic influence has been found to be modest in the case of ____________.
- ____________therapy has been found to be effective with patients of OCPD.
- Avoidant Personality Disorder may have its roots in an ___________ temperament.
9.4 SUMMARY
Now that we have come to the end of this unit, let us list all the major points that we have learnt.
Disorders of Personality, Paraphilic and Substance- related Disorders
Dependent personality disorder: Characterised by an individual’s extreme need to be taken care of, pointing towards her/his submissive and clingy behavior.
Obsessive-compulsive Personality Disorder: Excessive concern with maintaining order and control, exhibit perfectionist tendencies by paying attention to rules, orders and schedules are the main charecteristies.
9.6 REVIEW QUESTIONS
- Elucidate the clinical features of borderline personality disorder.
- List the criteria for dependent personality disorder, according to DSM-5.
- What are the main characteristics of Cluster C personality disorders?
- Discuss some of the causes of avoidant personality disorder?
- What are the sociocultural causes of personality disorders?
9.7 REFERENCES AND FURTHER READING
Albert, U., Maina, G., Forner, F., & Bogetto, F. (2004). DSM-IV obsessive- compulsive personality disorder: Prevalence in patients with anxiety disorders and in healthy comparison subjects. Compr. Psychiatry , 45, 325–32.
Allik, J. (2005). Personality dimensions across cultures. J. Pers. Disord ., 19, 212–
American Psychiatric Assocation. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM (5th ed.). Washington, DC: American Psychiatric Association
Arntz, A., Weertman, A., & Salet, S. (2011). Behaviour research and therapy interpretation bias in cluster-c and borderline personality disorders. Behav. Res. Ther ., 49(8), 472–81. Elsevier Ltd. Doi:10.1016/j. brat.2011.05.002.
Bandelow, B., Krause, J., Wedekind, D., Broocks, A., Hajak, G. R., & Ruther, E. (2005). Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with borderline personality disorder and healthy controls. Psychiat. Res ., 134(2), 169–79.
Barlow, D. H., & Durand, V.M. (2012). Abnormal Psychology: An Integrative Approach. (6th ed.) Wadsworth Cengage Learning.
Beck, A. T., Freeman, A., & Davis, D. D. (2007). Cognitive Therapy of Personality Disorders (2nd ed.). New York, NY: Guilford Press.
Beck, A. T., Freeman, A., et al. (1990). Cognitive Therapy of Personality Disorders. New York: Guilford.
Bender, E. (2004). Data show wide variation in addiction treatment costs. Psychiatric News , 39, 11.
Blashfield, R., Reynolds, S. M., & Stennett, B. (2012). The death of histrionic personality disorder. In T. Widiger (Ed.), The Oxford Handbook of Personality Disorders (pp. 603–27). Oxford: Oxford University Press.
Bleuler, E. (1924). Textbook of Psychiatry (A. A. Brill, Trans.). New York, NY: Macmillan.
Personality Disorders: Cluster B and Cluster C
Borge, F. M., Hoffart, A., Sexton, H., Martinsen, E., Gude, T., Hedley, L. M., Abrahamsen, G. (2010). Pre-treatment predictors and in-treatment factors associated with change in avoidant and dependent personality disorder traits among patients with social phobia. Clinical Psychology & Psychotherapy , 17(2), 87–99.
Bornstein, R. F. (2011). Reconceptualizing personality pathology in DSM-5: Limitations in evidence for eliminating dependent personality disorder and other DSM-IV syndromes. J. Pers. Disord ., 25(2), 235–47. Doi:10.1521/ pedi.2011.25.2.
Bornstein, R. F. (2012). Dependent personality disorder. In T. Widiger (Ed.), The Oxford Handbook of Personality Disorders (pp. 505–26). Oxford: Oxford University Press.
Bornstein, R. F., & Malka, I. L. (2009). Dependent and histrionic personality disorders. In P. H. Blaney & T. Millon (Eds.), Oxford Textbook of Psychopathology (2nd ed., pp. 602–21). New York: Oxford University Press.
Butcher, J. N., Hooley, J. M., & Mineka, S. (2013). Abnormal Psychology. ( ed.) Pearson.
Cain, N. M., Pincus, A. L., & Ansell, E. B. (2008). Narcissism at the crossroads: Phenotypic description of pathological narcissism across clinical theory, social/ personality psychology, and psychiatric diagnosis. Clin. Psychol. Rev., 28, 638–
Cale, E. M., & Lilienfeld, S. O. (2002a). Histrionic personality disorder and antisocial personality disorder: Sex-differentiated manifestations of psychopathy. J. Pers. Disord., 16(1), 52–72. Cale, E. M., & Lilienfeld, S. O. (2002b). Sex differences in psychopathy and antisocial personality disorder: A review and integration. Clin. Psychol. Rev., 22, 1179–207.
Calvo, R., Lazaro, L., Castro-Fornieles, J., Font, E., Moreno, E., & Toro, J. (2009). Obsessive-compulsive personality disorder traits and personality dimensions in parents of children with obsessive-compulsive disorder. Eur. Psychiat., 24, 201–
Carter, S. A., & Wu, K. D. (2010). Relations among symptoms of social phobia subtypes, avoidant personality disorder, panic, and depression. Behav. Ther ., 41(1), 2–13. Doi:10.1016/j. beth.2008.10.
Chronis, A. M., Lahey, B. B., Pelham, W. E., Jr., Williams, S. H., Baumann, B. L., Kipp, H., Rathouz, P.J.. (2007). Maternal depression and early positive parenting predict future conduct problems in young children with attention deficit/ hyperactivity disorder. Developmental Psychology , 43, 70–82.
Cleckley, H. M. (1941). The Mask of Sanity (1st ed.). St. Louis, MO: Mosby.
Cleckley, H. M. (1982). The Mask of Sanity (Rev. ed.). New York: Plume.
Cloninger, C. R., & Svakic, D. M. (2009). Personality disorders. In B. J. Sadock, V. A. Sadock, & P. Ruiz (Eds.), Kaplan & Sadock’s comprehensive textbook of psychiatry (9th ed., Vol. II, pp. 2197–2240). Philadelphia, PA: Lippincott Williams & Wilkins.
