Danny R Burgess, Jared W Keeley, Roger K Blashfield. 21st Century Psychology: A Reference Handbook. Editor: Stephen F Davis & William Buskist. Volume 2. Thousand Oaks, CA: Sage Publications, 2008.
Alex was an attractive, 36-year-old female. Alex’s mother was an extroverted woman who was married five times and who died while living with a sixth man. The man who was most like a father to Alex was her mother’s third husband, who showed her attention and affection but also abused her sexually. She was an intelligent woman with a good sense for business. Alex went to college at Swarthmore and then obtained her MBA at the University of California at Berkeley. She moved to New York, where she was hired as an editor by a publishing company. At a company party, she met Dan, who was an attractive, narcissistic attorney. They agreed to have dinner together, and during dinner Alex revealed that she had stood up her original date for that night to spend time with him. Dan added to the sexual tension by lighting her cigarette and revealing that his family was away for the weekend. The two went to her apartment, where their sexual affair started. They continued their intense affair throughout the weekend. Their sexual acts were aggressive, uninhibited, and risky. On their final night together, Alex asked Dan about his family. He disclosed that he had been married 9 years and that he and his wife had a 6-year-old daughter. Alex expressed her frustration that all the good men are always married, and she attempted to convince Dan to continue with their love affair. He indicated that their relationship could not continue, and Alex appeared to understand his plight. They spent one more night together for what was presumed to be the last time. When Dan began to leave Alex flew into a rage. He tried to calm her down and to explain why their affair must end, but she became more enraged and refused to hear his explanations. Once dressed, Dan said goodbye and began to walk out the door, but not before he heard an overly sweet and soft-spoken Alex telling him that she wanted to be friends. She apologized for becoming so angry and she began to kiss him passionately, putting her hands all over his face and through his hair. At this moment, Dan realized that there was blood on her hands and that she had slit both of her wrists. He bandaged her wrists and stayed the rest of the night to take care of her. As he left the next morning, Alex very calmly said goodbye to him, asking that he call her sometime. When Alex did not hear from Dan, she began to call him incessantly at work and home. Desperate to keep Dan in her life, she told him that she was pregnant with his child, even daring him to call her gynecologist for proof. Dan offered to pay for an abortion, but Alex insisted on keeping the baby, hoping that Dan would become a part of her family. Unable to convince Dan to leave his former life and start a new family with her, Alex conceived the ultimate revenge to ruin his life. Aware that Dan’s fingerprints were on her kitchen knife from their weekend dinners together, Alex sat on her bathroom floor and cut her throat with the knife. A smile came across her face as she pictured her diary lying on her bed detailing her relationship with Dan. In it, she portrayed him as a possessive and abusive lover, who frequently stated that if he could not have her than no one could. Alex was sure the police would find the evidence, and Dan would suffer the rest of his life from her suicide.
Alex’s story is disturbing and familiar to many film-goers who saw the previews of Fatal Attraction in the 1980s. Most people were shocked by her behavior and dismayed by the original ending of the movie, which they found to be completely unsatisfying. In the end, the film was reworked with an ending that audiences found more appropriate.
Film-goers found it hard to understand Alex’s seemingly unexplained mood swings and the manipulative nature of her actions. Most clinicians would diagnose Alex as having borderline personality disorder, or borderline for short. The diagnosis of a personality disorder implies that there is something pathological about the way someone’s personality functions. Thus, to understand what it means to have a personality disorder, we must first understand what we mean by the term “personality.”
Most people think of personality as it is represented in the following phrase: “She has a lot of personality.” In that context, personality refers to a certain characteristic of that person’s behavior—for instance, perhaps she is very outgoing or boisterous. Psychologists tend to use the term in a broader way. When psychologists refer to personality, they mean a total pattern of characteristics and behaviors that usually begins in childhood but solidifies in late adolescence. For example, you might describe Alex as an angry person. However, everyone feels angry from time to time. Psychologists make a distinction between state anger and trait anger. A state describes how you are feeling right now. If you are angry, perhaps it is because your roommate just took the last cookie when you wanted it. That sort of anger is usually short-lived and the result of some specific circumstance. However, trait anger is much more pervasive. It is a disposition to be angry more than the average person. Someone who is high on trait anger would become angry more easily and in situations that might not warrant it. Whereas you might be likely to become angry with your roommate but not your professor, someone high on trait anger would be much more likely to be angry in any context. When psychologists talk of personality, they are often referring to traits rather than states.
Thus, a personality disorder occurs when someone’s trait behavior is maladaptive, harmful, inflexible, and/or deviates markedly from the expectations of one’s culture. It is not enough for the behavior simply to be abnormal; it must be part of a pattern of behavior that is long lasting (i.e., has occurred since adolescence) and pervasive (i.e., it occurs across a variety of contexts). The person’s behavior must lead to significant distress or impairment in cognitive, emotional, occupational, or interpersonal functioning. For Alex, her ability to form a normal, healthy attachment is impaired, leaving her fragile and upset to the extent that she chooses to end her own life. Although not stated in the vignette above, Alex has a history of similar, albeit less extreme, relationships.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000), enumerates the personality disorders. The DSM-IV-TR codifies diagnoses into five axes. The majority of mental disorders are coded on Axis I. The personality disorders are placed on Axis II. The rationale for including the personality disorders on a separate diagnostic axis from the rest of the mental disorders was that the more florid psychopathology of Axis I disorders might overshadow personality disorder conditions (APA, 1980; Williams, 1985). In fact, many people who meet criteria for a personality disorder diagnosis enter treatment only because they are experiencing some other problem, such as depression or substance abuse. Other authors have contended that the personality disorders deserve separate attention because they follow a different course from other disorders: They are more pervasive, long lasting, and intractable. However, recent research has challenged this claim, finding that personality disorder diagnoses are no more stable than many other Axis I conditions (Grilo et al., 2004; Shea et al., 2002).
We will first outline the current classificatory structure of the personality disorders and provide a brief description of each. Next, we will describe various methods and strategies for assessing the personality disorders. Afterward, we will discuss current models for treating the personality disorders. Finally, we discuss the future of the personality disorders as we move toward the next edition of the DSM.
Personality Disorder Descriptions
Since the DSM-III, the personality disorders have been organized into three clusters. The chair and creator of the DSM-III, Robert Spitzer, felt that clinicians would have a hard time remembering all of the personality disorder categories, and in an effort to make the manual more user-friendly, he created three clusters of personality disorders (R. Spitzer, personal communication, April 3, 2007). Interestingly, these three clusters have remained in use, and even have some research support as a useful categorization tool (Bagby, Joffe, Parker, & Schuller, 1993), although such support is not unanimous (Schopp & Trull, 1993). Cluster A includes the odd or eccentric personality disorders: paranoid, schizoid, and schizotypal. Cluster B includes the wild or evocative personality disorders: antisocial, borderline, histrionic, and narcissistic. Cluster C includes the anxious and avoidant personality disorders: avoidant, dependent, and obsessive-compulsive. We will discuss each in turn.
Paranoid Personality Disorder
Paranoid personality disorder is exactly what it sounds like. Individuals with this disorder are continually suspicious of others, mistrusting their intentions and believing the rest of the world is out to get them. However, in the case of paranoid personality disorder, individuals lack sufficient basis to believe that others are truly exploiting them or plotting against them. It is possible to be paranoid and not meet the criteria for the disorder, if you are in circumstances that warrant such mistrust. For example, an undercover double agent has good reason to believe that others are out to get him. People with paranoid personality disorder usually lack close relationships because their mistrust of others is pervasive. A stereotypic example of paranoid personality disorder is a die-hard conspiracy theorist who always has to keep an eye out for “big brother” watching him. However, it is important to differentiate paranoid personality disorder from delusional disorder and schizophrenia, which can evidence very similar symptoms. In the case of paranoid personality disorder, individuals do not trust those around them, but the form of their suspicions is realistic. In contrast, a man with delusional disorder may believe that the government has implanted a chip in his brain so that it may listen to his thoughts. This sort of paranoia is not grounded in reality. However, believing that your neighbor does not like you and so will report made-up noise violations to the police to get you in trouble is an example of a paranoid thought that is not psychotic and may be seen in a case of paranoid personality disorder. People with paranoid personality disorder lack the other psychotic symptoms seen in both delusional disorder and schizophrenia.
Schizoid Personality Disorder
Someone with schizoid personality disorder is the prototypical loner. These people evidence a pervasive pattern of emotional detachment and lack of interest in social relationships. It is not that they are unsuccessful in finding friends, but that they are afraid of rejection and so fail to initiate new relationships. People with schizoid personality disorder are truly uninterested in other people. An ideal occupation for individuals with this disorder would be to sit in a cubicle devoted to their own work and never interact with others. People with this disorder tend to not show or experience much emotion. They usually report taking pleasure in few, if any, activities. Even social interactions as simple as a smile or nod to a stranger feel unnatural.
Schizotypal Personality Disorder
Imagine a man walking down the street attired in a top hat, cape, and walking stick. One hundred years ago, this man’s outfit would likely have been unremarkable. However, if you were to see a man dressed like this today, you would think he was odd. Someone with schizotypal personality disorder is odd in this sense. People with this disorder tend to have superstitious or magical beliefs, such as thinking that the weather report in the news will predict next week’s winning lottery numbers. These beliefs are not held with such conviction that they qualify as delusions, distinguishing schizotypal personality disorder from the psychotic disorders. However, schizotypal personality disorder is considered by some to be part of the “schizophrenic spectrum,” meaning that it is a potentially weaker, or premorbid, form of schizophrenia. Indeed, relatives of individuals with schizophrenia have a markedly increased chance of meeting criteria of schizotypal personality disorder (Kendler & Walsh, 1995). The characteristics of this disorder also include difficulty with interpersonal relationships due to insufficient social and emotional skills. Individuals with this disorder have a hard time recognizing normal social cues, such as interpreting a frown as meaning that a person disapproves of what they just said. Thus, such people often appear stilted or tense in conversation because they are uncomfortable in social interactions and do not know how to interact.
Antisocial Personality Disorder
The Cluster B disorders focus on patterns of behavior that are wild or evocative. When most people think of the term “antisocial,” they take it to describe a person who is a loner, much like the description of schizoid personality disorder. However, that meaning is better captured by the term “asocial.” “Antisocial” refers instead to someone who actively works against social norms and rules. In fact, the first criterion for a diagnosis of antisocial personality disorder is that the person repeatedly engages in behavior that would be grounds for arrest, such as stealing, drug use, physical assaults, and so on. However, these behaviors are only a part of the diagnosis. The rest of the diagnosis refers to a pattern of traits that speak to a fundamental mismatch between the person and society’s rules. People with antisocial personality disorder often lie for their own personal gain or pleasure, sometimes just to see if they can get away with it. A common characteristic of this disorder is an inability to plan ahead or see the consequences of one’s actions. This failure to plan can lead to dangerous or risky behaviors, endangering the person or those around him. However, perhaps the most interesting feature of antisocial personality disorder is the person’s lack of remorse. Most people feel bad when they do something they know is wrong, or if they hurt someone for whom they care. Individuals with this disorder seem genuinely not to care if they harm someone else. A related finding is that people with antisocial personality disorder do not respond to punishment in the same way as other people do. Most people who are punished for a behavior associate that punishment with their behavior and therefore do it less in the future. For people with antisocial personality disorder, that learning mechanism seems not to function the same way, and so they do not learn effectively from punishment (Blair, Morton, Leonard, & Blair, 2006). Ironically, society’s most common way of dealing with criminal behavior is a punishment-based system—sending the person to prison.
Borderline Personality Disorder
The case of Alex presented at the beginning of this chapter is a prototypical example of borderline personality disorder. Many theorists conceptualize borderline personality disorder as a failure to develop a stable self-image. Individuals with this disorder describe themselves as often feeling empty, as though they have no substance or identity. Because they lack a stable image of themselves, they tend to search for reassurance from others, and so have a pronounced fear of rejection or abandonment, which they interpret as meaning that they are worthless. This disorder is characterized by intense and unstable interpersonal relationships, just like the strong, quick bond that Alex formed with Dan over the course of a single weekend. People with this disorder alternate between viewing themselves and others as all good or all bad. Everything is black or white. These extremes can lead to rapid shifts in affect, such as when Dan tried to leave Alex and she suddenly became violently angry but then shifted quickly back to being sweet so that he would not leave her. Alex viewed Dan as the most wonderful man in the world one moment, but then when he did something she did not like, she immediately thought him to be a horrible person who deserves to be punished. As also seen in the case of Alex, self-mutilation and suicidal acts are common features of the disorder. As such, borderline personality disorder is often seen as the most severe and life threatening of the personality disorders.
Histrionic Personality Disorder
Everyone likes attention. However, individuals with histrionic personality disorder take this to the extreme. For such people, it is painfully uncomfortable when they are not the center of attention. As a result, they often employ a variety of techniques to ensure that others are watching them. They are often flirty and dress in sexually provocative ways. Exaggeration is a way of life. Everything that happens is the best or the worst thing that ever happened to them. People with histrionic personality disorder speak dramatically and display emotion theatrically. One interesting feature of the disorder is that individuals may believe that their relationships are much closer than they actually are. For instance, a woman may say that a famous movie star is her best friend, simply because they met once and exchanged a few pleasantries. In some ways, the description of histrionic personality disorder is the negative stereotype of a woman (Sprock, 2000). In fact, histrionic personality disorder is diagnosed much more frequently in women than in men (Hamilton, Rothbart, & Dawes, 1986). Many feminist authors have criticized the mental health field for the inclusion of histrionic personality disorder as a mental disorder because it propagates negative female stereotypes (Caplan & Cosgrove, 2004).
Narcissistic Personality Disorder
The Greek myth of Narcissus tells the story of a boy who falls in love with his own reflection. Borderline is a case of not having a fully developed self-image; narcissistic personality disorder is having an overdeveloped self-image. People with this disorder believe that they are the best thing in the world and cannot understand why others do not agree. Such people tend to exaggerate their personal talents and achievements. They view themselves as better than others or special in some way, and often search for admiration. Such individuals usually have lofty goals for themselves, and have no problem stepping on the toes of others if that will get them to their goal. Similar to antisocial personality disorder, narcissists lack empathy or the ability to understand someone else’s point of view. People with this disorder may feel right at home in a cutthroat business environment, and many CEOs and politicians seem to have some of these characteristics.
Avoidant Personality Disorder
Avoidant personality disorder may appear very similar to schizoid personality disorder on the surface. Both involve people who are socially isolated, spending very little time with others. The difference is that those with avoidant personality disorder want to be around others, but are afraid of criticism or rejection. At their core, these people feel that they are inadequate or inept in some way. Thus, individuals with this disorder avoid interacting with others, fearing others may conclude that they are worthless. Ironically, because of their fear of interaction, these individuals tend to come across as socially awkward when they interact with others, reinforcing the self-fulfilling prophecy of their fears. It also is easy to confuse avoidant personality disorder with social phobia. In fact, some have argued that the concepts are the same (Ralevski et al., 2005). Those who contend they are in fact separate disorders claim that the difference is the earlier onset and more stable course of avoidant personality disorder.
Dependent Personality Disorder
Dependent personality disorder is well named: The diagnosis is meant to capture those who are overly submissive and dependent to the point of losing their own identity. Such people have difficulty making decisions independently or disagreeing with others. Individuals with this disorder may seem obsequious for fear of offending or upsetting others and thereby driving them away. They have a fear of inadequacy and believe that it is necessary for others to care for them. This behavior is natural in a young child, but out of place in a fully grown adult. One area of contention regarding the disorder, however, is its translation into other cultures. American culture values independence and considers behavior like that seen in dependent personality disorder as indicative of a problem. However, in more collectivist cultures like China or Japan, the behaviors seen in this disorder are considered much more normal.
Obsessive-Compulsive Personality Disorder
Obsessive-compulsive personality disorder should not be considered the same as obsessive-compulsive disorder. The latter is an Axis I condition characterized by continued obsessional thoughts leading to anxiety that is relieved through compulsive rituals. The former is the prototypical perfectionist. Everything must be in its place and orderly. Such people are preoccupied with following rules and schedules even when the added organization decreases efficiency. Individuals with this disorder have a hard time being flexible or changing plans, and may become distressed if things do not work out in the way they were supposed to. It is not uncommon for them to be excessively moral or value driven, and their interpersonal relationships are usually strained because they must be in control at all times. On the positive side, people with this disorder tend to be incredibly productive and may be described as “workaholics,” making them ideal employees.
Personality Disorder, Not Otherwise Specified
The most common personality disorder diagnosis (at least in unstructured interviews; Verheul & Widiger, 2004) is ironically not really a diagnosis. A “junk” category known as personality disorder, not otherwise specified (NOS) is included in the DSM to catch all cases that seem to be a personality disorder but that do not meet criteria for any one of the disorders described. Most often, a person will meet some of the criteria for two or three disorders, but not the full criteria for any single one. Usually, in this case, the person is diagnosed with personality disorder NOS. For instance, even Alex, who may be considered the prototypic case of borderline personality disorder, displays the characteristics of several other personality disorders as well. She comes across as incredibly dependent upon other people. Her mannerisms and sexual acting out are indicative of histrionic personality disorder. Her lying and plotting to harm Dan are reminiscent of antisocial personality disorder. In actuality, even though she is a good example of borderline personality disorder, most cases of personality disorders evidence a great deal of overlap among the categories already listed. This overlap is commonly termed “comorbidity.”
Certain personality disorder diagnoses often co-occur. However, it is not that all personality disorders co-occur; rather, they follow certain patterns. In general, diagnoses are more comorbid with other personality disorders in the same cluster. For example, narcissistic and antisocial personality disorders are highly comorbid, as are narcissistic with histrionic (Zimmerman, Rothschild, & Chelminski, 2005). The personality disorders also co-occur with many Axis I conditions. For instance, depression and post-traumatic stress disorder (PTSD) have been linked to borderline personality disorder (Axelrod, Morgan, & Southwick, 2005; Brieger, Ehrt, & Marneros, 2003). This pattern can be seen in the case of Alex. Her destructive behavior pattern could easily lead her to feel depressed and worthless after someone abandons her, and her violent tendencies could place her in a situation whereby she might experience a traumatic event. In fact, several authors have argued that the personality disorders may predispose, or create a vulnerability for, individuals to develop an Axis I disorder (Clark, 2007).
The overlap seen among the personality disorders and between personality disorders and Axis I conditions can be thought of in two ways: artifactual co-occurrence and meaningful co-occurrence. Sometimes, overlap between two categories will occur from selection biases in studies (e.g., Berksonian bias; Lilienfeld, Waldman, & Israel, 1994), issues with the diagnostic process (Verheul & Widiger, 2004; Zimmerman et al., 2005), or overlapping diagnostic criteria (e.g., Blashfield & Breen, 1989). These examples represent artifactual co-occurrence, and do not mean much about personality disorders per se. Rather, they are methodological problems in studying personality disorders. However, even when these factors are controlled, personality disorders overlap at a level greater than that expected by chance (Zimmerman et al., 2005). Thus, there is something about personality pathology that the current categorical diagnostic system fails to capture. The categories listed above are assumed to be relatively discrete. However, there are many data to the contrary, suggesting that disordered personality follows some other sort of model (Widiger & Simonsen, 2005). In a later section, we will discuss dimensional models of personality, which attempt to capture some of that overlap through continuous rather than discrete measurement of personality traits.
Assessment of Personality Disorders
Alex presents a complicated and chaotic clinical picture that is difficult to grasp and comprehend. A psychologist, whether in a clinical or research setting, interested in gaining a greater understanding of Alex would need a way to make sense of her symptoms in a standardized and controlled manner. Fortunately, a vast array of personality assessment tools is readily available to psychologists to capture the complexity of Alex’s clinical picture. The goals of personality assessment are to describe and make predictions about an individual’s behavior, aid in the treatment of dysfunctional behaviors, and evaluate the effectiveness of such treatments being implemented. However, assessment measures need to be reliable and valid—they must provide consistent and dependable results while measuring what they claim to measure. In general, the procedures of personality assessment can be classified into three types: clinical interviews, objective personality tests, and projective personality tests.
The clinical interview is the primary tool psychologists use to gain information about the patient’s problems. With this method, the patient is able to use his or her own words to describe the difficulties present in the patient’s life. During the interview the psychologist is able to probe in certain areas that are unclear or vague while attending to the nonverbal behaviors of the patient (e.g., the patient suddenly becomes fidgety when talking about her boyfriend).
Clinical interviews vary as to how much structure the psychologist imposes on the interview process. Unstructured interviews allow the patient to dictate the course of the interview as the psychologist follows along with the issues presented by the patient. This style of interview is conducive to building rapport with the patient and pulls for a rich clinical presentation of the patient’s problems.
Semistructured interviews consist of predetermined questions asked by the psychologist with ample room for further discussion on topics that are a particular concern for the patient, or that the psychologist sees as necessary to address. In contrast, completely structured interviews include a detailed list of specific questions that the psychologist strictly adheres to with the goal of making a diagnostic decision. This style of interview greatly increases the standardization of the assessment on many facets, including the language used, the sequence of the questions asked, and the threshold used to determine a diagnosis. Such standardization improves diagnostic reliability and allows for systematic comparisons with other information sources (Rogers, 2003). Semistructured and structured interviews for personality disorders help psychologists obtain detailed descriptions of the patient’s pathology and dysfunction, which helps to formulate a possible personality disorder diagnosis. For example, the Structured Interview for DSM-IV Personality (SIDP-IV; Pfohl, Blum, & Zimmerman, 1995) and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997) contain questions that cover all the diagnostic criteria for the personality disorders, thus providing psychologists with a systematic approach to obtaining important diagnostic information.
Objective Personality Tests
Clinical interviews can be time-consuming and intrusive, resulting in patients becoming exhausted or frustrated with the interview process or reluctant to admit thoughts and behaviors that may seem embarrassing or strange. Another form of personality assessment that can quickly cover a wide range of pathology discreetly is objective personality tests. This form of testing requires the patient to respond to straightforward statements (usually in the form of multiple-choice or true or false items) that address a range of dimensions, from personality traits and physical problems to social interactions and occupational preferences. The scoring and results interpretation for these tests are objective and not biased by the psychologist’s impression of the patient. Such standardization allows for meaningful score comparisons between a single patient and other previously tested patients.
An example of a personality objective test is the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1943), which is currently the most widely used and researched objective personality test (Archer, 1992; Greene, 2000). Now in its second edition (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989), the MMPI-2 is a personality test with 567 true or false items designed to assess the personality and emotional disorders of adults. In addition, other objective tests of personality are available, such as the Personality Assessment Inventory (PAI; Morey, 1996), which is shorter than the MMPI-2 (only 344 items) but has the same goal of assessing for psychopathology and emotional disturbance. The Neuroticism, Extraversion, and Openness Inventory-Revised (NEO-PI-R; Costa & McCrae, 1992) measures adaptive and maladaptive personality traits on five primary dimensions of personality: neuroticism, extroversion, openness, agreeableness, and conscientiousness. Results from objective personality tests provide psychologists with a comprehensive clinical profile that is rich with specific psychological information. Objective inventories of personality offer an efficient way to complement the data gathered from clinical interviews.
Projective Personality Tests
Projective personality tests present an ambiguous stimulus that individuals attempt to describe. Psychologists assume that individuals will “project” their personality into their interpretation of the stimulus. Projective tests arose from the psychodynamic perspective, which suggests that the unconscious contains hidden urges and desires that want to be expressed. Two common projective tests are the Rorschach Inkblot Test (Rorschach, 1921) and the Thematic Apperception Test (TAT; Murray, 1943). The Rorschach requires people to respond to several inkblots, and the psychologist codes their responses, looking for any patterns or consistent themes that may emerge. The TAT consists of drawings that present human figures in ambiguous situations. For example, a picture may portray a man hugging a little girl with a young boy in the background turning to walk away. A psychologist would ask an individual to explain what is happening in the picture, what led up to the situation, and what will happen later on. Again, the psychologist looks for consistent themes in the person’s responses to the picture cards, such as despair, abandonment, or hopefulness. The assumption is that people will “project” themselves into the situation and tell the story based on their own needs and desires.
Historically, projective tests have played a significant role in assessing personality; however, they are no longer widely used. The clinical findings of projective tests are highly dependent on the interpretation of individuals’ responses by the psychologist administering the test. In contrast to objective personality tests, projective personality tests are not as standardized, potentially resulting in poor reliability (Wood, Nezworski, Lilienfeld, & Garb, 2003). Because of the concern about reliability, highly formalized systems for scoring the Rorschach have been developed for which reliability is much higher (Exner, 1969). Projective personality tests offer a unique approach to obtaining information about individuals that clinical interviews or objective tests may fail to acquire. Despite some of the problems inherent with projective tests, these tests do supply complementary clinical information when used with other personality assessment tools.
Maladaptive (and even adaptive) personality presentations are too complex to be measured by only one type of assessment. Just as you would want to throw multiple darts to hit the bull’s-eye of a dartboard, it is advantageous for psychologists to use multiple personality assessments in order to “hit the bull’s-eye” in terms of understanding people. Clinical interviews, objective tests, and projective tests provide an integrative assessment approach to describe the pathology seen with personality disorders. Such a comprehensive approach enables psychologists to understand and study individuals with personality disorders, as well as develop and implement treatment strategies.
Treatment of Personality Disorders
As a group, personality disorders have been considered far more difficult to treat compared to Axis I mental disorder groupings, such as mood disorders and anxiety disorders. Persons diagnosed with a personality disorder have very little motivation to change who they are, mainly because they do not see themselves as having problems—they see problems existing in everyone else. If an individual with a personality disorder seeks treatment, it is usually at the request of a spouse or family member who refuses to endure the pathology of the individual. Along with the difficulties in treating personality disorders, the presence of such disorders can complicate and hinder the treatment for other disorders (namely those disorders found on Axis I) that typically have successful treatment outcomes (Castonguay & Beutler, 2006).
If you were to reread the case history of Alex presented at the beginning of this chapter with the mind-set of constructing a treatment plan to alleviate her distress, you would likely feel overwhelmed by where to begin. For example, would you first address her intense and often explosive emotional reactions when things do not go her way, or her obsessional tendencies and behaviors when forming new relationships? Or you may go after her intentional, maladaptive pattern of establishing relationships that will ultimately fail, leaving her feeling helpless, distressed, and victimized. With this complex yet fairly representative case example of an individual with a personality disorder, there is no simple treatment protocol that can successfully address all the emotional, cognitive, and behavioral impairments. Remember that personality disorders are enduring and stable patterns of deeply ingrained attitudes and behaviors that are impaired and dysfunctional, resulting in difficulties across many aspects of a person’s life (i.e., social interactions, occupational/academic responsibilities). To treat personality disorders, psychologists undertake the task of deconstructing the individual’s disordered personality features that have developed over the course of a lifetime and constructing a new, more adaptive personality. Where would you begin with Alex?
Historically, the treatment of personality disorders was based on Freudian, psychodynamic theories of personality. Psychoanalytic treatments required long-term psychotherapy to address the deeply ingrained, maladaptive personality features of individuals with a personality disorder (Eskedal, 1998; Kernberg, 1996).
The psychodynamic perspective focused on the unconscious urges and conflicts that occur during childhood development and sought to uncover these impulses to explain an individual’s underlying character structure and motives. In Alex’s case, for instance, a psychodynamic therapist might focus on her childhood history. In doing so, the therapist might learn that Alex’s mother had multiple affairs with many men. When Alex’s mother married a third time when Alex was 10, this new stepfather became the only stable male figure of her childhood. However, fights would erupt between the mother and this stepfather. In those instances, the mother would storm out of the apartment, and the stepfather would come into Alex’s bedroom and seduce her. Alex responded to these events with a mixture of confusion, eroticism, and disgust.
From a psychodynamic perspective, the current events in Alex’s life with the married man, Dan, was a reenactment of the feelings associated with these childhood traumas. A psychodynamic therapist, especially if the therapist is a man, would expect that these past feelings would also appear in therapy—these feelings are called transference (i.e., the patient “transfers” her feelings about her “father” to her male therapist). Thus, the therapist might initially be idealized as a great person with exceptional insight. However, as therapy continued, Alex would be likely to become demanding of extra sessions at odd hours (e.g., after dinner) or to “Google” the therapist, learn where his parents live, and contact them to say what an exceptional son they have. Psychodynamic therapists would be concerned about establishing clear boundary conditions with a client such as Alex. For instance, therapy probably would be confined to one consistent hour per week with no exceptions. If Alex contacted the therapist’s parents, the therapist might either terminate therapy or at least have a serious discussion about termination of therapy with her. Clients such as Alex often generate strong countertransference feelings from a therapist. In less abstract terms, Alex is likely to pull for some of the same confused, conflicted feelings from the therapist that she elicited from Dan. Most psychodynamic therapists work in consultation with other therapists with a similar viewpoint because of the difficulty associated with treating a patient like Alex.
As research on personality disorders continued to develop, the conceptualization of personality disorders shifted from an exclusively psychodynamic explanation to a combination of biological, environmental, and psychological factors (Sperry, 1995). Consequently, new and modified treatment strategies emerged to address personality disorders by offering therapy contexts that were more structured, focused on the therapeutic relationship, and required a more active role from the psychologist (Critchfield & Benjamin, 2006; Eskedal, 1998).
Despite the shift from the traditional psychodynamic-based therapies to contemporary treatments of personality disorders, little research on treatment success for personality disorders currently exists. Only 2 (borderline personality disorder and avoidant personality disorder) of the 10 personality disorders have a sizeable literature on treatment outcomes, with borderline personality disorder receiving by far the most research attention (Critchfield & Benjamin, 2006). The cognitive-behavioral therapy approach has had tremendous success with treating Axis I disorders (Barlow, 2001) and has begun to be applied to personality disorders with the anticipation of similar treatment success. As opposed to the psychodynamic approach, a cognitive-behavioral psychologist does not focus on a patient’s childhood. Instead, the focus is on the here and now and how the patient currently is functioning. For Alex, cutting her wrists in response to Dan’s leaving is a prime example of how she is not functioning well. A cognitive-behavioral therapist would address and attempt to restructure Alex’s faulty cognitions with the expectation that the restructuring would change her tendency to engage in self-injurious behavior. When Dan left, Alex likely felt worthless and empty, so she attempted to relieve that emotional pain by cutting herself. The therapist will want to teach Alex that Dan’s leaving did not mean that she was worthless and that she can cope with his leaving in other, more positive ways. The goal of cognitive-behavioral therapy is for changes in cognitions to influence behaviors, thus hopefully promoting a more functional lifestyle.
There are many variations of cognitive-behavioral therapy, but in regards to personality disorders there is one form that has received a tremendous amount of attention—dialectical behavior therapy. Marsha Linehan’s (1993) dialectical behavior therapy, developed for the treatment of borderline personality disorder, teaches problem-solving and social skills to patients to help them regulate and contain their emotional and behavioral outbursts and begin to perceive and express appropriate thoughts and emotions. A hallmark symptom of borderline personality disorder is the vacillation of emotions from one extreme to the other. For example, Alex admitted her undying and unwavering love for Dan, but within minutes expressed her hatred toward him when he said goodbye. Dialectical behavior therapy seeks to resolve the tension created by the extreme emotions by teaching the patient that both emotions can exist; Alex can still love Dan despite being upset with his leaving. Several research studies have shown success applying dialectical behavior therapy to borderline personality disorder populations, including the reduction of self-injurious behaviors, fewer days of hospitalization, and less substance abuse (e.g., Koerner & Linehan, 2000; Linehan, Heard, & Armstrong, 1993).
The difficulties seen with the classification of personality disorders (such as comorbidity) directly influence the difficulties seen with the treatment of personality disorders. A solid classification system should help guide treatment practices, and without such a firm foundation, therapy strategies can be difficult to develop and implement. However, tremendous strides have been made in refining various treatment systems that adequately address the fundamental problems seen with personality disorders. For example, the American Psychological Association and the North American Society for Psychotherapy Research constructed a task force dedicated to researching principles that will inform treatment practices for personality disorders (Critchfield & Benjamin, 2006). This task force stressed the importance of several techniques needed for successfully treating personality disorders that were not seen with the more traditional, psychodynamic approaches. These techniques include an active role on the part of the psychologist to facilitate the patient’s motivation to change and learn new coping strategies. Furthermore, the psychologist must play an active role in maintaining structure within the treatment and establishing limits and boundaries that the patient can learn how to operate within. As an additional therapeutic component, Critchfield and Benjamin discussed the importance of positive therapeutic alliance between the psychologist and patient, which consists of empathy and positive regard. The contemporary treatment systems for personality disorders have embraced the importance of such a relationship because the consistent struggle across all personality disorders is the disturbed interpersonal functioning. Therefore, the therapeutic relationship is particularly salient in that this relationship can model for the patient how interpersonal interactions should occur outside of therapy.
Despite the enormous undertaking of treating Alex, there are treatment models available that can address most, if not all, of the problems she exhibits. However, more research is needed in the area of personality disorder treatments in order for psychologists to help those individuals like Alex who suffer from a very complex and messy presentation of symptoms.
The DSM classification of personality disorders is based on a categorical approach, which suggests that a disorder is its own unique entity with clear boundaries that contain the characteristics of that disorder. Consequently, individuals with the same disorder are assumed to present with similar symptoms and are distinct from other categories. However, the personality disorders often co-occur. For example, borderline personality disorder (a possible diagnosis for Alex) is defined by nine symptoms, of which five must be present for a diagnosis. Within a categorical approach, if Alex is diagnosed with borderline, then her psychopathology presentation should be very similar to that of other patients who meet criteria for this disorder. However, two individuals could potentially share only one symptom but both have a diagnosis of borderline. Another possible personality disorder to consider for Alex is histrionic personality disorder, as her presentation is flirtatious, provocative, and sexually charged. In diagnosing personality disorders, overlap of symptoms is the norm, which violates the assumption of a categorical approach that diagnoses are discrete.
Primarily due to “boundary cases” and comorbidity, where a patient meets the criteria of more than one diagnostic category, an alternative to the categorical approach has emerged. Several researchers have suggested that a dimensional system better represents the organization of personality disorders and should replace the DSM categorical system (Samuel & Widiger, 2006; Trull & Durrett, 2005). A dimensional approach inherently provides more descriptive and precise information.
The study of personality in psychology has historically focused on a dimensional measurement approach. For example, one of the first attempts to describe personality was proposed by Eysenck (1947), who saw personality composed of three dimensions: extraversion, psychoticism, and neuroticism. He described individuals’ personalities by their placement on all three dimensions. Alex would be on the high end of all these dimensions because she is energetic, outgoing, aggressive, and erratic.
A contemporary dimensional approach to personality characteristics is the five-factor model (FFM; Costa & McCrae, 1992), which considers the degree of expression of personality traits on five domains with the following names: neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. The five domains are each further divided into six facets (a total of 30 facets). For example, the Extraversion domain consists of personality traits related to warmth, gregariousness, assertiveness, activity, excitement-seeking, and positive emotionality. The FFM was developed to supply a comprehensive description of an individual’s personality functioning by providing clinicians with information on both adaptive and maladaptive personality traits.
In Alex’s case, mental health professionals using a dimensional system would have available to them the ratings on each of the facets for all the domains. These ratings would be based on the degree to which Alex exhibits such traits. For example, on the facet of impulsivity (found under the neuroticism domain), Alex would receive a high rating, such as a six or seven on a seven-point scale, suggesting that she may act without considering consequences, such as becoming sexually involved with strangers. The FFM system offers a complete clinical picture of Alex’s functioning on numerous traits. Dimensional models, such as the FFM, attempt to alleviate the problems presented by the categorical model, such as comorbidity. The problem of cases that fall between the boundaries of one categorical group and another categorical group ceases to exist. With a dimensional approach, patients are not forced to fit neatly into one category or another. There are no gaps in a dimensional system.
However, the dimensional system also has problems, such as being cumbersome and unfamiliar. Clinicians must describe the patient on numerous relevant dimensions, whereas categorical models provide the convenience of offering a simple diagnostic label. In addition, clinicians have been trained in the DSM system, and therefore are far more familiar with the categorical names of personality disorders. No agreement has been reached on what dimensions best represent personality pathology. The FFM is just one approach, but several alternatives are available that make a compelling case for three, seven, and even 16 dimensions.
Everyone has a personality. You may be described as warm and outgoing, or shy and solitary. These descriptions are known as personality traits, which are enduring patterns of characteristics and behaviors. Your personality traits likely have remained relatively stable since adolescence and are constant across many different situations. This same description can be applied to personality disorders, as listed in the DSM-IV-TR (APA, 2000). However, the difference between personality and personality disorders is that personality disorders are maladaptive patterns of behavior that lead to significant impairment in cognitive, emotional, occupational, or interpersonal functioning. Alex’s case is a prime example of a personality disorder. Her personality traits are extreme and excessive, resulting in harm toward others and herself. Once this harmful threshold has been passed, individuals are given a personality disorder diagnosis. Psychologists determine when this threshold has been reached through multiple means of assessment. Typically, psychologists use a combination of clinical interviews, objective tests, and projective tests. These assessment tools aid psychologists in creating a clear and rich personality profile of an individual suffering from a personality disorder. As a result, psychologists are better equipped to treat those with personality disorders. Historically, treatment of personality disorders has centered on the psychodynamic theory. As research and knowledge on the origins and course of personality disorders have increased, additional treatment approaches have emerged, such as cognitive-behavioral therapy.
The DSM-IV-TR lists 11 categorical diagnoses that describe different personality presentations. However, personality disorder categories tend to overlap one another, such that an individual is likely to receive multiple personality disorder diagnoses. This phenomenon is known as comorbidity, and it presents problems for researchers and clinicians who attempt to study and treat individuals with personality disorders. The current categorical diagnostic system, as established by the DSM-IV-TR, may not be the ideal classification to capture personality disorders. Consequently, dimensional models of personality have been introduced as an alternative to measuring and organizing personality pathology. As research on dimensional models of personality continues, our understanding and definition of the personality disorders will change as well, helping clinicians to more effectively diagnose and treat these complicated and devastating disorders.