Need assistance with biopsychosocial and diagnosis
SWK 7705 – Assessment & psychopathology
Chapter 16
Personality disorders
Personality – can be defined as those emotional and behavioral traits that characterize day-to-day living under normative conditions
An individual’s personality implies the manner in which a person interacts with his or her environment and other people
A personality disorder characterizes those individuals who usually respond poorly to changes, exhibit deficiencies in their capacity to form relationships, and have interpersonal problems in a variety of arenas, such as employment or school
Issues occur when traits, or those features that make up a personality, remain inflexible, thus impairing individuals’ ability to interact within their social environment and with others
Personality disorders
The DSM-5 defines a personality disorder as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, and has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (APA, 2013, p. 645).
There are 10 distinct personality disorders that are divided into 3 clusters:
Cluster A: Odd and eccentric—Individuals who have paranoid, schizoid, and schizotypal personality disorders
Cluster B: Emotional, dramatic, or erratic—Individuals with antisocial, histrionic, borderline, and narcissistic personality disorders
Cluster C: Anxious, fearful—Individuals with avoidant, dependent, and obsessive-compulsive personality disorders
Personality disorders – cluster A
Individuals with Cluster A PDs can be described as cold, withdrawn, suspicious, or irrational (Morrison, 2014)
Paranoid – these individuals are suspicious and are easily offended; they have few close friends and may find hidden meanings in innocent comments
Schizoid – these individuals find little value in social relationships, have restricted emotional ranges, and seem indifferent to praise or criticisms
Schizotypal – these individuals have difficult interpersonal relationships that seem strange or peculiar to others; they have few close friends and are not comfortable in social situations. They may show suspiciousness, unusual perceptions or thinking, eccentric speech, and inappropriate affect.
Personality disorders – cluster b
Individuals with Cluster B PDs can be emotional, seeks attention, and theatrical with moods that are shallow and change easily (Morrison, 2014). They often experience interpersonal conflicts that are intense in nature.
Antisocial – these individuals are irresponsible with criminal behavior that often begins in childhood or early adolescence such as running away, fighting, destructiveness, truancy, lying, and theft; as adults they may act impulsively or reckless, show no remorse, and not pay their debts
Borderline – these individuals engage in harmful behaviors that are internal such as sexual adventures, spending unwisely, and excessive use of food or substances. They are unstable affectively and express intense and inappropriate anger. They feel bored or empty and frantically work to avoid abandonment. They are unsure of who they are and are unable to keep stable interpersonal relationships.
Histrionic – these individuals are overly emotional, attention seeking, vague, and need constant reassurance of their attractiveness; they may be sexually seductive and self-centered
Narcissistic – these individuals are overly occupied with dreams of success, envy, and thoughts about the uniqueness of their issues; their sense of entitlement & lack of compassion can cause them to take advantage of others. They need a lot of accolades and attention and reject criticism.
Personality disorders – cluster c
Individuals with Cluster C PDs are often tense, anxious, and overly controlled (Morrison, 2014).
Avoidant – these individuals are timid and easily harmed by criticism which can cause them to be cautious of being involved with others; they fear being embarrassed if they show emotion or say the wrong thing. They might not have any close friends and might embellish the risks of performing tasks outside of their norm.
Dependent – these individuals have challenges making independent choices or beginning projects and need approval from others; this may lead them to agree with someone even if they know it is incorrect. They are afraid of being abandoned, are vulnerable after a break-up, and feel helpless being alone. They sometimes take on tasks that others do not want to do so that they can gain the favor of others and are easily hurt by criticism.
Obsessive-Compulsive – these individuals are characterized by rigidity and perfectionism; they tend to have a hard time making decisions, work too much, are excessively scrupulous, and are over-focused on small details. Things must be done their way, and they have issues expressing affection and are not overly generous.
Personality disorders – other causes
Personality changes due to another medical condition – medical conditions can sometimes negatively impact an individual’s personality (Morrison, 2014). These circumstances would not qualify the individual as having a PD as it might not be present from an early age and is less pervasive.
Other mental disorders – when disorders persist for a long time, it can sometimes change the way a person relates to others or behaves which can give the appearance of a PD. Examples of this might include social anxiety disorder, dysthymia, schizophrenia, and cognitive disorders.
Other specified, or unspecified, personality disorder – using these categories for issues in personality means that it does not meet the criteria
Personality disorders
While clustering PDs has been acknowledged as having serious limitations, it is a useful organization method (APA, 2013). Diagnosing PDs can be a challenge as they are often overlooked and yet sometimes over diagnosed such as Borderline personality disorder (Morrison, 2014)
Morrison (2014) from the DSM-5 Made Easy provides these tips:
Verify the duration of the symptoms (can interview family/friends/coworkers)
Verify that the symptoms affect multiple areas of the patient’s life (work/school, homelife, personal life, and social life) as patient’s do not often see their behavior as causing issues
Check that the patient fully qualifies for the specific diagnosis being considered; sometimes judgment calls are needed so you need to be as objective as possible
Ensure that symptoms have been present for at least the past 12 months for those under age 18
Personality disorders
Morrison (2014) from the DSM-5 Made Easy provides these tips (cont’d):
Rule out other mental pathology that may be more acute & have greater potential for doing harm
Make sure to review other general features for any other requirements that might have been missed. Each patient must have two or more types of lasting issues with thoughts, behaviors, or emotions from a list of four: cognitive, affective, interpersonal, and impulsive (this assists with making sure the patient’s issues truly do affect more than one life area)
Look for other PDs. Evaluate the entire history to identify whether an additional PD might be present. Many patients appear to have more than one. If you find too few symptoms to make any diagnosis, then you can add to your summary note such as: Schizoid and paranoid personality traits
Document all personality and non-personality mental diagnoses
Paranoid Personality Disorder (Cluster A)
Central characteristics of paranoid personality include a pervasive pattern of distrust and suspicion seen by (4 or more) the following:
Suspicion
Unjustified doubts
Problems with intimacy
Perceptions of hidden meanings
Holding grudges
Paranoia
Recurrent suspicions
The case of Ben Rogers illustrates Paranoid Personality Disorder
Schizoid Personality Disorder (Cluster A)
Individuals with schizoid personality disorder shows a lifelong pattern of social withdrawal seen in at least 4 (or more) of the following symptoms:
No penchant for social relationships
Preference for solitary activities
Little or no sex drive
Takes pleasure in few, if any, activities
Lacks close friends other than first-degree relatives
Acts indifferent to praise (or criticism) of others
Limited range of emotions
The Case of Tyrone White Illustrates Schizoid Personality Disorder
Schizotypal Personality Disorder (Cluster A)
Individuals with schizotypal personality disorder exhibit strikingly odd or strange mannerisms in addition to having a very active fantasy life seen in 5 (or more) of the following symptoms:
Ideas of reference
Odd beliefs
Unusual perceptual experiences
Odd thinking or speech
Suspiciousness or paranoid ideation
Inappropriate or constricted affect
Behavior or appearance that is odd, eccentric, or peculiar
Lack of friends or close confidants other than relatives
Anxiety in social situations
The case of Juan Enrique Martinez Illustrates Schizotypal Personality Disorder
Antisocial Personality Disorder (Cluster B)
Antisocial personality disorder is characterized by continual asocial or criminal acts occurring since 15 years of age seen by 3 (or more) of the following:
Defiance of or failure to conform to social norms
Deceitful or the absence of consistent truthfulness
Impulsive
Irritable and aggressive
Reckless disregard for the safety of self or others
Irresponsible
Lack of remorse or empathy
The Case of Luke Rossey Illustrates Antisocial Personality Disorder
Borderline Personality Disorder (Cluster B)
Borderline is characterized by an unstable mood, extremely poor relationships with others, and low self-image alternating between extremes of idealization and devaluation seen in 5 (or more) of the following symptoms:
Frantic efforts to avoid abandonment
Poor interpersonal relationships
Identity disturbance or unstable self-image
Marked impulsivity
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
Affective instability
Chronic feelings of emptiness
Inappropriate, intense anger
Transient stress-related paranoid ideation or severe dissociative symptoms
The Case of Suzie Hutchfield Illustrates Borderline Personality Disorder
Histrionic Personality Disorder (Cluster B)
Histrionic individuals tend to have a long-standing pattern of excessive emotionality and attention seeking, which seeps into most areas of their lives and characterized by 5 (or more) of the following symptoms:
Grandiose sense of self-importance
Preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
Show rapidly shifting and shallow expression of emotions
Concerns with “presentation” or physical appearance
Speech that is excessively impressionistic and lacks detail
Self-dramatization, theatric, and exaggerated expression of emotion
Easily influenced and susceptible
Considers relationships more intimate than they are
Tamika Brown’s Story Illustrates Histrionic Personality Disorder
Narcissistic Personality Disorder (Cluster B)
Narcissistic personality disorder is characterized by a heightened sense of self-importance and unrealistic inflated self-worth, often disguising an underlying fragile sense of self seen in 5 (or more) symptoms of:
Grandiose sense of self-importance
Fantasies of unlimited success, power, brilliance, beauty, ideal love
Belief in being special and unique
Constant desire or need for admiration
Sense of entitlement
Interpersonally exploitative
Lacks empathy
Envious of others or believes that others are envious of them
Shows arrogant, haughty behaviors/attitudes
The Case of Lawrence Shull Illustrates Narcissistic Personality Disorder
Avoidant Personality Disorder (Cluster C)
Main characteristics of avoidant personality disorder are a pervasive pattern of social inhibition, constant feelings of inadequacy and ineptitude, especially in social situations, and hypersensitivity to negative evaluation beginning in early adulthood seen in 4 (or more) symptoms of:
Avoids occupational activities involving significant interpersonal contact
Unwilling to get involved with other unless they can be certain they will be liked
Shows restraint within intimate relationships
Preoccupied with being criticized or rejected
Inhibited in new interpersonal situations
Consider themselves as socially inept, personally unappealing or inferior to others
Reluctant to take personal risks or to engage in any new activities
The Case of Mabel Humphries Highlights Avoidant Personality Disorder
Dependent Personality Disorder (Cluster C)
Dependent personality disorder characterizes a pervasive pattern of extreme inability to act independently of others seen in 5 (or more) of the following symptoms:
Difficulty making everyday decisions
Need for others to assume responsibility for most major areas of his or her life
Difficulty expressing disagreement
Difficulty initiating projects or doing things independently
Goes to extreme lengths to obtain nurturance and support
Feels uncomfortable (or helpless) when alone
When a close relationship has ended, seeks another relationship for support
Preoccupied with fears of being left alone to care for him- or herself
Walter Pearson’s Story Illustrates Dependent Personality Disorder
Obsessive-compulsive Personality Disorder (Cluster C)
Obsessive-compulsive individuals are characterized as rigid, orderly, inflexible, and emotionally constricted seen in 4 (or more) of the following symptoms:
Preoccupied with details, rules, lists, order, organization or schedules
Over conscientious, scrupulous, and inflexible about matters of morality ethics, or values
Perfectionism
Excessively devoted to work and productivity
Difficulty discarding worthless objects
Difficulty delegating tasks or to work with others
Miserly or stingy toward self and/or others
Shows rigidity or stubbornness
Geoffrey Hales Story Illustrates Obsessive-Compulsive Personality Disorder
Proposed DSM-5 Alternative Model
Included in Section III of the manual, “Emerging Measures and Models”
Describes a hybrid dimensional-categorical model
General diagnostic criteria requires:
An assessment of self and personality functioning (or how the individual typically experiences him- or herself as well as others) as well as interpersonal functioning
The presence of one or more pathological personality traits
These traits are consistent across social situations and stable over time
Comparing the DSM-IV-TR Multiaxial System and the DSM-5
Personality disorders were previously placed on Axis II in the DSM-IV, but in the DSM-5 this axis has been deleted and the personality disorders are situated on one axis with all other diagnoses
The 10 different types (and clusters) of personality disorders were retained
An alternative hybrid dimensional-categorical model for the personality disorders is included in Section III of the DSM-5, and this insertion is intended to encourage further research on this modified classification system
Susan W. Gray
Psychopathology: A Competency-Based Assessment Model for Social Workers
Chapter 16
The Personality Disorders
© Susan W. Gray – Chapter 16 Personality Disorders
A personality disorder is seen as a variant of character traits going far beyond the normative range found in most people characterized by:
An enduring pattern of inner experience and behavior that is stable and enduring beginning in at least adolescence (or early adulthood) causing significant functional impairment or subjective distress
Deviates from the expectations of one’s culture
Not attributed to effects of a substance or medical condition
Seen in 2 (or more areas) of:
Cognition
Affectivity
Interpersonal functioning
Impulse control
2
Grouping of the Personality Disorders
© Susan W. Gray – Chapter 16 Personality Disorders
Cluster A: Odd and eccentric—Individuals who have paranoid, schizoid, and schizotypal personality disorders
Cluster B: Emotional, dramatic, or erratic—Individuals with antisocial, histrionic, borderline, and narcissistic personality disorders
Cluster C: Anxious, fearful—Individuals with avoidant, dependent, and obsessive-compulsive personality disorders
Paranoid Personality Disorder (Cluster A)
© Susan W. Gray – Chapter 16 Personality Disorders
Central characteristics of paranoid personality include a pervasive pattern of distrust and suspicion seen by (4 or more) the following:
Suspicion
Unjustified doubts
Problems with intimacy
Perceptions of hidden meanings
Holding grudges
Paranoia
Recurrent suspicions
The case of Ben Rogers illustrates Paranoid Personality Disorder
Schizoid PersonalityDisorder
(Cluster A)
© Susan W. Gray – Chapter 16 Personality Disorders
The person shows a lifelong pattern of social withdrawal seen in at least 4 (or more) of the following symptoms:
No penchant for social relationships
Preference for solitary activities
Little or no sex drive
Takes pleasure in few, if any, activities
Lacks close friends other than first-degree relatives
Acts indifferent to praise (or criticism) of others
Limited range of emotions
The Case of Tyrone White Illustrates Schizoid Personality Disorder
Schizotypal Personality Disorder (Cluster A)
© Susan W. Gray – Chapter 16 Personality Disorders
Individuals with schizotypal personality disorder exhibit strikingly odd or strange mannerisms in addition to having a very active fantasy life seen in 5 (or more) of the following symptoms:
Ideas of reference
Odd beliefs
Unusual perceptual experiences
Odd thinking or speech
Suspiciousness or paranoid ideation
Inappropriate or constricted affect
Behavior or appearance that is odd, eccentric, or peculiar
Lack of friends or close confidants other than relatives
Anxiety in social situations
The case of Juan Enrique Martinez Illustrates Schizotypal Personality Disorder
Antisocial Personality Disorder (Cluster B)
© Susan W. Gray – Chapter 16 Personality Disorders
Characterized by continual asocial or criminal acts occurring since 15 years of age seen by 3 (or more) of the following:
Defiance of or failure to conform to social norms
Deceitful or the absence of consistent truthfulness
Impulsive
Irritable and aggressive
Reckless disregard for the safety of self or others
Irresponsible
Lack of remorse or empathy
The Case of Luke Rossey Illustrates Antisocial Personality Disorder
Borderline Personality Disorder (Cluster B)
© Susan W. Gray – Chapter 16 Personality Disorders
Characterized by an unstable mood, extremely poor relationships with others, and low self-image alternating between extremes of idealization and devaluation seen in 5 (or more) of the following symptoms:
Frantic efforts to avoid abandonment
Poor interpersonal relationships
Identity disturbance or unstable self-image
Marked impulsivity
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
Affective instability
Chronic feelings of emptiness
Inappropriate, intense anger
Transient stress-related paranoid ideation or severe dissociative symptoms
The Case of Suzie Hutchfield Illustrates Borderline Personality Disorder
Histrionic Personality Disorder (Cluster B)
© Susan W. Gray – Chapter 16 Personality Disorders
Individuals tend to have a long-standing pattern of excessive emotionality and attention seeking, which seeps into most areas of their lives and characterized by 5 (or more) of the following symptoms:
Grandiose sense of self-importance
Preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
Show rapidly shifting and shallow expression of emotions
Concerns with “presentation” or physical appearance
Speech that is excessively impressionistic and lacks detail
Self-dramatization, theatric, and exaggerated expression of emotion
Easily influenced and susceptible
Considers relationships more intimate than they are
Tamika Brown’s Story Illustrates Histrionic Personality Disorder
Narcissistic Personality Disorder (Cluster B)
© Susan W. Gray – Chapter 16 Personality Disorders
Characterized by a heightened sense of self-importance and unrealistic inflated self-worth, often disguising an underlying fragile sense of self seen in 5 (or more) symptoms of:
Grandiose sense of self-importance
Fantasies of unlimited success, power, brilliance, beauty, ideal love
Belief in being special and unique
Constant desire or need for admiration
Sense of entitlement
Interpersonally exploitative
Lacks empathy
Envious of others or believes that others are envious of them
Shows arrogant, haughty behaviors/attitudes
The Case of Lawrence Shull Illustrates Narcissistic Personality Disorder
Avoidant Personality Disorder (Cluster C)
© Susan W. Gray – Chapter 16 Personality Disorders
Main characteristics are a pervasive pattern of social inhibition, constant feelings of inadequacy and ineptitude, especially in social situations, and hypersensitivity to negative evaluation beginning in early adulthood seen in 4 (or more) symptoms of:
Avoids occupational activities involving significant interpersonal contact
Unwilling to get involved with other unless they can be certain they will be liked
Shows restraint within intimate relationships
Preoccupied with being criticized or rejected
Inhibited in new interpersonal situations
Consider themselves as socially inept, personally unappealing or inferior to others
Reluctant to take personal risks or to engage in any new activities
The Case of Mabel Humphries Highlights Avoidant Personality Disorder
Dependent Personality Disorder (Cluster C)
© Susan W. Gray – Chapter 16 Personality Disorders
Characterizes a pervasive pattern of extreme inability to act independently of others seen in 5 (or more) of the following symptoms:
Difficulty making everyday decisions
Need for others to assume responsibility for most major areas of his or her life
Difficulty expressing disagreement
Difficulty initiating projects or doing things independently
Goes to extreme lengths to obtain nurturance and support
Feels uncomfortable (or helpless) when alone
When a close relationship has ended, seeks another relationship for support
Preoccupied with fears of being left alone to care for him- or herself
Walter Pearson’s Story Illustrates Dependent Personality Disorder
Obsessive-compulsive Personality Disorder (Cluster C)
© Susan W. Gray – Chapter 16 Personality Disorders
Individuals are characterized as rigid, orderly, inflexible, and emotionally constricted seen in 4 (or more) of the following symptoms:
Preoccupied with details, rules, lists, order, organization or schedules
Perfectionism
Excessively devoted to work and productivity
Over conscientious, scrupulous, and inflexible about matters of morality ethics, or values
Difficulty discarding worthless objects
Difficulty delegating tasks or to work with others
Miserly or stingy toward self and/or others
Shows rigidity or stubbornness
Geoffrey Hales Story Illustrates Obsessive-Compulsive Personality Disorder
Proposed DSM-5 Alternative Model
© Susan W. Gray – Chapter 16 Personality Disorders
Included in Section III of the manual, “Emerging Measures and Models”
Describes a hybrid dimensional-categorical model
General diagnostic criteria requires:
An assessment of self and personality functioning (or how the individual typically experiences him- or herself as well as others) as well as interpersonal functioning
The presence of one or more pathological personality traits
These traits are consistent across social situations and stable over time
Comparing the DSM-IV-TR Multiaxial System and the DSM-5
© Susan W. Gray – Chapter 16 Personality Disorders
Personality disorders were previously placed on Axis II in the DSM-IV, but in the DSM-5 this axis has been deleted and the personality disorders are situated on one axis with all other diagnoses
The 10 different types (and clusters) of personality disorders were retained
An alternative hybrid dimensional-categorical model for the personality disorders is included in Section III of the DSM-5, and this insertion is intended to encourage further research on this modified classification system
