UNIT 9 PERSONALITY DISORDERS: CLUSTER B AND ..., Lecture notes of Psychiatry

Download UNIT 9 PERSONALITY DISORDERS: CLUSTER B AND ... and more Lecture notes Psychiatry in PDF only on Docsity! 228 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 229 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, 2012) 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). 232 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: 1) Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). 2) Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. 3) Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or highstatus people (or institutions). 4) Requires excessive admiration. 5) Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations). 6) Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends). 7) Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others. 8) Is often envious of others or believes that others are envious of him or her. 9) Shows arrogant, haughty behaviors or attitudes. 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 233 Personality Disorders: Cluster B and Cluster C emotions, physical and perhaps sexual abuse and intrusive, controlling or cold parenting styles (Miller, 2011; Miller & Campbell, 2008). Lasch (1978) suggested that increasing prevalence of narcissism is a consequence of large-scale social changes with emphasis on characteristics like individualism, competitiveness, hedonism and ambition (Huang et al., 2009). 9.1.2.2 Treatment For people with narcissistic personality disorder, both the number of studies carried out and the success report gathered is limited (Cloninger & Svakic, 2009). Here, the main focus of the therapy is grandiosity. After which attention is also paid to hypersensitivity to evaluation and lack of empathy for others (Beck et al., 2007). Relaxation techniques are used for such individuals which can be helpful for them in accepting and handling the criticism. Check Your Progress 1 Fill in the blanks 1) _____________ is characterised by extreme versions of two common personality traits- extraversion and, to a lesser extent, neuroticism. 2) _______________is characterised by exaggerated sense of self and the importance that the individual gives to one’s self. 3) Grandiose narcissism is not generally associated with _____________. 4) The main focus of the therapy is ______________ for the treatment of narcissistic personality disorder. 5) One hypothesis points out a genetic link between ___________with antisocial personality disorder. 9.1.3 Antisocial Personality Disorder People with antisocial personality disorder (ASPD) are found to be the most puzzling and intriguing of the individuals that the clinicians would see in their practicing career. They are characterised by their tendency to persistently disregard and violate social norms and rights of others with a combination of deceit, aggression and antisocial behavior and activities. They lack ethical or moral development and have no remorse or loyalty towards anyone. Robert Hare is considered to be the pioneer in studying people with this disorder and describes them as, “social predators who charm, manipulate, and ruthlessly plow their way through life, leaving a broad trail of broken hearts, shattered expectations, and empty wallets. Completely lacking in conscience and empathy, they selfishly take what they want and do as they please, violating social norms and expectations without the slightest sense of guilt or regret” (Hare, 1993, p. xi). They tend to be impulsive, deceitful and irresponsible as well (De Brito & Hodgins, 2009). Lying and cheating is their second nature making it difficult for them to distinguish between truth and lies to reach their goals. Almost 60 percent of the people with antisocial personality disorder are found to have substance abuse as well (Taylor & Lang, 2006). Cleckley (1941/1982) identifies a constellation of 16 characteristics to define “psychopathic personality”. Hare and colleagues build on it to develop a 20-item checklist that serves as a major 234 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. 237 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. 238 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: 1) Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) 2) A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3) Identity disturbance: markedly and persistently unstable self-image or sense of self. 4) Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior) 5) Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 6) Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7) Chronic feelings of emptiness. 8) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9) Transient, stress-related paranoid ideation or severe dissociative symptoms. 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 239 Personality Disorders: Cluster B and Cluster C volume of hippocampus and amygdala perhaps thus showing more aggression and impulsivity. Some of the retrospective psychosocial studies have pointed towards the role of childhood trauma, adversity and maltreatment (Bandelow et al., 2005). Paris (1999, 2007) had offered a diathesis-stress theory to understand the probably causality of BPD- people with high levels of impulsivity and affective instability may have a diathesis which may lead to the development of BPD but in the presence of certain triggers and risk factors such as trauma, parental neglect, failure, or some kind of loss. In the presence of such nonspecific factors an individual who is already affectively unstable may become labile or dysphoric, coupled with impulsivity, they may also act out on it to cope up with their negative affect. Weakening of the family structures may be a major reason of increasing prevalence of BPD in today’s times. 9.1.4.2 Treatment It has been found that people with BPD seek for treatment much more than ASPDs or other disorders. Anticonvulsants and antipsychotics are usually found to be effective in treating the core symptoms of BPD. However, the efforts become slightly complicated due to their drug abuse or suicide attempts. Marsha Linehan has developed an approach called as Dialectical Behavior Therapy (DBT) which has been found to be quite successful in these cases (Linehan et al., 2006). In this treatment priority is given to the suicidal behavior then the ones that interfere with the therapy and its continuation followed by the behaviors which may interfere with the quality of life of the individual. Patients are taught to regulate their emotions and handling problems on an everyday basis. They are also given treatment similar to those of patients with PTSD as that they can dowse off the fear associated with traumatic events. Then they are made to trust their own responses more than depending on other people for constant validation by helping them in visualizing themselves where they are not reacting to the criticisms negatively. DBT has been found to be an effective therapy which is impactful in helping people with BPD (Stanley et al., 2007). Check Your Progress 2 Fill in the blanks 1) Tendency to persistently disregard and violate social norms is characteristic of ________. 2) ____________ says that the psychopaths have a higher threshold for experiencing fear than most of the other people. 3) Identifying behavioral problems and using a reward-based system to encourage prosocial behavior is treatment method adopted for __________. 4) The characteristic pattern of people with bipolar personality disorder is ________________. 5) Anticonvulsants and antipsychotics are usually found to be effective in treating the core symptoms of ______________. 242 Disorders of Personality, Paraphilic and Substance- related Disorders Box 9.7: DSM 5 Criteria for Dependent Personality Disorder (APA, 2013) A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1) Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others. 2) Needs others to assume responsibility for most major areas of his or her life. 3) Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include realistic fears of retribution.) 4) Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy). 5) Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. 6) Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself. 7) Urgently seeks another relationship as a source of care and support when a close relationship ends. 8) Is unrealistically preoccupied with fears of being left to take care of himself or herself. 9.2.2.1 Causes Factors Genetic influence has been found to be modest in the case of dependent personality disorder (Bornstein, 2011, 2012). Traits such as neuroticism and agreeableness (prominent in dependent personality disorder) have a genetic component to it. There is also a possibility that at least partial predisposition to dependence and anxiousness may make them prone to negative impact of authoritarian and overprotective parenting, thus, reinforcing their dependent behavior. As described by cognitive researchers, people with dependent personality disorder, the underlying schemas about themselves might be maladaptive and thus they may have a core belief about them being weak, incompetent and requiring others for their survival (Ramussen, 2005). This has also been supported by recent researches (Arntz et al., 2011). 9.2.2.2 Treatment Majority of the treatment literature in this case is descriptive. They look like ideal patients because of their attentiveness towards the therapist and eagerness to share their problems but they are eventually found to be compliant to everything the therapist says. Their submissiveness becomes a major hindrance in the therapy (Borge et al., 2010). Their core belief about themselves being weak and dependent on others is challenged using cognitive behavior therapy (Beck et al., 2007) and the urge to be confident, independent and take decisions on their own is instilled in them. 243 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: 1) Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. 2) Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met). 3) Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity). 4) Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification). 5) Is unable to discard worn-out or worthless objects even when they have no sentimental value. 6) Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. 7) Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. 8) Shows rigidity and stubbornness. 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 244 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 1) __________ and ___________are characteristic patterns of avoidant personality disorder. 2) _____________ exhibit perfectionist tendencies by paying attention to rules, orders and schedules. 3) Genetic influence has been found to be modest in the case of ____________. 4) ____________therapy has been found to be effective with patients of OCPD. 5) 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. 247 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.2011.25.2.235 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. (16 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– 56. 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– 06. 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.2008.10.002 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. 248 Disorders of Personality, Paraphilic and Substance- related Disorders Coccaro, E. F. (2001). Biological and treatment correlates. In W. J. Livesley (Ed.), Handbook of Personality Disorders (pp. 124–35). New York: Guilford. Constantino, J., Abbacchi, A., Lavesser, P., Reed, H., Givens, L., Chiang, L., Todd, R. D. (2009). Developmental course of autistic social impairment in males. Development and Psychopathology, 21(01), 127–138. Crowe, R. R. (1974). An adoption study of antisocial personality. Archives of General Psychiatry, 31, 785–791. De Brito, S. A., & Hodgins, S. (2009). Antisocial personality disorder. In M. McMurran & R. C. Howard (Eds.), Personality, Personality Disorder and Violence: An Evidence Based Approach (pp. 133–154). New York, NY: Wiley Depue, R. A. (2009). Genetic, environmental, and epigenetic factors in the development of personality disturbance. Develop. Psychopath., 21(4), 1031–63. Doi:10.1017/S0954579409990034 Depue, R. A., & Lenzenweger, M.F. (2005). A neurobehavioral model of personality disturbance. In: Clarkin, J.F ,& Lenzenweger, M.F., editors. Major Theories of Personality Disorder. Second. New York, NY: Guilford. Dvorak-Bertscha, J., Curtin, J., Rubinstein, T., & Newman, J. (2009). Psychopathic traits moderate the interaction between cognitive and affective processing. Psychophysiology, 46(5), 913. Exline, J. J., Baumeister, R. F., Bushman, B. J., Campbell, W. K., & Finkel, E. J. (2004). Too proud to let go: Narcissistic entitlement as a barrier to forgiveness. J. Pers. Soc. Psych., 87(6), 894–912. Falkum, E., Pedersen, G., & Karterud, S. (2009). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, paranoid personality disorder diagnosis: A unitary or a two-dimensional construct? Compr. Psychiatry, 50(6), 533–41. Doi:10.1016/j.comppsych.2009.01.003 Farmer, C. M., O’Donnell, B. F., Niznikiewicz, M. A., Voglmaier, M. M., McCarley, R. W., & Shenton, M. E. (2000). Visual perception and working memory in schizotypal personality disorder. Am. J. Psychiatry, 157(5), 781–86. Ferguson, C. (2010). Genetic contributions to antisocial personality and behavior: A meta-analytic review from an evolutionary perspective. The Journal of Social Psychology, 150(2), 160–180. Freeman, A., Freeman, S. M., & Rosenfield, B. (2005). Histrionic personality disorder. In G. O. Gabbard, J. S. Beck, & J. Holmes (Eds.), Oxford Textbook of Psychotherapy (pp. 305–10). New York: Oxford University Press. Freeman, A., Pretzer, J., Fleming, B., & Simon, K. M. (1990). Clinical Applications of Cognitive Therapy. New York, NY: Plenum Press. Golomb, M., Fava, M., Abraham, M., & Rosenbaum, J. F. (1995). Gender differences in personality disorders. Am. J. Psychiatry, 152(4), 579–82. Granic, I., & Patterson, G. R. (2006). Toward a comprehensive model of antisocial development: A dynamic systems approach. Psychological Review, 113, 101– 131. 249 Personality Disorders: Cluster B and Cluster C Grant, B. F., Stinson, F. S., Dawson, D. A., Chou, S. P., & Ruan, W. J. (2005). Co-occurrence of DSM-IV personality disorders in the United States: Results from the national epidemiologic survey on alcohol and related conditions. Compr. Psychiatry, 46, 1–5. Gray, J. A. (1987). The Psychology of Fear and Stress (2nd ed.). New York, NY: Cambridge University Press. Hare, R. D. (1993). Without Conscience: The Disturbing World of the Psychopaths Among Us. New York, NY: Pocket Books. Hare, R. D., Nuemann, C. S., & Widiger, T. A. (2012). Psychopathy. In T. A. Widiger (ed.). The Oxford Handbook of Personality Disorders (pp. 478– 504). New York: Oxford University Press. Harris, G. T., & Rice, M. E. (2006). Treatment of psychopathy: A review of empirical findings. In C. J. Patrick (Ed.), Handbook of the Psychopathy (pp. 555–72). New York: Guilford Press. Hooley, J., Cole, S., & Gironde, S. (2012). Borderline personality disorder. In T. Widiger (Ed.), The Oxford Handbook of Personality Disorders (pp. 409–36). Oxford: Oxford University Press. Huang, Y., Kotov, R., de Girolamo, G., Preti, A., Angermeyer, M., Benjet, C., Kessler, R. C.. (2009). DSM-IV personality disorders in the WHO World Mental Health Surveys. The British Journal of Psychiatry, 195(1), 46–53. doi:10.1192/ bjp.bp.108.058552 John, O., & Naumann, L. (2008). Paradigm shift to the integrative Big-Five trait taxonomy: History, measurement, and conceptual issues. In O. P. John, R. Robins, & L. Pervin (Eds.), Handbook of Personality: Theory and Research (3rd ed., pp. 114–58). New York: Guilford Press. Johnson, J. G., Bromley, E., & McGeoch, P. G. (2005). Role of childhood experiences in the development of maladaptive and adaptive traits. In J. M. Oldham, A. E. Skodol, & D. S. Bender (Eds.), Textbook of Personality Disorders (pp. 209–221). Washington, DC: American Psychiatric Publishing. Kaminski, J. W., Valle, L., Filene, J., & Boyle, C. (2008). A meta-analytic review of components associated with parent training program effectiveness. Journal of Abnormal Child Psychology, 36(4), 567–589. Kass, D. J., Silvers, F. M., & Abrams, G. M. (1972). Behavioral group treatment of hysteria. Archives of General Psychiatry, 26, 42–50. Kendler, K. S., Aggen, S. H., Czajkowski, N., Røysamb, E., Tambs, K., Torgersen, S., et al. (2008). The structure of genetic and environmental risk factors for DSM- IV personality disorders. Arch. Gen. Psychiatry, 65(12), 1438–46. Doi:10.1017/ S0033291710002436 Kohut, H., & Wolff, E. (1978). The disorders of the self and their treatment: An outline. Inter. J. Psychoanal., 59, 413–26 Krueger, R. F., & Eaton, N. R. (2010). Personality traits and the classification of mental disorders: Toward a more complete integration in DSM-5 and an empirical 252 Disorders of Personality, Paraphilic and Substance- related Disorders Robins, L. N. (1978). Sturdy childhood predictors of adult antisocial behavior: Replications from longitudinal studies. Psychological Medicine, 8, 611–622. Rogler, L. (2007). Framing research on culture in psychiatric diagnosis. In J. E. Mezzich & G. Caracci (Eds.), Cultural Formulation: A Reader for Psychiatric Diagnosis (pp. 151–166). Lanham, MD: Jason Aronson Inc. Ronningstam, E. (2012). Narcissistic personality disorder: The diagnostic process. In T. Widiger (Ed.), The Oxford Handbook of Personality Disorders (pp. 527– 48). Oxford: Oxford University Press. Ronningstam, E. F. (2005). Narcissistic personality disorder: A review. In M. Maj, H. S. Akiskal, J. E. Mezzich, & A. Okasha (Eds.), Evidence and experience in psychiatry. Vol. 8: Personality disorders (pp. 277–27). New York: Wiley. Ronningstam, E. F. (2009). Narcissistic personality disorder: Facing DSM-V. Psychiatr. Ann., 39, 111–21. Roussos, P., & Siever, L. J. (2012). Neurobiological contributions. In T. Widiger (Ed.), The Oxford Handbook of Personality Disorders (pp. 299–324). Oxford: Oxford University Press. Salekin, R. T. (2006). Psychopathy in children and adolescents: Key issues in conceptualization and assessment. In C. J. Patrick (Ed.), Handbook of Psychopathy (pp. 389–414). New York, NY: Guilford Press. Samuel, D. B., & Widiger, T. A. (2008). A meta-analytic review of the relationships between the five-factor model and DSM-IV-TR personality disorders: A facet level analysis. Clinical Psychology Review, 28(8), 1326–1342. doi: 10.1016/ j.cpr.2008.07.002 Samuel, D. B., & Widiger, T. A. (2011). Conscientiousness and obsessive- compulsive personality disorder. Personality Disorders: Theory, Research, and Treatment, 2(3), 161–74. Doi:10.1037/ a0021216 Sanislow, C. A., da Cruz, K., Gianoli, M. O., & Reagan, E. (2012). Avoidant personality disorder, traits and type. In T. Widiger (Ed.), The Oxford Handbook of Personality Disorders (pp. 549–65). Oxford: Oxford University Press. Sheets, E., & Craighead, W. E. (2007). Toward an empirically based classification of personality pathology. Clin. Psychol. Sci. Prac., 14(2), 77–93. Skodol, A. E., & Gunderson, J. G. (2008). Personality disorders. In R. E. Hales, S. C. Yudofsky, & G. O. Gabbard (Eds.), The American Psychiatric Publishing textbook of psychiatry (5th ed., pp. 821–860). Arlington, VA: American Psychiatric Publishing. Stanley, B., Brodsky, B., Nelson, J., & Dulit, R. (2007). Brief dialectical behavior therapy for suicidality and self-injurious behaviors. Arch. Suicide Res., 11, 337– 41. Strauss, J. L., Hayes, A. M., Johnson, S. L., Newman, C. F., Brown, G. K., Barber, J. P., . Beck, A.T. (2006). Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive- 253 Personality Disorders: Cluster B and Cluster C compulsive personality disorders. Journal of Consulting and Clinical Psychology, 74, 337–345. Svartberg, M., Stiles, T. C., & Seltzer, M. H. (2004). Randomized, controlled trial of the effectiveness of short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders. American Journal of Psychiatry, 161, 810–817 Sylvers, P., Ryan, S., Alden, S., & Brennan, P. (2009). Biological factors and the development of persistent criminality. In J. Savage (Ed.), The Development of Persistent Criminality (pp. 141– 162). New York, NY: Oxford University Press. Taylor, C., Laposa, J., & Alden, L. (2004). Is avoidant personality disorder more than just social avoidance? J. Pers. Disord., 18, 571–94. Taylor, J., & Lang, A. R. (2006). Psychopathy and substance use disorders. In C. J. Patrick (Ed.), Handbook of Psychopathy (pp. 495–511). New York, NY: Guilford Press. Tessner, K. D., Mittal, V., & Walker, E. F. (2011). Longitudinal study of stressful life events and daily stressors among adolescents at high risk for psychotic disorders. Schizo. Bull., 37(2), 432–41. Doi:10.1093/ schbul/sbp087 Thomas, C. R. (2009). Oppositional defiant disorder and conduct disorder. In M. K. Dulcan (Ed.), Dulcan’s textbook of child and adolescent psychiatry (pp. 223– 239). Arlington, VA: American Psychiatric Publishing. Watson, D., Clark, L. A., & Chmielewski, M. (2008). Structures of personality and their relevance to psychopathology: II. Further articulation of a comprehensive unified trait structure. J. Pers., 76(6), 1545–86. Doi:10.1111/j.1467- 6494.2008.00531.x Weinberg, R. S., & Gould, D. (1999). Personality and sport. Foundations of Sport and Exercise Psychology, 25-46. Widiger, T. A., & Bornstein, R. F. (2001). Histrionic, dependent, and narcissistic personality disorders. In H. E. Adams & P. B. Sutker (Eds.), Comprehensive Handbook of Psychopathology (pp. 509–34). New York: Kluwer Academic. Widiger, T. A., Trull, T. J., Clarkin, J. F., Sanderson, C. J., & Costa, P. T. (2002). A description of the DSM-IV personality disorders with the five-factor model of personality. In P. T. Costa, Jr. & T. A. Widiger (Eds.), Personality disorders and the five-factor model of personality (pp. 89–102). Washington, DC: American Psychological Association. Wink, P. (1991). Two faces of narcissism. J. Pers. Soc. Psychol., 61, 590–97. Wu, K. D., Clark, L. A., & Watson, D. (2006). Relations between obsessive- compulsive disorder and personality: Beyond Axis I-Axis II comorbidity. Anxiety Disorders, 20, 695–717. Yovel, I., Revelle, W., & Mineka, S. (2005). Who sees trees before forest: The obsessive-compulsive style of visual-attention.Psychol. Sci., 16, 123–29. 254 Disorders of Personality, Paraphilic and Substance- related Disorders Zimmerman, M., Rothchild, L., & Chelminski, I. (2005). The prevalence of DSM- IV personality disorders in psychiatric outpatients.Am. J. Psychiatry, 162, 1911– 18. 9.18 WEB RESOURCES Case of David Berkowitz (Psychopathy and ASPD) http://maamodt.asp.radford.edu/Psyc%20405/serial%20killers/ Berkowitz,%20David.pdf Portrayal of Borderline Personality Disorder (BPD) in the movie; Girl, Interrupted (1999) directed by James Mangold (Starring, Winona Ryder, Angelina Jolie, Clea DuVall, Brittany Murphy, Whoopi Goldberg, Elisabeth Moss, and Vanessa Redgrave). Answers to Check Your Progress Check Your Progress 1 1) Histrionic personality disorder 2) Narcissistic personality disorder 3) Parental overevaluation 4) Grandiosity 5) Histrionic personality disorder. Check Your Progress 2 1) Antisocial personality disorder 2) Fearlessness hypothesis 3) Antisocial personality disorder 4) Impulsivity and instability in self-image, moods and even in relationships 5) Borderline personality disorder. Check Your Progress 3 1) Extreme social inhibition; and introversion 2) Obsessive-compulsive personality disorder 3) Dependent personality disorder 4) Cognitive Behaviour 5) Innate “inhibited”.