Table of Contents

Biological Aspects of Personality Disorders

Causes of Personality Disorders:

1. Genetic Factors

Clinicians study identical twins (monozygotic) coming from the same fertilised egg and compare these with fraternal non-identical twins (dizygotic) coming from two different eggs.

Investigations of 15,000 pairs of twins in the United States showed that the chances that personality disorders occur in identical twins was several times higher than among twins.

Moreover, when monozygotic twins are reared apart in different places and with different adopting parents they develop symptoms of personality disorder in a similar way to monozygotic twins reared together. Similarities include multiple measures of personality and temperament, occupational and leisure-time interests, and social attitudes.

Cluster A personality disorders (DSM-V) are more common in the biological relatives of patients with schizophrenia than in other groups. More relatives with schizotypal personality disorder occur in the family of persons with schizophrenia than in other groups. This is less likely in the case of paranoid or schizoid personality disorder and schizophrenia.

Cluster B personality disorders apparently have a genetic base. Antisocial personality disorder is associated with alcohol use disorders. Depression is common in the family backgrounds of patients with borderline personality disorder. These patients have more relatives with mood disorders and persons with borderline personality disorder often have a mood disorder as well. A strong association is found between histrionic personality disorder and somatization disorder (Briquet's syndrome); patients with each disorder show an overlap of symptoms.

Cluster C personality disorders may also have a genetic base. Patients with avoidant personality disorder often have high anxiety levels. Obsessive-compulsive traits are more common in monozygotic twins than in dizygotic twins, and patients with obsessive-compulsive personality disorder show some signs associated with depression.

2. Biological Factors


Persons who exhibit impulsive traits also often show high levels of testosterone, 17-estradiol, and estrone. In nonhuman primates, androgens increase the likelihood of aggression and sexual behaviour, but the role of testosterone in human aggression is unclear.

Smooth Pursuit Eye Movements

Smooth pursuit eye movements are jumpy) in persons who are introverted, who have low self-esteem and tend to withdraw, and who have schizotypal personality disorder. These findings have no clinical application, but they do indicate the role of inheritance.


Endorphins are neurochemical substances occurring naturally in the brain and have effects similar to those of exogenous morphine, such as analgesia and the suppression of arousal. High endogenous endorphin levels may be associated with persons who are unemotional.

Studies of other chemicals in the brain responsible for transmission of nerve impulse between nerve cells in gave evidence of role of neurotransmitters in personality traits. The dopamine and serotonin systems play an arousal-activating function in the brain. Levels of the end product of serotonin, 5-hydroxyindoleacetic acid (5-HIAA), are low in persons who attempt suicide and in patients who are impulsive and aggressive.

Raising serotonin levels with drugs such as fluoxetine (Prozac) can produce dramatic changes in some character traits of personality. In many persons, serotonin reduces depression, impulsiveness, and rumination, and can produce a sense of general well-being.

Increased dopamine concentrations in the central nervous system, produced by certain psychostimulants such as amphetamines can induce euphoria. The effects of neurotransmitters on personality traits have generated much interest and controversy about whether personality traits are inborn or acquired.

Brain Electrical activity:

Electroencephalography (EEG) records the electrical changes near the surface of the brain through electrodes attached to the scalp of the head. Changes in electrical conductance on the electroencephalogram (EEG) occur in some patients with personality disorders, most commonly antisocial and borderline types. These changes appear as slow-wave activity on EEGs.

3. Psychoanalytic Factors

Sigmund Freud suggested that personality traits are related to a fixation at one psychosexual stage of development. For example, those with an oral character are passive and dependent because they are fixated at the oral stage, when the dependence on others for food is prominent. Those with an anal character are stubborn, parsimonious, and highly conscientious because of struggles over toilet training during the anal period.

Wilhelm Reich subsequently coined the term character armor to describe persons' characteristic defensive styles for protecting themselves from internal impulses and from interpersonal anxiety in significant relationships. Reich's theory has had a broad influence on contemporary concepts of personality and personality disorders. For example, each human being's unique stamp of personality is considered largely determined by his or her characteristic defence mechanisms. Each personality disorder has a cluster of defences that help psychodynamic clinicians recognize the type of character pathology present. Persons with paranoid personality disorder, for instance, use projection, whereas schizoid personality disorder is associated with withdrawal.

When defences work effectively, persons with personality disorders master feelings of anxiety, depression, anger, shame, guilt, and other affects. They often view their behaviour as acceptable; that is, it creates no distress for them, even though it may adversely affect others. They may also be reluctant to engage in a treatment process; because their defences are important in controlling unpleasant affects, they are not interested in surrendering them.

In addition to characteristic defences in personality disorders, another central feature is internal object relations. During development, particular patterns of self in relation to others are internalized. Through introjection, children internalize a parent or another significant person as an internal presence that continues to feel like an object rather than a self. Through identification, children internalize parents and others in such a way that the traits of the external object are incorporated into the self and the child “owns” the traits.

These internal self-representations and object representations are crucial in developing the personality and, through externalization and projective identification, are played out in interpersonal scenarios in which others are coerced into playing a role in the person's internal life. Hence, persons with personality disorders are also identified by particular patterns of interpersonal relatedness that stem from these internal object relations patterns.

Défense Mechanisms

To help those with personality disorders, psychiatrists must appreciate patients' underlying defences, the unconscious mental processes that the ego uses to resolve conflicts among the four models of the inner life: instinct (wish or need), reality, important persons, and conscience. When defences are most effective, especially in those with personality disorders, they can abolish anxiety and depression. Thus, abandoning a defence increases conscious anxiety and depression—a major reason that those with personality disorders are reluctant to alter their behaviour.

Although patients with personality disorders may be characterized by their most dominant or rigid mechanism, each patient uses several defences. Therefore, the management of defence mechanisms used by patients with personality disorders is discussed here as a general topic and not as an aspect of the specific disorders. Many formulations presented here in the language of psychoanalytic psychiatry can be translated into principles consistent with cognitive and behavioural approaches.


Many persons who are often labelled schizoid—those who are eccentric, lonely, or frightened—seek solace and satisfaction within themselves by creating imaginary lives, especially imaginary friends. In their extensive dependence on fantasy, these persons often seem to be strikingly aloof. Therapists must understand that the unsociableness of these patients rests on a fear of intimacy. Rather than criticizing them or feeling rebuffed by their rejection, therapists should maintain a quiet, reassuring, and considerate interest without insisting on reciprocal responses. Recognition of patients' fear of closeness and respect for their eccentric ways are both therapeutic and useful.


Dissociation or denial is a replacement of unpleasant affects with pleasant ones. Persons who frequently dissociate are often seen as dramatizing and emotionally shallow; they may be labelled histrionic personalities. They behave like anxious adolescents who, to erase anxiety, carelessly expose themselves to exciting dangers. Accepting such patients as exuberant and seductive is to overlook their anxiety, but confronting them with their vulnerabilities and defects makes them still more defensive. Because these patients seek appreciation of their courage and attractiveness, therapists should not behave with inordinate reserve. While remaining calm and firm, clinicians should realize that these patients are often inadvertent liars, but they benefit from ventilating their own anxieties and may in the process “remember” what they “forgot.” Often therapists deal best with dissociation and denial by using displacement. Thus, clinicians may talk with patients about an issue of denial in an unthreatening circumstance. Empathizing with the denied affect without directly confronting patients with the facts may allow them to raise the original topic themselves.


Isolation is characteristic of the orderly, controlled persons who are often labeled obsessive-compulsive personalities. Unlike those with histrionic personality, persons with obsessive-compulsive personality remember the truth in fine detail but without affect. In a crisis, patients may show intensified self-restraint, overly formal social behaviour, and obstinacy. Patients' quests for control may annoy clinicians or make them anxious. Often, such patients respond well to precise, systematic, and rational explanations and value efficiency, cleanliness, and punctuality as much as they do clinicians' effective responsiveness. Whenever possible, therapists should allow such patients to control their own care and should not engage in a battle of wills.


In projection, patients attribute their own unacknowledged feelings to others. Patients' excessive fault-finding and sensitivity to criticism may appear to therapists as prejudiced, hypervigilant injustice collecting, but should not be met by defensiveness and argument. Instead, clinicians should frankly acknowledge even minor mistakes on their part and should discuss the possibility of future difficulties. Strict honesty, concern for patients' rights, and maintaining the same formal, concerned distance as used with patients who use fantasy defences are all helpful. Confrontation guarantees a lasting enemy and early termination of the interview. Therapists need not agree with patients' injustice collecting, but they should ask whether both can agree to disagree.

The technique of counter projection is especially helpful. Clinicians acknowledge and give paranoid patients full credit for their feelings and perceptions; they neither dispute patients' complaints nor reinforce them, but agree that the world described by patients is conceivable. Interviewers can then talk about real motives and feelings, misattributed to someone else, and begin to cement an alliance with patients.


In splitting, persons toward whom patients' feelings are, or have been, ambivalent are divided into good and bad. For example, in an inpatient setting, a patient may idealize some staff members and uniformly disparage others. This defence behaviour can be highly disruptive on a hospital ward and can ultimately provoke the staff to turn against the patient. When staff members anticipate the process, discuss it at staff meetings, and gently confront the patient with the fact that no one is all good or all bad, the phenomenon of splitting can be dealt with effectively.

Passive Aggression

Persons with passive-aggressive defence turn their anger against themselves. In psychoanalytic terms this phenomenon is called masochism and includes failure, procrastination, silly or provocative behaviour, self-demeaning clowning, and frankly self-destructive acts. The hostility in such behaviour is never entirely concealed. Indeed, in a mechanism such as wrist cutting, others feel as much anger as if they themselves had been assaulted and view the patient as a sadist, not a masochist. Therapists can best deal with passive aggression by helping patients to ventilate their anger.

Acting Out

In acting out, patients directly express unconscious wishes or conflicts through action to avoid being conscious of either the accompanying idea or the affect. Tantrums, apparently motiveless assaults, child abuse, and pleasureless promiscuity are common examples. Because the behaviour occurs outside reflective awareness, acting out often appears to observers to be unaccompanied by guilt, but when acting out is impossible, the conflict behind the defence may be accessible. The clinician faced with acting out, either aggressive or sexual, in an interview situation, must recognize that the patient has lost control, that anything the interviewer says will probably be misheard, and that getting the patient's attention is of paramount importance. Depending on the circumstances, a clinician's response may be, “How can I help you if you keep screaming?” Or, if the patient's loss of control seems to be escalating, say, “If you continue screaming, I'll leave.” An interviewer who feels genuinely frightened of the patient can simply leave and, if necessary, ask for help from ward attendants or the police.

Projective Identification

The defence mechanism of projective identification appears mainly in borderline personality disorder and consists of three steps. First, an aspect of the self is projected onto someone else. The projector then tries to coerce the other person into identifying with what has been projected. Finally, the recipient of the projection and the projector feel a sense of oneness or union.

Types of Personality Disorders

Paranoid Personality Disorder

Persons with paranoid personality disorder are characterized by long-standing suspiciousness and mistrust of persons in general. They refuse responsibility for their own feelings and assign responsibility to others. They are often hostile, irritable, and angry. Bigots, injustice collectors, pathologically jealous spouses, and litigious cranks often have paranoid personality disorder.


The prevalence of paranoid personality disorder is 0.5 to 2.5 percent of the general population. Those with the disorder rarely seek treatment themselves; when referred to treatment by a spouse or an employer, they can often pull themselves together and appear undistressed. Relatives of patients with schizophrenia show a higher incidence of paranoid personality disorder than controls. The disorder is more common in men than in women and does not appear to have a familial pattern. The prevalence among persons who are homosexual is no higher than usual, as was once thought, but it is believed to be higher among minority groups, immigrants, and persons who are deaf than it is in the general population.


On psychiatric examination, patients with paranoid personality disorder may be formal in manner and act baffled about having to seek psychiatric help. Muscular tension, an inability to relax, and a need to scan the environment for clues may be evident, and the patient's manner is often humourless and serious. Although some premises of their arguments may be false, their speech is goal directed and logical. Their thought content shows evidence of projection, prejudice, and occasional ideas of reference. The DSM-IV-TR diagnostic criteria are listed in Table 27-2.

Clinical Features

The hallmarks of paranoid personality disorder are excessive suspiciousness and distrust of others expressed as a pervasive tendency to interpret actions of others as deliberately demeaning, malevolent, threatening, exploiting, or deceiving. This tendency begins by early adulthood and appears in a variety of contexts. Almost invariably, those with the disorder expect to be exploited or harmed by others in some way. They frequently dispute, without any justification, friends' or associates' loyalty or trustworthiness. Such persons are often pathologically jealous and, for no reason, question the fidelity of their spouses or sexual partners. Persons with this disorder externalize their own emotions and use the defense of projection; they attribute to others the impulses and thoughts that they cannot accept in themselves. Ideas of reference and logically defended illusions are common.

Diagnostic Criteria for Paranoid Personality Disorder

  1. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
  2. suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
  3. is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
  4. is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
  5. reads hidden demeaning or threatening meanings into benign remarks or events
  6. persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights
  7. perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
  8. has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner

  9. Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, or another psychotic disorder and is not due to the direct physiological effects of a general medical condition.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g., “paranoid personality disorder (premorbid).”

Persons with paranoid personality disorder are affectively restricted and appear to be unemotional. They pride themselves on being rational and objective, but such is not the case. They lack warmth and are impressed with, and pay close attention to, power and rank. They express disdain for those they see as weak, sickly, impaired, or in some way defective. In social situations, persons with paranoid personality disorder may appear business-like and efficient, but they often generate fear or conflict in others.

Differential Diagnosis

Paranoid personality disorder can usually be differentiated from delusional disorder by the absence of fixed delusions. Unlike persons with paranoid schizophrenia, those with personality disorders have no hallucinations or formal thought disorder. Paranoid personality disorder can be distinguished from borderline personality disorder because patients who are paranoid are rarely capable of overly involved, tumultuous relationships with others. Patients with paranoia lack the long history of antisocial behavior of persons with antisocial character. Persons with schizoid personality disorder are withdrawn and aloof and do not have paranoid ideation.

Course and Prognosis

No adequate, systematic long-term studies of paranoid personality disorder have been conducted. In some, paranoid personality disorder is lifelong; in others, it is a harbinger of schizophrenia.

In still others, paranoid traits give way to reaction formation, appropriate concern with morality, and altruistic concerns as they mature or as stress diminishes. In general, however, those with paranoid personality disorder have lifelong problems working and living with others. Occupational and marital problems are common.



Psychotherapy is the treatment of choice for paranoid personality disorder. Therapists should be straightforward in all their dealings with these patients. If a therapist is accused of inconsistency or a fault, such as lateness for an appointment, honesty and an apology are preferable to a defensive explanation. Therapists must remember that trust and toleration of intimacy are troubled areas for patients with this disorder. Individual psychotherapy, thus, requires a professional and not overly warm style from therapists.

Clinicians' overzealous use of interpretation—especially interpretation about deep feelings of dependence, sexual concerns, and wishes for intimacy—increase patients' mistrust significantly. Patients who are paranoid usually do not do well in group psychotherapy, although it can be useful for improving social skills and diminishing suspiciousness through role playing. Many cannot tolerate the intrusiveness of behavior therapy, also used for social skills training.

At times, patients with paranoid personality disorder behave so threateningly that therapists must control or set limits on their actions. Delusional accusations must be dealt with realistically but gently and without humiliating patients. Patients who are paranoid are profoundly frightened when they feel that those trying to help them are weak and helpless; therefore, therapists should never offer to take control unless they are willing and able to do so.


Pharmacotherapy is useful in dealing with agitation and anxiety. In most cases, an antianxiety agent such as diazepam (Valium) suffices. It may be necessary, however, to use an antipsychotic such as haloperidol (Haldol) in small dosages and for brief periods to manage severe agitation or quasi-delusional thinking. The antipsychotic drug pimozide (Orap) has successfully reduced paranoid ideation in some patients.

Schizoid Personality Disorder

Schizoid personality disorder is diagnosed in patients who display a lifelong pattern of social withdrawal. Their discomfort with human interaction, their introversion, and their bland, constricted affect are noteworthy. Persons with schizoid personality disorder are often seen by others as eccentric, isolated, or lonely.


The prevalence of schizoid personality disorder is not clearly established, but the disorder may affect 7.5 percent of the general population. The sex ratio of the disorder is unknown; some studies report a 2-to-1 male-to-female ratio. Persons with the disorder tend to gravitate toward solitary jobs that involve little or no contact with others. Many prefer night work to day work, so that they need not deal with many persons.

Diagnostic Criteria for Schizoid Personality Disorder

  1. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
  2. neither desires nor enjoys close relationships, including being part of a family
  3. almost always chooses solitary activities
  4. has little, if any, interest in having sexual experiences with another person
  5. takes pleasure in few, if any, activities
  6. lacks close friends or confidants other than first-degree relatives
  7. appears indifferent to the praise or criticism of others
  8. shows emotional coldness, detachment, or flattened affectivity

  9. Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder, or a pervasive developmental disorder and is not due to the direct physiological effects of a general medical condition.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g., “schizoid personality disorder (premorbid).”


On an initial psychiatric examination, patients with schizoid personality disorder may appear ill at ease. They rarely tolerate eye contact, and interviewers may surmise that such patients are eager for the interview to end. Their affect may be constricted, aloof, or inappropriately serious, but underneath the aloofness, sensitive clinicians can recognize fear.

These patients find it difficult to be lighthearted: Their efforts at humor may seem adolescent and off the mark. Their speech is goal-directed, but they are likely to give short answers to questions and to avoid spontaneous conversation. They may occasionally use unusual figures of speech, such as an odd metaphor, and may be fascinated with inanimate objects or metaphysical constructs. Their mental content may reveal an unwarranted sense of intimacy with persons they do not know well or whom they have not seen for a long time. Their sensorium is intact, their memory functions well, and their proverb interpretations are abstract. The DSM-IV-TR diagnostic criteria are listed in Table 27-3.

Clinical Features

Persons with schizoid personality disorder seem to be cold and aloof; they display a remote reserve and show no involvement with everyday events and the concerns of others. They appear quiet, distant, seclusive, and unsociable. They may pursue their own lives with remarkably little need or longing for emotional ties, and they are the last to be aware of changes in popular fashion.

The life histories of such persons reflect solitary interests and success at noncompetitive, lonely jobs that others find difficult to tolerate. Their sexual lives may exist exclusively in fantasy, and they may postpone mature sexuality indefinitely. Men may not marry because they are unable to achieve intimacy; women may passively agree to marry an aggressive man who wants the marriage. Persons with schizoid personality disorder usually reveal a lifelong inability to express anger directly. They can invest enormous affective energy in nonhuman interests, such as mathematics and astronomy, and they may be very attached to animals. Dietary and health fads, philosophical movements, and social improvement schemes, especially those that require no personal involvement, often engross them.

Although persons with schizoid personality disorder appear self-absorbed and lost in daydreams, they have a normal capacity to recognize reality. Because aggressive acts are rarely included in their repertoire of usual responses, most threats, real or imagined, are dealt with by fantasized omnipotence or resignation. They are often seen as aloof, yet such persons can sometimes conceive, develop, and give to the world genuinely original, creative ideas.

Differential Diagnosis

Schizoid personality disorder is distinguished from schizophrenia, delusional disorder, and affective disorder with psychotic features based on periods with positive psychotic symptoms, such as delusions and hallucinations in the latter. Although patients with paranoid personality disorder share many traits with those with schizoid personality disorder, the former exhibit more social engagement, a history of aggressive verbal behavior, and a greater tendency to project their feelings onto others.

If just as emotionally constricted, patients with obsessive-compulsive and avoidant personality disorders experience loneliness as dysphoric, possess a richer history of past object relations, and do not engage as much in autistic reverie. Theoretically, the chief distinction between a patient with schizotypal personality disorder and one with schizoid personality disorder is that the patient who is schizotypal is more similar to a patient with schizophrenia in oddities of perception, thought, behavior, and communication. Patients with avoidant personality disorder are isolated but strongly wish to participate in activities, a characteristic absent in those with schizoid personality disorder. Schizoid personality disorder is distinguished from autistic disorder and Asperger's syndrome by more severely impaired social interactions and stereotypical behaviors and interests than in those two disorders.

Course and Prognosis

The onset of schizoid personality disorder usually occurs in early childhood. As with all personality disorders, schizoid personality disorder is long lasting, but not necessarily lifelong. The proportion of patients who incur schizophrenia is unknown.



The treatment of patients with schizoid personality disorder is similar to that of those with paranoid personality disorder. Patients who are schizoid tend toward introspection, however, these tendencies are consistent with psychotherapists' expectations, and such patients may become devoted, if distant, patients. As trust develops, patients who are schizoid may, with great trepidation, reveal a plethora of fantasies, imaginary friends, and fears of unbearable dependence—even of merging with the therapist.

In group therapy settings, patients with schizoid personality disorder may be silent for long periods; nonetheless, they do become involved. The patients should be protected against aggressive attack by group members for their proclivity to be silent. With time, the group members become important to patients who are schizoid and may provide the only social contact in their otherwise isolated existence.


Pharmacotherapy with small dosages of antipsychotics, antidepressants, and psychostimulants has benefitted some patients. Serotonergic agents may make patients less sensitive to rejection. Benzodiazepines may help diminish interpersonal anxiety.

Schizotypal Personality Disorder

Persons with schizotypal personality disorder are strikingly odd or strange, even to laypersons. Magical thinking, peculiar notions, ideas of reference, illusions, and derealization are part of a schizotypal person's everyday world.


Schizotypal personality disorder occurs in about 3 percent of the population. The sex ratio is unknown. A greater association of cases exists among the biological relatives of patients with schizophrenia than among controls, and a higher incidence among monozygotic twins than among dizygotic twins (33 percent versus 4 percent in one study).


Schizotypal personality disorder is diagnosed on the basis of the patients' peculiarities of thinking, behavior, and appearance. Taking a history may be difficult because of the patients' unusual way of communicating. The DSM-IV-TR diagnostic criteria for schizotypal personality disorder are given in Table 27-4.

Clinical Features

Patients with schizotypal personality disorder exhibit disturbed thinking and communicating. Although frank thought disorder is absent, their speech may be distinctive or peculiar, may have meaning only to them, and often needs interpretation. As with patients with schizophrenia, those with schizotypal personality disorder may not know their own feelings and yet are exquisitely sensitive to, and aware of, the feelings of others, especially negative affects such as anger. These patients may be superstitious or claim powers of clairvoyance and may believe that they have other special powers of thought and insight. Their inner world may be filled with vivid imaginary relationships and child-like fears and fantasies.

They may admit to perceptual illusions or macropsia and confess that other persons seem wooden and all the same.

Because persons with schizotypal personality disorder have poor interpersonal relationships and may act inappropriately,they are isolated and have few, if any, friends. Patients may show features of borderline personality disorder, and indeed, both diagnoses can be made. Under stress, patients with schizotypal personality disorder may decompensate and have psychotic symptoms, but these are usually brief. Patients with severe cases of the disorder may exhibit anhedonia and severe depression.

DSM-IV-TR Diagnostic Criteria for Schizotypal Personality Disorder

  1. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
  2. ideas of reference (excluding delusions of reference)
  3. odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations)
  4. unusual perceptual experiences, including bodily illusions
  5. odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped)
  6. suspiciousness or paranoid ideation
  7. inappropriate or constricted affect
  8. behavior or appearance that is odd, eccentric, or peculiar
  9. lack of close friends or confidants other than first-degree relatives
  10. excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

  11. Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder, or a pervasive developmental disorder.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g., “schizotypal personality disorder (premorbid).”

A 41-year-old man was referred to a community mental health center's activities program for help in improving his social skills. He had a lifelong pattern of social isolation, with no real friends, and spent long hours worrying that his angry thoughts about his older brother would cause his brother harm. He had previously worked as a clerk in civil service, but had lost his job because of poor attendance and low productivity.

On interview, the patient was distant and somewhat distrustful. He described in elaborate and often irrelevant detail his rather uneventful and routine daily life. He told the interviewer that he had spent an hour and a half in a pet store deciding which of two brands of fish food to buy and explained their relative merits. For 2 days he had studied the washing instructions on a new pair of jeans—Did “Wash before wearing” mean that the jeans were to be washed before wearing the first time, or did they need, for some reason, to be washed each time before they were worn? He did not regard concerns such as these as senseless, though he acknowledged that the amount of time spent thinking about them might be excessive. He described how he often would buy several different brands of the same item, such as different kinds of can openers, and then would keep them in their original bags in his closet, expecting that at some future time he would find them useful. He was, however, usually very reluctant to spend money on things that he actually needed, although he had a substantial bank account. He could recite from memory his most recent monthly bank statement, including the amount of every check and the running balance as each check was written. He knew his balance on any particular day, but sometimes got anxious if he considered whether a certain check or deposit had actually cleared. He asked the interviewer whether, if he joined the program, he would be required to participate in groups. He said that groups made him very nervous because he felt that if he revealed too much personal information, such as the amount of money that he had in the bank, people would take advantage of him or manipulate him for their own benefit. (From DSM-IV-TR Casebook.)

Differential Diagnosis

Theoretically, persons with schizotypal personality disorder can be distinguished from those with schizoid and avoidant personality disorders by the presence of oddities in their behavior, thinking, perception, and communication and perhaps by a clear family history of schizophrenia. Patients with schizotypal personality disorder can be distinguished from those with schizophrenia by their absence of psychosis. If psychotic symptoms do appear, they are brief and fragmentary. Some patients meet the criteria for both schizotypal personality disorder and borderline personality disorder. Patients with paranoid personality disorder are characterized by suspiciousness, but lack the odd behavior of patients with schizotypal personality disorder.

Course and Prognosis

A long-term study by Thomas McGlashan reported that 10 percent of those with schizotypal personality disorder eventually committed suicide. Retrospective studies have shown that many patients thought to have had schizophrenia actually had schizotypal personality disorder and, according to current clinical thinking, the schizotype is the premorbid personality of the patient with schizophrenia. Some, however, maintain a stable schizotypal personality throughout their lives and marry and work, despite their oddities.



The principles of treatment of schizotypal personality disorder do not differ from those of schizoid personality disorder, but clinicians must deal sensitively with the former. These patients have peculiar patterns of thinking, and some are involved in cults, strange religious practices, and the occult. Therapists must not ridicule such activities or be judgmental about these beliefs or activities.


Antipsychotic medication may be useful in dealing with ideas of reference, illusions, and other symptoms of the disorder and can be used in conjunction with psychotherapy. Antidepressants are useful when a depressive component of the personality is present.

Antisocial Personality Disorder

Antisocial personality disorder is an inability to conform to the social norms that ordinarily govern many aspects of a person's adolescent and adult behavior. Although characterized by continual antisocial or criminal acts, the disorder is not synonymous with criminality (the 10th revision of International Statistical Classification of Diseases and Related Health Problems [ICD-10] uses the name dissocial personality disorder).


The prevalence of antisocial personality disorder is 3 percent in men and 1 percent in women. It is most common in poor urban areas and among mobile residents of these areas. Boys with the disorder come from larger families than girls with the disorder. The onset of the disorder is before the age of 15. Girls usually have symptoms before puberty, and boys even earlier. In prison populations, the prevalence of antisocial personality disorder may be as high as 75 percent. A familial pattern is present; the disorder is five times more common among first-degree relatives of men with the disorder than among controls.


Patients with antisocial personality disorder can fool even the most experienced clinicians. In an interview, patients can appear composed and credible, but beneath the veneer (or, to use Hervey Cleckley's term, the mask of sanity) lurks tension, hostility, irritability, and rage.

A stress interview, in which patients are vigorously confronted with inconsistencies in their histories, may be necessary to reveal the pathology.

A diagnostic workup should include a thorough neurological examination. Because patients often show abnormal EEG results and soft neurological signs suggesting minimal brain damage in childhood, these findings can be used to confirm the clinical impression. The DSM-IV-TR diagnostic criteria are listed in Table 27-5.

Clinical Features

Patients with antisocial personality disorder can often seem to be normal and even charming and ingratiating. Their histories, however, reveal many areas of disordered life functioning. Lying, truancy, running away from home, thefts, fights, substance abuse, and illegal activities are typical experiences that patients report as beginning in childhood.

These patients often impress opposite-sex clinicians with the colorful, seductive aspects of their personalities, but same-sex clinicians may regard them as manipulative and demanding. Patients with antisocial personality disorder exhibit no anxiety or depression, a lack that may seem grossly incongruous with their situations, although suicide threats and somatic preoccupations may be common. Their own explanations of their antisocial behavior make it seem mindless, but their mental content reveals the complete absence of delusions and other signs of irrational thinking. In fact, they frequently have a heightened sense of reality testing and often impress observers as having good verbal intelligence. Persons with antisocial personality disorder are highly representative of so-called con men.

They are extremely manipulative and can frequently talk others into participating in schemes for easy ways to make money or to achieve fame or notoriety. These schemes may eventually lead the unwary to financial ruin or social embarrassment or both. Those with this disorder do not tell the truth and cannot be trusted to carry out any task or adhere to any conventional standard of morality. Promiscuity, spousal abuse, child abuse, and drunk driving are common events in their lives. A notable finding is a lack of remorse for these actions; that is, they appear to lack a conscience.

DSM-IV-TR Diagnostic Criteria for Antisocial Personality Disorder

  1. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:
  2. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
  3. deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
  4. impulsivity or failure to plan ahead
  5. irritability and aggressiveness, as indicated by repeated physical fights or assaults
  6. reckless disregard for safety of self or others
  7. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
  8. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

  9. The individual is at least age 18 years.

  10. There is evidence of conduct disorder with onset before age 15 years.

  11. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode.

A 19-year-old youth sporting a punk-style haircut and T-shirt with “Twisted Sister” written across the front was brought, by ambulance, at midnight to a hospital emergency room. He was accompanied by a 23-year-old male friend who called the ambulance because he was afraid his companion “was going to die like that basketball player” (a reference to a famous basketball player who died from a cocaine overdose).

The patient was agitated and argumentative, his breathing was irregular and rapid, his pulse was rapid, and his pupils were dilated. Reluctantly, the patient's friend admitted they used a lot of cocaine that evening.

By the time the patient's mother arrived, his condition had improved somewhat, although he created a commotion in the emergency room with his loud singing and gesticulations. The mother, looking disheveled and smelling of alcohol, was distraught and tearful. She told a disorganized story about her son's problems at home: he was disobedient and resentful of authority, unwilling to take part in family activities, and violently argumentative when confronted about his carrying on and partying at all hours of the night. She reported that he had been arrested twice for shoplifting and once for driving while intoxicated and that he spent almost all of his time with an older crowd. “They drag race a lot and hang out in the streets,” she said.

Divorced for almost 15 years, the mother admitted that not having a stable father figure in the household made disciplining quite difficult. She suspected that her son used drugs because she had heard him talk to his friends about drugs, but she did not have any direct evidence. She claimed that her son was not all bad, that he was a fairly good student and even a star member of the basketball team. (In fact, the son was quite successful in deceiving his nonvigilant mother into believing that. Actually, the patient never completed high school, had poor or failing grades, and never played on the school's basketball team.) When asked about her own drinking habits, the mother became defensive and claimed she drank only occasionally and in small amounts.

Within 24 hours the patient was physically well and quite willing to talk. He stated, almost boastfully, that he had been using alcohol and other drugs regularly since age 13. He told of repeated instances in which he and his friends had each consumed an entire case of beer in a day (“I can drink a lot before I feel anything. We call ourselves the ‘Andre the Giant Club’.”) in addition to using other drugs. These drug orgies had often included a dangerous game called “hurricane drag racing,” in which intoxicated contestants engaged in drag racing on side roads until somebody “chickens out” to avoid an oncoming car. During this heavy drug use, it was common for him to skip school because of the drug activity; when he had to be in school, he typically was intoxicated. To help support his drug involvement, he had devised various schemes for acquiring money, such as “borrowing” money from friends that would never be repaid or stealing car radios from the student parking lot, plus blatant stealing of money from his mother. This behavior was justified by a “Robin Hood” attitude: “I take from people who have a lot of money anyway.”

Despite the patient's admission of heavy drug involvement, he stopped short of admitting that he had a real problem. In response to a question about his ability to control drug use, he replied in a hostile manner, “Of course I could. No problem. I just don't see any damn good reason to stop.”

Somewhat fidgety and restless, the patient said he was finished with the interview. Before the interviewer had an opportunity to press him further about seeking treatment, the patient began to roam around the hospital unit, looking for someone who had an extra cigarette. (From DSM-IV-TR Casebook.)

Differential Diagnosis

Antisocial personality disorder can be distinguished from illegal behavior in that antisocial personality disorder involves many areas of a person's life. When antisocial behavior is the only manifestation, patients are classified in the DSM-IV-TR category of additional conditions that may be a focus of clinical attention—specifically, adult antisocial behavior. Dorothy Lewis found that many of these persons have a neurological or mental disorder that has been either overlooked or undiagnosed. More difficult is the differentiation of antisocial personality disorder from substance abuse. When both substance abuse and antisocial behavior begin in childhood and continue into adult life, both disorders should be diagnosed. When, however, the antisocial behavior is clearly secondary to premorbid alcohol abuse or other substance abuse, the diagnosis of antisocial personality disorder is not warranted.

In diagnosing antisocial personality disorder, clinicians must adjust for the distorting effects of socioeconomic status, cultural background, and sex. Furthermore, the diagnosis of antisocial personality disorder is not warranted when mental retardation, schizophrenia, or mania can explain the symptoms.

Course and Prognosis

Once an antisocial personality disorder develops, it runs an unremitting course, with the height of antisocial behavior usually occurring in late adolescence. The prognosis varies. Some reports indicate that symptoms decrease as persons grow older. Many patients have somatization disorder and multiple physical complaints. Depressive disorders, alcohol use disorders, and other substance abuse are common.



If patients with antisocial personality disorder are immobilized (e.g., placed in hospitals), they often become amenable to psychotherapy. When patients feel that they are among peers, their lack of motivation for change disappears. Perhaps for this reason, self-help groups have been more useful than jails in alleviating the disorder. Before treatment can begin, firm limits are essential. Therapists must find ways of dealing with patients' self-destructive behavior. And to overcome patients' fear of intimacy, therapists must frustrate patients' desire to run from honest human encounters. In doing so, a therapist faces the challenge of separating control from punishment and of separating help and confrontation from social isolation and retribution.


Pharmacotherapy is used to deal with incapacitating symptoms such as anxiety, rage, and depression, but because patients are often substance abusers, drugs must be used judiciously. If a patient shows evidence of attention-deficit/hyperactivity disorder, psychostimulants such as methylphenidate (Ritalin) may be useful. Attempts have been made to alter catecholamine metabolism with drugs and to control impulsive behavior with antiepileptic drugs, for example, carbamazepine (Tegretol) or valproate (Depakote), especially if abnormal waveforms are noted on an EEG. β-Adrenergic receptor antagonists have been used to reduce aggression.

Borderline Personality Disorder

Patients with borderline personality disorder stand on the border between neurosis and psychosis and they are characterized by extraordinarily unstable affect, mood, behavior, object relations, and self-image. The disorder has also been called ambulatory schizophrenia, as-if personality (a term coined by Helene Deutsch), pseudoneurotic schizophrenia (described by Paul Hoch and Phillip Politan), and psychotic character disorder (described by John Frosch). ICD-10 uses the term emotionally unstable personality disorder.


No definitive prevalence studies are available, but borderline personality disorder is thought to be present in about 1 to 2 percent of the population and is twice as common in women as in men. An increased prevalence of major depressive disorder, alcohol use disorders, and substance abuse is found in first-degree relatives of persons with borderline personality disorder.

Table 27-6 DSM-IV-TR Diagnostic Criteria for Borderline Personality Disorder A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  • frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
  • a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
  • identity disturbance: markedly and persistently unstable self-image or sense of self
  • impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
  • recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
  • affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only hours and only rarely more than a few days)
  • chronic feelings of emptiness
  • inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
  • transient, stress-related paranoid ideation or severe dissociative symptoms


According to DSM-IV-TR, the diagnosis of borderline personality disorder can made by early adulthood when patients show at least five of the criteria listed in Table 27-6. Biological studies may aid in the diagnosis; some patients with borderline personality disorder show shortened REM latency and sleep continuity disturbances, abnormal DST results, and abnormal thyrotropin-releasing hormone test results. Those changes, however, are also seen in some patients with depressive disorders.

Clinical Features

Persons with borderline personality disorder almost always appear to be in a state of crisis. Mood swings are common. Patients can be argumentative at one moment, depressed the next, and later complain of having no feelings. Patients can have short-lived psychotic episodes (so-called micropsychotic episodes) rather than full-blown psychotic breaks, and the psychotic symptoms of these patients are almost always circumscribed, fleeting, or doubtful. The behavior of patients with borderline personality disorder is highly unpredictable, and their achievements are rarely at the level of their abilities. The painful nature of their lives is reflected in repetitive self-destructive acts. Such patients may slash their wrists and perform other self-mutilations to elicit help from others, to express anger, or to numb themselves to overwhelming affect.

Because they feel both dependent and hostile, persons with this disorder have tumultuous interpersonal relationships. They can be dependent on those with whom they are close and, when frustrated, can express enormous anger toward their intimate friends. Patients with borderline personality disorder cannot tolerate being alone, and they prefer a frantic search for companionship, no matter how unsatisfactory, to their own company. To assuage loneliness, if only for brief periods, they accept a stranger as a friend or behave promiscuously. They often complain about chronic feelings of emptiness and boredom and the lack of a consistent sense of identity (identity diffusion); when pressed, they often complain about how depressed they usually feel, despite the flurry of other affects.

Otto Kernberg described the defense mechanism of projective identification that occurs in patients with borderline personality disorder. In this primitive defense mechanism, intolerable aspects of the self are projected onto another; the other person is induced to play the projected role, and the two persons act in unison. Therapists must be aware of this process so that they can act neutrally toward such patients.

Most therapists agree that these patients show ordinary reasoning abilities on structured tests, such as the Wechsler Adult Intelligence Scale, and show deviant processes only on unstructured projective tests, such as the Rorschach test.

Functionally, patients with borderline personality disorder distort their relationships by considering each person to be either all good or all bad. They see persons as either nurturing attachment figures or as hateful, sadistic figures who deprive them of security needs and threaten them with abandonment whenever they feel dependent. As a result of this splitting, the good person is idealized, and the bad person devalued. Shifts of allegiance from one person or group to another are frequent. Some clinicians use the concepts of panphobia, pananxiety, panambivalence, and chaotic sexuality to delineate these patients' characteristics.

Differential Diagnosis

The disorder is differentiated from schizophrenia on the basis that the patient with borderline personality lacks prolonged psychotic episodes, thought disorder, and other classic schizophrenic signs. Patients with schizotypal personality disorder show marked peculiarities of thinking, strange ideation, and recurrent ideas of reference. Those with paranoid personality disorder are marked by extreme suspiciousness. Patients with borderline personality disorder generally have chronic feelings of emptiness and short-lived psychotic episodes; they act impulsively and demand extraordinary relationships; they may mutilate themselves and make manipulative suicide attempts.

Course and Prognosis

Borderline personality disorder is fairly stable; patients change little over time. Longitudinal studies show no progression toward schizophrenia, but patients have a high incidence of major depressive disorder episodes. The diagnosis is usually made before the age of 40, when patients are attempting to make occupational, marital, and other choices and are unable to deal with the normal stages of the life cycle.


Summarizes the American Psychiatric Association guidelines for treating this disorder. Common Features of Recommended Psychotherapy for Borderline Personality Disorder Therapy is not expected to be brief.

  • A strong helping relationship develops between patient and therapist.
  • Clear roles and responsibilities of patient and therapist are established.
  • Therapist is active and directive, not a passive listener.
  • Patient and therapist mutually develop a hierarchy of priorities.
  • Therapist conveys empathic validation plus the need for patient to control his/her behavior.
  • Flexibility is needed as new circumstances, including stresses, develop.
  • Limit setting, preferably mutually agreed upon, is used.
  • Concomitant individual and group approaches are used.


Psychotherapy for patients with borderline personality disorder is an area of intensive investigation and has been the treatment of choice. For best results, pharmacotherapy has been added to the treatment regimen.

Psychotherapy is difficult for patient and therapist alike. Patients regress easily, act out their impulses, and show labile or fixed negative or positive transferences, which are difficult to analyze. Projective identification may also cause countertransference problems when therapists are unaware that patients are unconsciously trying to coerce them to act out a particular behavior. The splitting defense mechanism causes patients to alternately love and hate therapists and others in the environment. A reality-oriented approach is more effective than in-depth interpretations of the unconscious.

Therapists have used behavior therapy to control patients' impulses and angry outbursts and to reduce their sensitivity to criticism and rejection. Social skills training, especially with videotape playback, helps enable patients to see how their actions affect others and thereby improve their interpersonal behavior.

Patients with borderline personality disorder often do well in a hospital setting in which they receive intensive psychotherapy on both an individual and a group basis. In a hospital, they can also interact with trained staff members from a variety of disciplines and can be provided with occupational, recreational, and vocational therapy. Such programs are especially helpful when the home environment is detrimental to a patient's rehabilitation because of intrafamilial conflicts or other stresses, such as parental abuse. Within the protected environment of the hospital, patients who are excessively impulsive, self-destructive, or self-mutilating can be given limits, and their actions can be observed. Under ideal circumstances, patients remain in the hospital until they show marked improvement, up to 1 year in some cases. Patients can then be discharged to special support systems, such as day hospitals, night hospitals, and halfway houses.

A particular form of psychotherapy called dialectical behavior therapy (DBT) has been used for patients with borderline personality disorder, especially those with parasuicidal behavior, such as frequent cutting. (For further discussion of DBT see Section 35.5 in Chapter 35.)


Pharmacotherapy is useful to deal with specific personality features that interfere with patients' overall functioning. Antipsychotics have been used to control anger, hostility, and brief psychotic episodes. Antidepressants improve the depressed mood common in patients with borderline personality disorder. The MAO inhibitors (MAOIs) have successfully modulated impulsive behavior in some patients. Benzodiazepines, particularly alprazolam (Xanax), help anxiety and depression, but some patients show a disinhibition with this class of drugs. Anticonvulsants, such as carbamazepine, may improve global functioning for some patients. Serotonergic agents such as selective serotonin reuptake inhibitors (SSRIs) have been helpful in some cases.

Histrionic Personality Disorder

Persons with histrionic personality disorder are excitable and emotional and behave in a colorful, dramatic, extroverted fashion. Accompanying their flamboyant aspects, however, is often an inability to maintain deep, long-lasting attachments.


According to DSM-IV-TR, limited data from general population studies suggest a prevalence of histrionic personality disorder of about 2 to 3 percent. Rates of about 10 to 15 percent have been reported in inpatient and outpatient mental health settings when structured assessment is used. The disorder is diagnosed more frequently in women than in men. Some studies have found an association with somatization disorder and alcohol use disorders.


In interviews, patients with histrionic personality disorder are generally cooperative and eager to give a detailed history. Gestures and dramatic punctuation in their conversations are common; they may make frequent slips of the tongue, and their language is colorful. Affective display is common, but, when pressed to acknowledge certain feelings (e.g., anger, sadness, and sexual wishes), they may respond with surprise, indignation, or denial. The results of the cognitive examination are usually normal, although a lack of perseverance may be shown on arithmetic or concentration tasks, and the patients' forgetfulness of affect-laden material may be astonishing. The DSM-IV-TR diagnostic criteria are listed in Table 27-8.

Clinical Features

Persons with histrionic personality disorder show a high degree of attention-seeking behavior. They tend to exaggerate their thoughts and feelings and make everything sound more important than it really is. They display temper tantrums, tears, and accusations when they are not the center of attention or are not receiving praise or approval. Seductive behavior is common in both sexes. Sexual fantasies about persons with whom patients are involved are common, but patients are inconsistent about verbalizing these fantasies and may be coy or flirtatious rather than sexually aggressive. In fact, histrionic patients may have a psychosexual dysfunction; women may be anorgasmic, and men may be impotent. Their need for reassurance is endless. They may act on their sexual impulses to reassure themselves that they are attractive to the other sex. Their relationships tend to be superficial, however, and they can be vain, self-absorbed, and fickle. Their strong dependence needs make them overly trusting and gullible.

DSM-IV-TR Diagnostic Criteria for Histrionic Personality Disorder

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: - is uncomfortable in situations in which he or she is not the center of attention - interaction with others is often characterized by inappropriate sexually seductive or provocative behavior - displays rapidly shifting and shallow expression of emotions - consistently uses physical appearance to draw attention to self - has a style of speech that is excessively impressionistic and lacking in detail - shows self-dramatization, theatricality, and exaggerated expression of emotion - is suggestible, i.e., easily influenced by others or circumstances - considers relationships to be more intimate than they actually are

The major defenses of patients with histrionic personality disorder are repression and dissociation. Accordingly, such patients are unaware of their true feelings and cannot explain their motivations. Under stress, reality testing easily becomes impaired.

Differential Diagnosis

Distinguishing between histrionic personality disorder and borderline personality disorder is difficult, but in borderline personality disorder, suicide attempts, identity diffusion, and brief psychotic episodes are more likely. Although both conditions may be diagnosed in the same patient, clinicians should separate the two. Somatization disorder (Briquet's syndrome) may occur in conjunction with histrionic personality disorder. Patients with brief psychotic disorder and dissociative disorders may warrant a coexisting diagnosis of histrionic personality disorder.

Course and Prognosis

With age, persons with histrionic personality disorder show fewer symptoms, but because they lack the energy of earlier years, the difference in number of symptoms may be more apparent than real. Persons with this disorder are sensation seekers, and they may get into trouble with the law, abuse substances, and act promiscuously.



Patients with histrionic personality disorder are often unaware of their own real feelings; clarification of their inner feelings is an important therapeutic process. Psychoanalytically oriented psychotherapy, whether group or individual, is probably the treatment of choice for histrionic personality disorder.


Pharmacotherapy can be adjunctive when symptoms are targeted (e.g., the use of antidepressants for depression and somatic complaints, antianxiety agents for anxiety, and antipsychotics for derealization and illusions). Narcissistic Personality Disorder

Persons with narcissistic personality disorder are characterized by a heightened sense of self-importance and grandiose feelings of uniqueness.


According to DSM-IV-TR, estimates of the prevalence of narcissistic personality disorder range from 2 to 16 percent in the clinical population and less than 1 percent in the general population. Persons with the disorder may impart an unrealistic sense of omnipotence, grandiosity, beauty, and talent to their children; thus, offspring of such parents may have a higher than usual risk for developing the disorder themselves. The number of cases of narcissistic personality disorder reported is increasing steadily.


DSM-IV-TR diagnostic criteria for narcissistic personality disorder.

Diagnostic Criteria for Narcissistic Personality Disorder

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following. - has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements) - is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love - believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions) - requires excessive admiration - has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations - is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends - lacks empathy: is unwilling to recognize or identify with the feelings and needs of others - is often envious of others or believes that others are envious of him or her - shows arrogant, haughty behaviors or attitudes

Clinical Features

Persons with narcissistic personality disorder have a grandiose sense of self-importance; they consider themselves special and expect special treatment. Their sense of entitlement is striking. They handle criticism poorly and may become enraged when someone dares to criticize them, or they may appear completely indifferent to criticism. Persons with this disorder want their own way and are frequently ambitious to achieve fame and fortune.

Their relationships are fragile, and they can make others furious by their refusal to obey conventional rules of behavior. Interpersonal exploitiveness is commonplace. They cannot show empathy, and they feign sympathy only to achieve their own selfish ends. Because of their fragile self-esteem, they are susceptible to depression. Interpersonal difficulties, occupational problems, rejection, and loss are among the stresses that narcissists commonly produce by their behavior—stresses they are least able to handle.

Differential Diagnosis

Borderline, histrionic, and antisocial personality disorders often accompany narcissistic personality disorder, so a differential diagnosis is difficult. Patients with narcissistic personality disorder have less anxiety than those with borderline personality disorder; their lives tend to be less chaotic, and they are less likely to attempt suicide. Patients with antisocial personality disorder have a history of impulsive behavior, often associated with alcohol or other substance abuse, which frequently gets them into trouble with the law. Patients with histrionic personality disorder show features of exhibitionism and interpersonal manipulativeness that resemble those of patients with narcissistic personality disorder.

Course and Prognosis

Narcissistic personality disorder is chronic and difficult to treat. Patients with the disorder must constantly deal with blows to their narcissism resulting from their own behavior or from life experience. Aging is handled poorly; patients value beauty, strength, and youthful attributes, to which they cling inappropriately. They may be more vulnerable, therefore, to midlife crises than are other groups.



Because patients must renounce their narcissism to make progress, the treatment of narcissistic personality disorder is difficult. Psychiatrists such as Kernberg and Heinz Kohut have advocated using psychoanalytic approaches to effect change, but much research is required to validate the diagnosis and to determine the best treatment. Some clinicians advocate group therapy for their patients so they can learn how to share with others and, under ideal circumstances, can develop an empathic response to others.


Lithium (Eskalith) has been used with patients whose clinical picture includes mood swings. Because patients with narcissistic personality disorder tolerate rejection poorly and are susceptible to depression, antidepressants, especially serotonergic drugs, may also be of use.

Avoidant Personality Disorder

Persons with avoidant personality disorder show extreme sensitivity to rejection and may lead a socially withdrawn life. Although shy, they are not asocial and show a great desire for companionship, but they need unusually strong guarantees of uncritical acceptance. Such persons are commonly described as having an inferiority complex. (ICD-10 uses the term anxious personality disorder.)


Avoidant personality disorder is common. The prevalence of the disorder is 1 to 10 percent of the general population. No information is available on sex ratio or familial pattern. Infants classified as having a timid temperament may be more susceptible to the disorder than those who score high on activity-approach scales.


In clinical interviews, patients' most striking aspect is anxiety about talking with an interviewer. Their nervous and tense manner appears to wax and wane with their perception of whether an interviewer likes them. They seem vulnerable to the interviewer's comments and suggestions and may regard a clarification or interpretation as criticism. The DSM-IV-TR diagnostic criteria for avoidant personality disorder are listed in Table 27-10.

Clinical Features

Hypersensitivity to rejection by others is the central clinical feature of avoidant personality disorder, and patients' main personality trait is timidity. These persons desire the warmth and security of human companionship, but justify their avoidance of relationships by their alleged fear of rejection. When talking with someone, they express uncertainty, show a lack of self-confidence, and may speak in a self-effacing manner. Because they are hypervigilant about rejection, they are afraid to speak up in public or to make requests of others. They are apt to misinterpret other persons' comments as derogatory or ridiculing. The refusal of any request leads them to withdraw from others and to feel hurt.

DSM-IV-TR Diagnostic Criteria for Avoidant Personality Disorder

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: - avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection - is unwilling to get involved with people unless certain of being liked - shows restraint within intimate relationships because of the fear of being shamed or ridiculed - is preoccupied with being criticized or rejected in social situations - is inhibited in new interpersonal situations because of feelings of inadequacy - views self as socially inept, personally unappealing, or inferior to others - is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

In the vocational sphere, patients with avoidant personality disorder often take jobs on the sidelines. They rarely attain much personal advancement or exercise much authority, but seem shy and eager to please. These persons are generally unwilling to enter relationships unless they are given an unusually strong guarantee of uncritical acceptance. Consequently, they often have no close friends or confidants.

Differential Diagnosis

Patients with avoidant personality disorder desire social interaction, unlike patients with schizoid personality disorder, who want to be alone. Patients with avoidant personality disorder are not as demanding, irritable, or unpredictable as those with borderline and histrionic personality disorders. Avoidant personality disorder and dependent personality disorder are similar. Patients with dependent personality disorder are presumed to have a greater fear of being abandoned or unloved than those with avoidant personality disorder, but the clinical picture may be indistinguishable.

Course and Prognosis

Many persons with avoidant personality disorder are able to function in a protected environment. Some marry, have children, and live their lives surrounded only by family members. Should their support system fail, however, they are subject to depression, anxiety, and anger. Phobic avoidance is common, and patients with the disorder may give histories of social phobia or incur social phobia in the course of their illness.



Psychotherapeutic treatment depends on solidifying an alliance with patients. As trust develops, a therapist must convey an accepting attitude toward the patient's fears, especially the fear of rejection. The therapist eventually encourages a patient to move out into the world to take what are perceived as great risks of humiliation, rejection, and failure. But therapists should be cautious when giving assignments to exercise new social skills outside therapy; failure can reinforce a patient's already poor self-esteem. Group therapy may help patients understand how their sensitivity to rejection affects them and others. Assertiveness training is a form of behavior therapy that may teach patients to express their needs openly and to enlarge their self-esteem.


Pharmacotherapy has been used to manage anxiety and depression when they are associated with the disorder. Some patients are helped by β-adrenergic receptor antagonists, such as atenolol (Tenormin), to manage autonomic nervous system hyperactivity, which tends to be high in patients with avoidant personality disorder, especially when they approach feared situations. Serotonergic agents may help rejection sensitivity. Theoretically, dopaminergic drugs might engender novelty-seeking behavior in these patients; however, the patient must be psychologically prepared for any new experience that might result.

Dependent Personality Disorder

Persons with dependent personality disorder subordinate their own needs to those of others, get others to assume responsibility for major areas of their lives, lack self-confidence, and may experience intense discomfort when alone for more than a brief period. The disorder has been called passive-dependent personality. Freud described an oral-dependent personality dimension characterized by dependence, pessimism, fear of sexuality, self-doubt, passivity, suggestibility, and lack of perseverance; his description is similar to the DSM-IV-TR categorization of dependent personality disorder.


Dependent personality disorder is more common in women than in men. One study diagnosed 2.5 percent of all personality disorders as falling into this category. It is more common in young children than in older ones. Persons with chronic physical illness in childhood may be most susceptible to the disorder.


In interviews, patients appear compliant. They try to cooperate, welcome specific questions, and look for guidance. The DSM-IV-TR diagnostic criteria for dependent personality disorder are listed in Table 27-11.

Clinical Features

Dependent personality disorder is characterized by a pervasive pattern of dependent and submissive behavior. Persons with the disorder cannot make decisions without an excessive amount of advice and reassurance from others. They avoid positions of responsibility and become anxious if asked to assume a leadership role. They prefer to be submissive. When on their own, they find it difficult to persevere at tasks, but may find it easy to perform these tasks for someone else.

Because persons with the disorder do not like to be alone, they seek out others on whom they can depend; their relationships, thus, are distorted by their need to be attached to another person. In folie à deux (shared psychotic disorder), one member of the pair usually has dependent personality disorder; the submissive partner takes on the delusional system of the more aggressive, assertive partner on whom he or she depends.

Pessimism, self-doubt, passivity, and fears of expressing sexual and aggressive feelings all typify the behavior of persons with dependent personality disorder. An abusive, unfaithful, or alcoholic spouse may be tolerated for long periods to avoid disturbing the sense of attachment.

DSM-IV-TR Diagnostic Criteria for Dependent Personality Disorder

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:

  • has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
  • needs others to assume responsibility for most major areas of his or her life
  • has difficulty expressing disagreement with others because of fear of loss of support or approval. Note: Do not include realistic fears of retribution
  • 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)
  • goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
  • feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself
  • urgently seeks another relationship as a source of care and support when a close relationship ends
  • is unrealistically preoccupied with fears of being left to take care of himself or herself

Differential Diagnosis

The traits of dependence are found in many psychiatric disorders, so differential diagnosis is difficult. Dependence is a prominent factor in patients with histrionic and borderline personality disorders, but those with dependent personality disorder usually have a long-term relationship with one person, rather than a series of persons on whom they are dependent, and they do not tend to be overtly manipulative. Patients with schizoid and schizotypal personality disorders may be indistinguishable from those with avoidant personality disorder. Dependent behavior can occur in patients with agoraphobia, but these patients tend to have a high level of overt anxiety or even panic.

Course and Prognosis

Little is known about the course of dependent personality disorder. Occupational functioning tends to be impaired, because persons with the disorder cannot act independently and without close supervision. Social relationships are limited to those on whom they can depend, and many suffer physical or mental abuse because they cannot assert themselves. They risk major depressive disorder if they lose the person on whom they depend, but with treatment, the prognosis is favorable.



The treatment of dependent personality disorder is often successful. Insight-oriented therapies enable patients to understand the antecedents of their behavior, and with the support of a therapist, patients can become more independent, assertive, and self-reliant. Behavioral therapy, assertiveness training, family therapy, and group therapy have all been used, with successful outcomes in many cases.

A pitfall may arise in treatment when a therapist encourages a patient to change the dynamics of a pathological relationship (e.g., supports a physically abused wife in seeking help from the police). At this point, patients may become anxious and unable to cooperate in therapy; they may feel torn between complying with the therapist and losing a pathological external relationship. Therapists must show great respect for these patients' feelings of attachment, no matter how pathological these feelings may seem.


Pharmacotherapy has been used to deal with specific symptoms, such as anxiety and depression, which are common associated features of dependent personality disorder. Patients who experience panic attacks or who have high levels of separation anxiety may be helped by imipramine (Tofranil). Benzodiazepines and serotonergic agents have also been useful. If a patient's depression or withdrawal symptoms respond to psychostimulants, they may be used.

Obsessive-Compulsive Personality Disorder

Obsessive-compulsive personality disorder is characterized by emotional constriction, orderliness, perseverance, stubbornness, and indecisiveness. The essential feature of the disorder is a pervasive pattern of perfectionism and inflexibility. (ICD-10 uses the name anancastic personality disorder.)


The prevalence of obsessive-compulsive personality disorder is unknown. It is more common in men than in women and is diagnosed most often in oldest children. The disorder also occurs more frequently in first-degree biological relatives of persons with the disorder than in the general population. Patients often have backgrounds characterized by harsh discipline. Freud hypothesized that the disorder is associated with difficulties in the anal stage of psychosexual development, generally around the age of 2, but various studies have failed to validate this theory.


In interviews, patients with obsessive-compulsive personality disorder may have a stiff, formal, and rigid demeanor. Their affect is not blunted or flat, but can be described as constricted. They lack spontaneity, and their mood is usually serious. Such patients may be anxious about not being in control of the interview. Their answers to questions are unusually detailed. The defense mechanisms they use are rationalization, isolation, intellectualization, reaction formation, and undoing. The DSM-IV-TR diagnostic criteria for obsessive-compulsive personality disorder are listed in Table 27-12.

Clinical Features

Persons with obsessive-compulsive personality disorder are preoccupied with rules, regulations, orderliness, neatness, details, and the achievement of perfection. These traits account for the general constriction of the entire personality. They insist that rules be followed rigidly and cannot tolerate what they consider infractions. Accordingly, they lack flexibility and are intolerant. They are capable of prolonged work, provided it is routinized and does not require changes to which they cannot adapt.

DSM-IV-TR Diagnostic Criteria for Obsessive-Compulsive Personality Disorder

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: - is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost - shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met) - is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity) - is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification) - is unable to discard worn-out or worthless objects even when they have no sentimental value - is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things - adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes - shows rigidity and stubbornness

Persons with obsessive-compulsive personality disorder have limited interpersonal skills. They are formal and serious and often lack a sense of humor. They alienate persons, are unable to compromise, and insist that others submit to their needs. They are eager to please those whom they see as more powerful than they are, however, and they carry out these persons' wishes in an authoritarian manner. Because they fear making mistakes, they are indecisive and ruminate about making decisions. Although a stable marriage and occupational adequacy are common, persons with obsessive-compulsive personality disorder have few friends. Anything that threatens to upset their perceived stability or the routine of their lives can precipitate much anxiety otherwise bound up in the rituals that they impose on their lives and try to impose on others.

The patient was a 45-year-old lawyer who sought treatment at his wife's insistence. She was fed up with their marriage; she could no longer tolerate his emotional coldness, rigid demands, bullying behavior, sexual disinterest, long work hours, and frequent business trips. The patient felt no particular distress in his marriage and had agreed to the consultation only to humor his wife.

It soon developed, however, that the patient was troubled by problems at work. He was known as that hardest-driving member of a hard-driving law firm. He was the youngest full partner in the firm's history and is famous for being able to handle many cases at the same time. Lately, he found himself increasingly unable to keep up. He was too proud to turn down a new case and too much of a perfectionist to be satisfied with the quality of work performed by his assistants. Displeased by their writing style and sentence structure, he found himself constantly correcting their briefs and, therefore, unable to stay abreast of his schedule. People at work complained that his attention to detail and inability to delegate responsibility were reducing his efficiency. He has had two or three secretaries a year for 15 years. No one could tolerate working for him for very long because he was so critical of any mistakes made by others. When assignments got backed up, he could not decide which to address first, started making schedules for himself and his staff, but then was unable to meet them and worked 15 hours a day. He found it difficult to be decisive now that his work had expanded beyond his own direct control.

The patient discussed his children as if they were mechanical dolls, but also with a clear underlying affection. He described his wife as a “suitable mate” and had trouble understanding why she was dissatisfied. He was punctilious in his manners and dress and slow and ponderous in his speech, dry and humorless, with a stubborn determination to get his point across.

The patient was the son of two upwardly mobile, extremely hardworking parents. He grew up feeling that he was never working hard enough, that he had much to achieve and very little time. He was a superior student, a “bookworm,” awkward and unpopular in adolescent social pursuits. He had always been competitive and a high achiever. He had trouble relaxing on vacations, developed elaborate activity schedules for every family member, and became impatient and furious if they refused to follow his plans. He liked sports but had little time for them and refused to play if he couldn't be at the top of his form. He was a ferocious competitor on the tennis courts and a poor loser. (From the DSM-IV-TR Casebook.)

Differential Diagnosis

When recurrent obsessions or compulsions are present, obsessive-compulsive disorder should be noted on Axis I. Perhaps the most difficult distinction is between outpatients with some obsessive-compulsive traits and those with obsessive-compulsive personality disorder. The diagnosis of personality disorder is reserved for those with significant impairments in their occupational or social effectiveness. In some cases, delusional disorder coexists with personality disorders and should be noted.

Course and Prognosis

The course of obsessive-compulsive personality disorder is variable and unpredictable. From time to time, persons may develop obsessions or compulsions in the course of their disorder. Some adolescents with obsessive-compulsive personality disorder evolve into warm, open, and loving adults; in others, the disorder can be either the harbinger of schizophrenia or—decades later and exacerbated by the aging process—major depressive disorder.

Persons with obsessive-compulsive personality disorder may flourish in positions demanding methodical, deductive, or detailed work, but they are vulnerable to unexpected changes, and their personal lives may remain barren. Depressive disorders, especially those of late onset, are common.



Unlike patients with the other personality disorders, those with obsessive-compulsive personality disorder are often aware of their suffering, and they seek treatment on their own. Overtrained and oversocialized, these patients value free association and no-directive therapy highly. Treatment, however, is often long and complex, and countertransference problems are common.

Group therapy and behavior therapy occasionally offer certain advantages. In both contexts, it is easy to interrupt the patients in the midst of their maladaptive interactions or explanations. Preventing the completion of their habitual behavior raises patients' anxiety and leaves them susceptible to learning new coping strategies. Patients can also receive direct rewards for change in group therapy, something less often possible in individual psychotherapies.


Clonazepam (Klonopin), a benzodiazepine with anticonvulsant use, has reduced symptoms in patients with severe obsessive-compulsive disorder. Whether it is of use in the personality disorder is unknown. Clomipramine (Anafranil) and such serotonergic agents as fluoxetine, usually at dosages of 60 to 80 mg a day, may be useful if obsessive-compulsive signs and symptoms break through. Nefazodone (Serzone) may benefit some patients. Personality Disorder not Otherwise Specified

In DSM-IV-TR, the category personality disorder not otherwise specified is reserved for disorders that do not fit into any of the personality disorder categories described above. Passive-aggressive personality disorder and depressive personality disorder are now listed as examples of personality disorder not otherwise specified. A narrow spectrum of behavior or a particular trait—such as oppositionalism, sadism, or masochism—can also be classified in this category. A patient with features of more than one personality disorder but without the complete criteria of any one disorder can be assigned this classification. The DSM-IV-TR criteria for personality disorder not otherwise specified are presented in Table 27-13.

DSM-IV-TR Diagnostic Criteria for Personality Disorder Not Otherwise Specified

This category is for disorders of personality functioning that do not meet criteria for any specific personality disorder. An example is the presence of features of more than one specific personality disorder that do not meet the full criteria for any one personality disorder (“mixed personality”), but that together cause clinically significant distress or impairment in one or more important areas of functioning (e.g., social or occupational).

This category can also be used when the clinician judges that a specific personality disorder that is not included in the classification is appropriate. Examples include depressive personality disorder and passive-aggressive personality disorder.

DSM-IV-TR Research Criteria for Passive-Aggressive Personality Disorder

  1. A pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
  2. passively resists fulfilling routine social and occupational tasks
  3. complains of being misunderstood and unappreciated by others
  4. is sullen and argumentative
  5. unreasonably criticizes and scorns authority
  6. expresses envy and resentment toward those apparently more fortunate
  7. voices exaggerated and persistent complaints of personal misfortune
  8. alternates between hostile defiance and contrition

  9. Does not occur exclusively during major depressive episodes and is not better accounted for by dysthymic disorder.

Passive-Aggressive Personality Disorder

Persons with passive-aggressive personality disorder are characterized by covert obstructionism, procrastination, stubbornness, and inefficiency. Such behavior is a manifestation of passively expressed underlying aggression. In DSM-IV-TR, the disorder is also called negativistic personality disorder.


No data are available about the epidemiology of the disorder. Sex ratio, familial patterns, and prevalence have not been adequately studied. Diagnosis The criteria for passive-aggressive personality disorder are presented in Table 27-14.

Clinical Features

Patients with passive-aggressive personality disorder characteristically procrastinate, resist demands for adequate performance, find excuses for delays, and find fault with those on whom they depend; yet they refuse to extricate themselves from the dependent relationships. They usually lack assertiveness and are not direct about their own needs and wishes. They fail to ask needed questions about what is expected of them and may become anxious when forced to succeed or when their usual defense of turning anger against themselves is removed.

In interpersonal relationships, these persons attempt to manipulate themselves into a position of dependence, but others often experience this passive, self-detrimental behavior as punitive and manipulative. Persons with this disorder expect others to do their errands and to carry out their routine responsibilities. Friends and clinicians may become enmeshed in trying to assuage the patients' many claims of unjust treatment. The close relationships of persons with passive-aggressive personality disorder, however, are rarely tranquil or happy. Because they are bound to their resentment more closely than to their satisfaction, they may never even formulate goals for finding enjoyment in life. Persons with the disorder lack self-confidence and are typically pessimistic about the future.

Differential Diagnosis

Passive-aggressive personality disorders must be differentiated from histrionic and borderline personality disorders. Patients with passive-aggressive personality disorder, however, are less flamboyant, dramatic, affective, and openly aggressive than those with histrionic and borderline personality disorders.

Course and Prognosis

In a follow-up study averaging 11 years of 100 inpatients with passive-aggressive disorder, Ivor Small found that the primary diagnosis in 54 was passive-aggressive personality disorder; 18 were also alcohol abusers, and 30 could be clinically labeled as depressed. Of the 73 former patients located, 58 (79 percent) had persistent psychiatric difficulties, and 9 (12 percent) were considered symptom free. Most seemed irritable, anxious, and depressed; somatic complaints were numerous. Only 32 (44 percent) were employed full time as workers or homemakers. Although neglect of responsibility and suicide attempts were common, only one patient had committed suicide in the interim. Twenty-eight (38 percent) had been readmitted to a hospital, but only three had been diagnosed as having schizophrenia.


Patients with passive-aggressive personality disorder who receive supportive psychotherapy have good outcomes, but psychotherapy for these patients has many pitfalls. Fulfilling their demands often supports their pathology, but refusing their demands rejects them. Therapy sessions, thus, can become a battleground on which a patient expresses feelings of resentment against a therapist on whom the patient wishes to become dependent. With these patients, clinicians must treat suicide gestures as any covert expression of anger, and not as object loss in major depressive disorder. Therapists must point out the probable consequences of passive-aggressive behaviors as they occur. Such confrontations may be more helpful than a correct interpretation in changing patients' behavior.

Antidepressants should be prescribed only when clinical indications of depression and the possibility of suicide exist. Depending on the clinical features, some patients have responded to benzodiazepines and psychostimulants.

Depressive Personality Disorder

Persons with depressive personality disorder are characterized by lifelong traits that fall along the depressive spectrum. They are pessimistic, anhedonic, duty bound, self-doubting, and chronically unhappy. The disorder is newly classified in DSM-IV-TR, but melancholic personality was described by early 20th century European psychiatrists such as Ernst Kretschmer.


Because depressive personality disorder is a new category, no epidemiological data are available. On the basis of the prevalence of depressive disorders in the overall population, however, depressive personality disorder seems to be common, to occur equally in men and women, and to occur in families in which depressive disorders are found. Etiology

The cause of depressive personality disorder is unknown, but the same factors involved in dysthymic disorder and major depressive disorder may be at work. Psychological theories involve early loss, poor parenting, punitive superegos, and extreme feelings of guilt. Biological theories involve the hypothalamic-pituitary-adrenal-thyroid axis, including the noradrenergic and serotonergic amine systems. Genetic predisposition, as indicated by Stella Chess's studies of temperament, may also play a role.

Diagnosis and Clinical Features

A classic description of depressive personality was provided in 1963 by Arthur Noyes and Laurence Kolb:

They feel but little of the normal joy of living and are inclined to be lonely and solemn, to be gloomy, submissive, pessimistic, and self-deprecatory. They are prone to express regrets and feelings of inadequacy and hopelessness. They are often meticulous, perfectionistic, overconscientious, preoccupied with work, feel responsibility keenly, and are easily discouraged under new conditions. They are fearful of disapproval, tend to suffer in silence and perhaps to cry easily, although usually not in the presence of others. A tendency to hesitation, indecision, and caution betrays an inherent feeling of insecurity.

DSM-IV-TR Research Criteria for Depressive Personality Disorder

  1. A pervasive pattern of depressive cognitions and behaviors beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
  2. usual mood is dominated by dejection, gloominess, cheerlessness, joylessness, unhappiness
  3. self-concept centers around beliefs of inadequacy, worthlessness, and low self-esteem
  4. is critical, blaming, and derogatory toward self
  5. is brooding and given to worry
  6. is negativistic, critical, and judgmental toward others
  7. is pessimistic
  8. is prone to feeling guilty or remorseful

  9. Does not occur exclusively during major depressive episodes and is not better accounted for by dysthymic disorder.

More recently, Hagop Akiskal described seven groups of depressive traits: quiet, introverted, passive, and nonassertive; gloomy, pessimistic, serious, and incapable of fun; self-critical, self-reproachful, and self-derogatory; skeptical, critical of others, and hard to please; conscientious, responsible, and self-disciplined; brooding and given to worry; and preoccupied with negative events, feelings of inadequacy, and personal shortcomings. Patients with depressive personality disorder complain of chronic feelings of unhappiness.

They admit to low self-esteem and difficulty finding anything in their lives about which they are joyful, hopeful, or optimistic. They are self-critical and derogatory and are likely to denigrate their work, themselves, and their relationships with others. Their physiognomy often reflects their mood—poor posture, depressed facies, hoarse voice, and psychomotor retardation. The DSM-IV-TR criteria are listed in Table 27-15.

Differential Diagnosis

Dysthymic disorder is a mood disorder characterized by greater fluctuation in mood than occurs in depressive personality disorder. The personality disorder is chronic and lifelong, whereas dysthymic disorder is episodic, can occur at any time, and usually has a precipitating stressor. The depressive personality can be conceptualized as part of a spectrum of affective conditions in which dysthymic disorder and major depressive disorder are more severe variants. Patients with avoidant personality disorder are introverted and dependent, but they tend to be more anxious than depressed, compared with persons with depressive personality disorder.

Course and Prognosis

Persons with depressive personality disorder may be at great risk for dysthymic disorder and major depressive disorder. In a recent study by Donald Klein and Gregory Mills, subjects with depressive personality exhibited significantly higher rates of current mood disorder, lifetime mood disorder, major depression, and dysthymia than subjects without depressive personality.


Psychotherapy is the treatment of choice for depressive personality disorder. Patients respond to insight-oriented psychotherapy, and because their reality testing is good, they can gain insight into the psychodynamics of their illness and appreciate its effects on their interpersonal relationships. Treatment is likely to be long term. Cognitive therapy helps patients understand the cognitive manifestations of their low self-esteem and pessimism. Group psychotherapy and interpersonal therapy are also useful. Some persons respond to self-help measures.

Psychopharmacological approaches include the use of antidepressant medications, especially such serotonergic agents as sertraline (Zoloft), 50 mg a day. Some patients respond to small dosages of psychostimulants, such as amphetamine, 5 to 15 mg a day. In all cases, psychopharmacological agents should be combined with psychotherapy to achieve maximum effects.

Sadomasochistic Personality Disorder

Some personality types are characterized by elements of sadism or masochism or a combination of both. Sadomasochistic personality disorder is listed here because it is of major clinical and historical interest in psychiatry. It is not an official diagnostic category in DSM-IV-TR or its appendix, but it can be diagnosed as personality disorder not otherwise classified.

Sadism is the desire to cause others pain by being either sexually abusive or generally physically or psychologically abusive. It is named for the Marquis de Sade, a late 18th century writer of erotica describing persons who experienced sexual pleasure while inflicting pain on others. Freud believed that sadists ward off castration anxiety and are able to achieve sexual pleasure only when they can do to others what they fear will be done to them.

Masochism, named for Leopold von Sacher-Masoch, a 19th century German novelist, is the achievement of sexual gratification by inflicting pain on the self. So-called moral masochists generally seek humiliation and failure rather than physical pain. Freud believed that masochists' ability to achieve orgasm is disturbed by anxiety and guilt feelings about sex, which are alleviated by suffering and punishment.

Clinical observations indicate that elements of both sadistic and masochistic behavior are usually present in the same person. Treatment with insight-oriented psychotherapy, including psychoanalysis, has been effective in some cases. As a result of therapy, patients become aware of the need for self-punishment secondary to excessive unconscious guilt and also come to recognize their repressed aggressive impulses, which originate in early childhood.

Sadistic Personality Disorder

Sadistic personality disorder is not included in DSM-IV-TR, but it still appears in the literature and may be of descriptive use. Beginning in early adulthood, persons with sadistic personality disorder show a pervasive pattern of cruel, demeaning, and aggressive behavior that is directed toward others. Physical cruelty or violence is used to inflict pain on others, not to achieve another goal, such as mugging a person to steal. Persons with the disorder like to humiliate or demean persons in front of others and have usually treated or disciplined persons uncommonly harshly, especially children. In general, persons with sadistic personality disorder are fascinated by violence, weapons, injury, or torture. To be included in this category, such persons cannot be motivated solely by the desire to derive sexual arousal from their behavior; if they are so motivated, the paraphilia of sexual sadism should be diagnosed.

Personality Change due to a General Medical Condition

Personality change due to a general medical condition (see Table 10.5-13) deserves some discussion here. ICD-10 includes the category personality and behavioral disorders due to brain disease, damage, and dysfunction, which includes organic personality disorder (see Table 10.5-18), postencephalitic syndrome, and postconcussional syndrome. Personality change due to a general medical condition is characterized by a marked change in personality style and traits from a previous level of functioning. Patients must show evidence of a causative organic factor antedating the onset of the personality change.

Medical Conditions Associated with Personality Change

  • Head trauma
  • Cerebrovascular diseases
  • Cerebral tumors
  • Epilepsy (particularly, complex partial epilepsy)
  • Huntington's disease
  • Multiple sclerosis
  • Endocrine disorders
  • Heavy metal poisoning (manganese, mercury)
  • Neurosyphilis
  • Acquired immune deficiency syndrome (AIDS)


Structural damage to the brain is usually the cause of the personality change, and head trauma is probably the most common cause. Cerebral neoplasms and vascular accidents, particularly of the temporal and frontal lobes, are also common causes. The conditions most often associated with personality change are listed in Table 27-16.

Anabolic Steroids

An increasing number of high school and college athletes and bodybuilders are using anabolic steroids as a shortcut to maximize physical development. Anabolic steroids include oxymetholone (Anadrol), somatropin (Humatrope), stanozolol (Winstrol), and testosterone. DSM-IV-TR does not include a diagnostic category for substance-induced personality disorder, so it is unclear whether a personality change caused by steroid abuse is better diagnosed as personality change due to a general medical condition or as one of the other (or unknown) substance use disorders. It is mentioned here because anabolic steroids can cause persistent alterations of personality and behavior. Anabolic steroid abuse is discussed in Section 12.13.

Differential Diagnosis

Dementia involves global deterioration in intellectual and behavioral capacities, of which personality change is just one category. A personality change may herald a cognitive disorder that eventually will evolve into dementia. In these cases, as deterioration begins to encompass significant memory and cognitive deficits, the diagnosis of the disorder changes from personality change caused by a general medical condition to dementia. In differentiating the specific syndrome from other disorders in which personality change may occur—such as schizophrenia, delusional disorder, mood disorders, and impulse control disorders—physicians must consider the most important factor, the presence in personality change disorder of a specific organic causative factor.

Course and Prognosis

Both the course and the prognosis of personality change due to a general medical condition depend on its cause. If the disorder results from structural damage to the brain, the disorder tends to persist. The disorder may follow a period of coma and delirium in cases of head trauma or vascular accident and may be permanent. The personality change can evolve into dementia in cases of brain tumor, multiple sclerosis, and Huntington's disease. Personality changes produced by chronic intoxication, medical illness, or drug therapy (such as levodopa [Larodopa] for parkinsonism) may be reversed if the underlying cause is treated. Some patients require custodial care or at least close supervision to meet their basic needs, avoid repeated conflicts with the law, and protect themselves and their families from the hostility of others and from destitution resulting from impulsive and ill-considered actions.


Management of personality change disorder involves treatment of the underlying organic condition when possible. Psychopharmacological treatment of specific symptoms may be indicated in some cases, such as imipramine or fluoxetine for depression. Patients with severe cognitive impairment or weakened behavioral controls may need counseling to help avoid difficulties at work or to prevent social embarrassment. As a rule, patients' families need emotional support and concrete advice on how to help minimize patients' undesirable conduct. Alcohol should be avoided, and social engagements should be curtailed when patients tend to act in a grossly offensive manner.

Psychobiological Model of Treatment

The psychobiological model of treatment combines psychotherapy and pharmacotherapy and is based on the established structural, clinical, and postulated neurochemical characteristics of temperament and character. Pharmacotherapy and psychotherapy can be systematically matched to the personality structure and stage of character development of each patient—clearly a unique advantage over other available approaches.

The newest development is treating personality disorders pharmacologically. Target symptoms are identified, and particular drugs with known effects on personality traits (e.g., harm avoidance) are used. Table 27-17 summarizes drug choices for various target symptoms of personality disorders.

In his book, Listening to Prozac, Peter Kramer described dramatic personality changes when serotonin levels are raised by fluoxetine administration, such as decreased sensitivity to rejection, increased assertiveness, improved self-esteem, and the ability to tolerate stress. These changes in personality traits occur in patients with a wide range of psychiatric conditions as well as in persons without diagnosable mental disorders. Using medications to treat specific traits in a person who is otherwise normal (i.e., does not meet the criteria for a full-blown personality disorder) is controversial. It has been called “cosmetic psychopharmacology” by its critics.

Biological Character Traits

Four character traits have been described (Table 27-18), each with certain neurochemical and neurophysiological substrates. Some workers postulate specific genes for some traits, e.g., novelty seeking gene.

Harm Avoidance

Harm avoidance involves a heritable bias in the inhibition of behavior in response to signals of punishment and nonreward. High harm avoidance is observed as fear of uncertainty, social inhibition, shyness with strangers, rapid fatigability, and pessimistic worry in anticipation of problems, even in situations that do not worry other persons. Persons low in harm avoidance are carefree, courageous, energetic, outgoing, and optimistic, even in situations that worry most persons.

The psychobiology of harm avoidance is complex. Benzodiazepines disinhibit avoidance by γ-aminobutyric acid (GABA)-ergic inhibition of serotonergic neurons originating in the dorsal raphe nuclei.

Positron emission tomography (PET) at the National Institute of Mental Health (NIMH) with [18F]-deoxyglucose (FDG) in 31 healthy adult volunteers during a simple, continuous, performance task showed that harm avoidance was associated with increased activity in the anterior paralimbic circuit, specifically the right amygdala and insula, the right orbitofrontal cortex, and the left medial prefrontal cortex.

High GABA concentrations in plasma have also been correlated with low harm avoidance. Plasma GABA concentration has also been correlated with other measures of anxiety susceptibility, and it correlates highly with GABA concentration in the brain. Finally, a gene on chromosome 17q12 that regulates the expression of the serotonin transporter accounts for 4 to 9 percent of the total variance in harm avoidance. These findings support a role for both GABA and serotonergic projections from the dorsal raphe underlying individual differences in behavioral inhibition as measured by harm avoidance. Persons given serotonin drugs show decreased harm avoidance behavior.

Novelty Seeking

Novelty seeking reflects a heritable bias in the initiation or activation of appetitive approach in response to novelty, approach to signals of reward, active avoidance of conditioned signals of punishment, and escape from unconditioned punishment (all of which are hypothesized to covary as part of one heritable system of learning). Novelty seeking is observed as exploratory activity in response to novelty, impulsiveness, extravagance in approach to cues of reward, and active avoidance of frustration. Individuals high in novelty seeking are quick-tempered, curious, easily bored, impulsive, extravagant, and disorderly. Persons low in novelty seeking are slow tempered, uninquiring, stoical, reflective, frugal, reserved, tolerant of monotony, and orderly.

Dopaminergic projections have a crucial role in novelty seeking. Novelty seeking involves increased reuptake of dopamine at presynaptic terminals, thereby requiring frequent stimulation to maintain optimal levels of postsynaptic dopaminergic stimulation. Novelty seeking leads to various pleasure-seeking behaviors, including cigarette smoking, which may explain the frequent observation of low platelet MAO type B (MAOB) activity, because cigarette smoking inhibits MAOB activity in platelets and brain.

Studies of genes involved in dopamine neurotransmission, such as the dopamine transporter gene (DAT1) and the type 4 dopamine receptor gene (DRD4) have provided evidence of association with novelty seeking or risk-taking behavior.

Reward Dependence

Reward dependence reflects maintenance of behavior in response to cues of social reward. Individuals high in reward dependence are tender hearted, sensitive, socially dependent, and sociable. Individuals low in reward dependence are practical, tough minded, cold, socially insensitive, irresolute, and indifferent if alone.

Noradrenergic projections from the locus ceruleus and serotonergic projections from the median raphe are thought to influence such reward conditioning. High reward dependence is associated with increased activity in the thalamus. The 3-methoxy-4-hydroxyphenylglycol (MHPG) concentration is low in persons with high reward dependence.


Persistence reflects maintenance of behavior, despite frustration, fatigue, and intermittent reinforcement. Highly persistent persons are hard-working, perseverant, and ambitious overachievers who tend to intensify their effort in response to anticipated reward and view frustration and fatigue as a personal challenge. Individuals low in persistence are indolent, inactive, unstable, and erratic; they tend to give up easily when faced with frustration, rarely strive for higher accomplishments, and manifest little perseverance even in response to intermittent reward.

Recent work in rodents related the integrity of the partial reinforcement extinction effect to hippocampal connections and glutamate metabolism. Persistence may be enhanced by psychostimulants.


In ICD-10, personality disorders are described as severe disturbances of personality and behavior that are pronounced deviations from normal cultural patterns. ICD-10's diagnostic guidelines include disturbances of long-standing duration in several areas of functioning; pervasive and maladaptive behavior; onset in childhood or adolescence; continuation into adulthood; considerable personality distress (although sometimes apparent only late in the disorder's course); and usually, but not always, significant problems in work and in social behavior. ICD-10 also allows for the possibility of criteria developed to describe personality disorders in different cultures. The diagnostic criteria for specific personality disorders appear in Table 27-1.


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