Psychopathology (MPSY 301)

M.A. Applied psychology//[Link] Clinical Psychology

Unit III Personality Disorders

Dr. Jyoti Ssharma

Assistant Professor, Chitkara school of Psychology and Counselling
 Definition
• “An enduring pattern of inner experience and
behavior that deviates markedly from the
expectations of the individual’s culture, is
pervasive and inflexible, has an onset in
adolescence or early adulthood, is stable over
time, and leads to distress or impairment”
(APA,
2013)
• Personality disorders are among the most difficult
of disorders to treat because they involve well-
established behaviors that can be integral to a
client’s self-image
 Five-Factor Model of Personality
Disorder
•O
•C
•E
•A
•N
 Adler’s insights about personality type
• social interest and activity level yields a four-fold
personality typology
• The ruling type (high active, low social interest);
the avoiding type (low active, low social interest);
the getting type (low active and high social
interest); and socially useful type (high active,
high social interest)
• Adler also described a type of movement that he
called “hesitating,” i.e., movement back and forth,
which today is commonly referred to as
ambivalent. He also indicated that activity level
was primarily active or passive
• The typology is based on four types of movement: toward,
against, away, and ambivalent, along with two types of
activity: active or passive.
• By combining these two dimensions, eight basic personality
styles—and their derived personality disorders—can be
articulated (Sperry, 2011).
• These are: the antisocial personality (against—active);
• the narcissistic personality (against—passive);
• the histrionic personality (toward—active);
• the dependent personality (toward—passive);
• the avoidant personality (away—active);
• the schizoid personality (away—passive);
• the passive-aggressive personality (ambivalent—active);
and
• the obsessive-compulsive personality (ambivalent
— passive).
 CLUSTER
• Cluster A S
– Odd or eccentric
– Paranoid, schizoid, schizotypal

• Cluster B
– Dramatic, emotional, erratic
– Antisocial, borderline, histrionic, narcissistic

• Cluster C
– Fearful or anxious
– Avoidant, dependent, obsessive-compulsive
 CLUSTER
S oneself and others
• Way of thinking about
• Way of responding emotionally
• Way of relating to other people
• Way of controlling one’s behavior

• CLUSTER A
• Social awkwardness and social withdrawal are common
features. Although people with Cluster A personality
disorders may have a strong link to a relative who has
been diagnosed with schizophrenia, these disorders are
typically less extensive and impact daily functioning less
than schizophrenia.
• People with Cluster A personality disorders
tend to have relationship issues because their
behavior is seen as peculiar, suspicious, or
detached. Three types of personality disorder
are included in the first cluster.
• Paranoid personality disorder (ymptoms
include chronic, pervasive distrust of other
people; suspicion of being deceived or
exploited by others, including friends, family,
and partners; angry outbursts in response to
deception; and cold, secretive, or jealous
behavior)
• Schizoid personality disorder (Characterized by
social isolation and indifference toward other
people, schizoid personality disorder affects more
men than women. People with this relatively rare
disorder often are described as cold or
withdrawn, rarely have close relationships with
other people, and may be preoccupied with
introspection and fantasy)
• Schizotypal personality disorder. Symptoms of
schizotypal personality disorder include odd
speech, behavior, and appearance, as well as
strange beliefs and difficulty forming
relationships.
 CLUSTER B
• Dramatic, emotional, or erratic. Impulse control and
emotional regulation are problems for people with
disorders categorized in Cluster B.
• Tend to experience very intense emotions or engage in
extremely impulsive, theatrical, promiscuous, or law-
breaking behaviors.
• Antisocial personality disorder. Showing up earlier than
most other personality disorders, antisocial personality
disorder tends to show up in childhood. Symptoms include a
disregard for rules and social norms and a lack of empathy
for other people.
• Borderline personality disorder. Characterized by
emotional instability, intense interpersonal relationships,
and impulsive behaviors.
• Histrionic personality disorder. With a need
to always be the center of attention that often
leads to socially inappropriate behavior to get
attention, people with histrionic personality
disorder may have frequent mood swings as
well.
• Narcissistic personality disorder. Associated
with self-centeredness, exaggerated self-
image, and lack of empathy for others.
 CLUSTER C
• The anxious or fearful cluster. This group features an overlap
of symptoms of anxiety and depressive disorders
• Avoidant personality disorder. Characterized by a disregard
for rules and a lack of empathy and remorse, this disorder
can show up during childhood.
• Dependent personality disorder. Involves a fear of being
alone and often causes those who have the disorder to do
things to try to get other people to take care of them.
• Obsessive-compulsive personality disorder. Characterized
by a preoccupation with orderliness, perfection, and control
of relationships, this is not the same as obsessive-
compulsive disorder (OCD)
 PREVALENCE (INDIA)
• Personality disorders had a prevalence of 1.07%, with a
preponderance of those aged 21-40 years (69.4%), men
(64.9%), employed and students (37.3% and 32.8%
respectively), unmarried (56%), graduates and
undergraduates (27.6% each), and referred by the family
(68.7%). The most common personality disorders were
anxious-avoidant and borderline.
• (Gupta, Mattoo, 2012- North India)

• The prevalence of any personality disorder was 9.1% and

borderline personality disorder was 1.4%.
(2012)
 CASE
She believed, without cause, that her neighbors were harassing her by allowing their young
children to make loud noise outside her apartment door. Rather than asking the neighbors to be
more considerate, she stopped speaking to them and began a campaign of unceasingly
antagonistic behavior: giving them “dirty looks,” pushing past them aggressively in the hallway,
slamming doors, and behaving rudely toward their visitors. After over a year had passed, when
the neighbors finally confronted her about her obnoxious behavior, she accused them of
purposely harassing her. “Everyone knows that these doors are paper thin,” she said, “and that I
can hear everything that goes on in the hallway. You are doing it deliberately.” Nothing that the
neighbors said could convince her otherwise. Despite their attempts to be more considerate
about the noise outside her apartment, she continued to behave in a rude and aggressive manner
toward them.
Neighbors and visitors commented that [Amaya] appeared tense and angry. Her face looked like a
hard mask. She was rarely seen smiling. She walked around the neighborhood wearing dark
sunglasses, even on cloudy days. She was often seen yelling at her children, behavior that had
earned her the nickname “the screamer” among the parents at her children’s school. She had
forced her children to change schools several times within the same district because she was
dissatisfied with the education they were receiving. An unstated reason, perhaps, was that she
had alienated so many other parents. [Amaya] worked at home during the day at a job that
required her to have little contact with other people. She had few social contacts, and in
conversation was often perceived to be sarcastic and hypercritical.
 PARANOID PERSONALITY DISORDER
01.0 (F60.0)
• Paranoid personalities are aloof, emotionally
cold individuals who display unjustified
suspiciousness, hypersensitivity, jealousy, and
a fear of intimacy. In addition they can be
grandiose, rigid, contentious, and litigious.
Because of their hypersensitivity to criticism
and tendency to project blame on others, they
tend to lead isolated lives and are often
disliked by others
 Clinical Presentation
• characterized by the following behavior interpersonal styles,
cognitive style, and emotional style. Behaviorally, paranoid
individuals are resistive of external influences. They tend to
be chronically tense, because they are constantly mobilized
against perceived threats from their environment. Their
behavior also is marked by guardedness, defensiveness,
argumentativeness, and litigiousness. Interpersonally, they
tend to be distrustful, secretive, and isolative
• Their cognitive style is characterized by mistrusting
preconceptions. They carefully scrutinize every situation
encountered and scan the environment for “clues” or
“evidence” to confirm their preconceptions, rather than
objectively focus on data. Thus, while their perception may
be accurate, their judgment often is not.
• The affective style of the paranoid
personalities is characterized as cold, aloof,
unemotional, and humorless. In addition, they
lack a deep sense of affection, warmth, and
sentimentality. Because of their
hypersensitivity to real or imagined slights,
and their subsequent anger at what they
believe to be deceptions and betrayals, they
tend to have few, if any, friends
(ANGER//INTENSE JEALOUSY)
 DSM Criteria
• Diagnosis assigned to individuals who have a pervasive, persistent,
and enduring mistrust of others, and a profoundly cynical view of
others and the world
• Symptoms of Paranoid Personality Disorder
• According to the DSM-5, there are two primary diagnostic criterion for
Paranoid Personality Disorder of which criterion A has seven sub features,
four of which must be present to warrant a diagnosis of PPD:
• Criterion A is: Global mistrust and suspicion of others motives which
commences in adulthood. The seven sub features of criterion A are:
• [Link] person with PPD will believe others are using, lying to, or
harming
them, without apparent evidence thereof.
• [Link] will have doubts about the loyalty and trustworthiness of
others,
• 3.,They will not confide in others due to the belief that their
confidence
will be betrayed.
• [Link] will interpret ambiguous or benign remarks as hurtful or
threatening, and
• 5. Hold grudges,
• 6. In the absence of objective evidence, believe their
reputation or character are being assailed by others,
and will retaliate in some manner and
• 7. Will be jealous and suspicious without cause that
intimate partners are being unfaithful.
• Criterion B is that the above symptoms will not be
during a psychotic episode in schizophrenia, bipolar
disorder, or depressive disorder with psychotic
features,
• A qualifier is that if the diagnostic criteria for PPD is
met prior to the onset of Schizophrenia, it should be
noted Paranoid Personality Disorder was premorbid
(American Psychiatric Association, 2013).
• Onset - may be apparent in childhood and
adolescence. Children may act strangely,
resulting in teasing
• Prevalence - According to the DSM-5, the
prevalence of Paranoid Personality Disorder is
2.3 % to 4.4 % of the US population, and is
more frequently diagnosed in males.
(American Psychiatric Association, 2013).
 Biopsychosocial Conceptualization
• Biologically, a low threshold for limbic system
stimulation and deficiencies in inhibitory centers seem
to influence the behavior of the paranoid personality
• Temperament// Parental and Enviornmental Factors
• Psychologically, paranoid individuals view themselves,
others, the world, and life’s purpose in terms of the
following themes. They tend to view themselves by
some variant of the theme: “I’m special and different.
I’m alone and no one likes me because I’m better than
others.” Life and the world are viewed by some variant
of the theme: “Life is unfair, unpredictable, and
demanding. It can and will sneak up and harm you
when you are least expecting it.”
• The most common defensive mechanism associated
with the paranoid disorder is projection
• Socially, predictable patterns of parenting and
environmental factors can be noted for the Paranoid
Personality Disorder. For all the subtypes the parental
injunction appears to be “You’re different. Don’t make
mistakes.”
• This paranoid pattern is confirmed, reinforced, and
perpetuated by the following individual and systems
factors: A sense of specialness, rigidity, attributing
malevolence to others, blaming others, and
misinterpreting motives of others leads to social
alienation and isolation, which further confirms the
individual’s persecutory stance
 Treatmen
t
• increasing the benignness of perception and
interpretation of reality, and increasing trusting
behavior.
• The social-skills training intervention
• individuals are taught how to reduce their perceptual
scanning and attending to inappropriate cues, to
attending to more appropriate cues; and rather than
using idiosyncratic logic and misinterpretation to
process their cues, they learn to use more common
logic and a more benign interpretation of cues
 SCHIZOID PERSONALITY DISORDER
301.20 (F60.1)
• Individuals with Schizoid Personality Disorders
tend to be reclusive individuals who have little
desire or capacity for interpersonal relationships
and derive little pleasure from them. Yet, they
can perform well if left alone. For instance, they
make excellent night watchmen and security
guards.
• They have little emotional range, they daydream
excessively, and appear to be humorless and
aloof.
 Clinical Presentation
• The behavioral pattern of schizoids can be
described as lethargic, inattentive, and
occasionally eccentric. They exhibit slow and
monotone speech and are generally non-
spontaneous in both their behavior and
speech. Interpersonally, they appear to be
content to remain socially aloof and alone.
These individuals prefer to engage in solitary
pursuits, they are reserved and reclusive, and
rarely respond to others’ feelings and actions.
• Their thinking style can be characterized as
cognitively distracted. That is, their thinking and
communication can easily become derailed
through internal or external distraction. This is
noted in clinical interviews, when these patients
have difficulty organizing their thoughts, are
vague, or wander into irrelevance such as the
shoes certain people prefer (very less
introspection)
• Their emotional style is characterized as being
humorless, cold, aloof, and unemotional. They
appear to be indifferent to praise and criticism,
and they lack spontaneity. Not surprisingly, their
rapport and ability to empathize with others is
poor
 DSM Criteria 301.20 (F60.1)
• Individuals with Schizoid personality disorder are fearful of the world,
ultimately entering into a secluded and hidden environment that
they create. They lean towards extreme submissiveness and give the
impression of only seeking any form of validation from within.
• A persistent pattern of disinterest from social interactions and a
limited variety of expression of emotions in a close personal settings,
starting in early adulthood and there in an array of contexts, as
shown by at least four (or more) of the subsequent:
• neither wants nor likes close relationships, counting being part of a
family
• almost constantly picks introverted activities
• has little if any, thought in engaging in any sexual experiences
• seldom derives pleasure from any activities
• has no close friends other than immediate relatives
• appears apathetic to the admiration or disapproval of others
• shows emotional coldness, detachment, or flattened affectivity
 ETIOLOGY
• First degrees relatives of those with schizophrenia
• End up having schizophrenia
• RISK FACTORS- These factors focus on situations
surrounding the individual’s childhood
experiences, as well as heritability.
• An individual who was raised in a home, where
emotional needs went unmet
• hypersensitive as a teenager, and who felt
emotionally disconnected, as well as one who
was abandoned as a child, or suffered
mistreatment as a child.
 Biopsychological – Conceptualization
• Biologically, the schizoid personality was likely to have had a
passive and anhedonic infantile pattern and temperament.
Millon (2011) suggested that this pattern results, in part,
from increased dopaminergic postsynaptic limbic and
frontal lobe receptor activity (BODY TYPE- ECOMORPHIC )
• Psychologically, schizoids view themselves, others, the
world, and life’s purpose in terms of the following themes.
They view themselves by some variant of the theme: “I’m a
misfit from life, so I don’t need anybody. I am indifferent to
everything.” For schizoid personalities, the world and others
are viewed by some variant of the theme: “Life is a difficult
place and relating to people can be harmful.” As such, they
are likely to conclude, “Therefore, trust nothing and keep a
distance from others and you won’t get hurt.”
• The most common defense mechanism utilized by
them is intellectualization. Socially, predictable
patterns of parenting and environmental factors can be
noted for schizoids. Parenting style is usually
characterized by indifference and impoverishment.
• It is as if the parental injunction was: “You’re a misfit,”
or, “Who are you, what do you want?” Their family
pattern is characterized by fragmented
communications and rigid, unemotional
responsiveness. Because of these conditions, schizoids
are grossly undersocialized and develop few if any
interpersonal relating and coping skills.
• social insensitivity leads to reinforcement of social
isolation
 TREATMENT
• Treatment strategy involves a crisis and
supportive approach, as well as providing a
consistent and supportive therapeutic
interaction. Medications, particularly the
neuroleptics, do not appear to be useful with
schizoid personality unless some psychotic
decompensation has been noted
SCHIZOTYPAL PERSONALITY DISORDER
301 (F21)
• schizotypal disorder is characterized by
eccentric behavior and peculiar thought
content. Schizotypals describe strange
intrapsychic experiences, think in odd and
unusual ways, and are difficult to engage.
• schizotypal personality is one of the
schizophrenic spectrum disorders because
schizophrenia occurs with increased frequency
in family members of the schizotypal.
 CLINICAL PRESENTATION
• Behaviorally, schizotypals are noted for their
eccentric, erratic, and bizarre mode of
functioning. Their speech is markedly peculiar
without being incoherent.
• Occupationally, they are inadequate, either
quitting or being fired from jobs after short
periods of time. Typically, they become drifters,
moving from job to job and town to town. They
tend to avoid enduring responsibilities
• Interpersonally, they are loners with few if any friends.
Their solitary pursuits and social isolation may be the
result of intense social anxiety, which may be
expressed with apprehensiveness. If married, their
style of superficial and peripheral relating often leads
to separation and divorce in a short period of time
• The cognitive style of schizotypals is described as
scattered and ruminative, and is characterized by
cognitive slippage. Presentations of superstitiousness,
telepathy, and bizarre fantasies are characteristic. They
may describe vague ideas of reference and recurrent
illusions of depersonalizing, derealizing experiences
without the experience of delusions of reference, or
auditory or visual hallucinations
• Their affective style is described as cold, aloof,
and unemotional with constricted affect. They
can be humorless individuals and difficult to
engage in conversation, probably because of
their general suspicious and mistrustful
nature.
• HYPERSENSITIVE
 DSM CRITERIA 301 (F21)

• ANY 5
• Unusual perceptual experiences, including
bodily illusions. Odd thinking and speech (e.g.
- vague, circumstantial, metaphorical,
overelaborate, or stereotyped) Suspiciousness
or paranoid ideation. Inappropriate or
constricted affect
 Biopsychosocial - Conceptualization
• Passive infantile pattern, probably resulting from low
autonomic-nervous-system reactivity and parental
indifference that led to impoverished infantile stimulation
• impaired eye-tracking motions, which is a characteristic
shared with schizophrenic individuals.
• Psychologically, the schizotypals view themselves, others, the
world, and life’s purpose in terms of the following themes.
They tend to view themselves by some variant of the theme:
“I’m on a different wavelength than others.” They commonly
experience being selfless; that is, they experience feeling
empathy, estranged, and disconnected or dissociated from
the rest of life. Their world-view is some variant of the
theme: “Life is strange and unusual, and others have special
magical intentions.” (MAGICAL THINKING)
• Socially, predictable patterns of parenting and
environmental factors can be noted for the
Schizotypal Personality Disorder. The parenting
patterns noted previously of the cold indifference
of the schizoid subtype, or the deprecating and
derogatory parenting style and family
environment of the avoidant subtype
• The parental injunction is likely to have been
“You’re a strange bird.”
 TREATMENT
• the focus of treatment is on “management”
rather than on “treatment.”
CLUSTER B
 Cluster B – Borderline Personality
Disorder
• Individuals with borderline personalities present
with a complex clinical picture, including diverse
combinations of anger, anxiety, intense and
labile affect, and brief disturbances of
consciousness such as depersonalization and
dissociation.
• In addition, their presentation includes chronic
loneliness, a sense of emptiness, boredom,
volatile interpersonal relations, identity confusion,
and impulsive behavior that can include self-
injury or self-mutilation.
• Stress can even precipitate a transient psychosis.
 Clinical Presentation
• Behaviorally, borderlines are characterized by
physically self-damaging acts such as suicide
gestures, self-mutilation, or the provocation of
fights.
• Their social and occupational accomplishments
are often less than their intelligence and ability
warrant.
• Of all the personality disorders, they are more
likely to have irregularities of circadian rhythms,
especially of the sleep-wake cycle. Chronic
Insomnia is a common complaint .
• Interpersonally, borderlines are characterized by their
paradoxical instability. That is, they fluctuate quickly
between idealizing and clinging to another individual,
to devaluing and opposing that individual.
• They are exquisitely rejection-sensitive, and
experience abandonment depression following the
slightest of stressors. Separation anxiety is a primary
motivator.
• Interpersonal relationships develop rather quickly and
intensely, yet borderlines’ social adaptiveness is
rather superficial.
• They are extraordinarily intolerant of being alone, and
they go to great lengths to seek out the company of
others, whether in indiscriminate sexual affairs, late-night
phone calls to relatives and recent acquaintances, or
after- hours visits to hospital emergency rooms, with a
host of vague medical and/or psychiatric complaints.
• Their cognitive style is described as inflexible and impulsive.- rigid
abstractions, easily led grandiose, idealized perceptions of others not as
real people, but as personifications of “all good” or “all bad”. They
reason by analogy from past experiences and have difficulty reasoning
logically and learning from past mistakes.

• Because of “Locus of control”, they blame others when things go

wrong. By accepting responsibility for their own incompetence,
borderlines believe they would feel even more powerless to change
circumstances. Accordingly, their emotions fluctuate between hope and
despair, because they believe that external circumstances are
well beyond their control

• Their cognitive style is also marked by impulsivity, and just as they

vacillate between idealization and devaluation of others, their thoughts
shift from one extreme to another: “I like people; no, I don’t like
them”; “Having goals is good; no, it’s not”; “I need to get my life
together; no, I can’t, it’s hopeless.”
• This inflexibility and impulsivity complicates the
process of identity formation. Their uncertainty about
self-image, gender identity, goals, values, and career
choice reflects this impulsive and flexible stance. Their
inflexibility and impulsivity are further noted in their
tendency toward
“splitting.” Splitting is the inability to synthesize
contradictory qualities, such that the individual
views others as all good or all bad, and utilizes
“projective
identification,” that is, attributing his or her own
negative or dangerous feelings to others. They have
inability to tolerate frustration.
• The emotional style of individuals with this disorder
is characterized by marked mood shifts from a normal
or euthymic mood to a dysphoric mood.
• In addition, inappropriate and intense anger and rage
may easily be triggered. On the other extreme are
feelings of
 DSM 5 Characterization
• An unremitting pattern of unstable relationships, emotional
reactions, identity, and impulsivity.
• They engage in frantic efforts to avoid abandonment, whether
it is real or imagined.
• Their interpersonal relationships are intense, unstable, and
alternate between the extremes of idealization and devaluation.
• They have chronic identity issues and an unstable sense of self.
• Their impulsivity can result in self-damaging actions such as
reckless driving or drug use, binge-eating, or high-risk sex.
• These individuals engage in recurrent suicidal threats, gestures,
acting out, or self-mutilating behavior.
• They can exhibit markedly reactive moods, chronic feelings of
emptiness, emotional outbursts, and difficulty controlling
their anger.
• They may also experience brief stress-related,
paranoid thinking, or severe episodes of dissociation
 BPD- Biopsychosocial- Alderian
conceptualization
• Borderlines can be understood by 3 main sub types-
Borderline dependent, Borderline histrionic and borderline
passive aggressive
• Borderline dependent type is passive infantile pattern. Low
autonomic-nervous-system reactivity plus an overprotective
parenting style
facilitates restrictive interpersonal skills and a clinging
relational style
• Histrionic subtype – hyper responsive infantile pattern.--
because of high autonomic-nervous-system reactivity and
increased parental stimulation and expectations for
performance
• passive-aggressive borderline was likely to have been the
“difficult child”. This pattern, plus parental inconsistency,
marks the affective irritability
• Psychologically, they perceive self and others in
world in terms of following themes -- “I don’t know
who I am or where I’m going.” In short, their
identity problems involve gender, career, loyalties,
and values, while their self-esteem fluctuates with
each thought or feeling about their self-identity.

• Borderlines tend to view their world with some

variant of the theme: “People are great; no, they are
not”; “Having goals is good; no, it’s not”; or, “If life
doesn’t go my way, I can’t tolerate it.” As such,
they are likely to conclude: “Therefore keep all
options open. Don’t commit to anything.

• The defense mechanism used is Regression,

Splitting, Projective identification
• Parenting and environmental factors- Overprotectiveness
(dependent); demanding parenting (histrionic); inconsistent
parenting (passive aggressive)- increasing likelihood that
child has learnt defeating coping strategies. The parental
junction is like to have been “If you grow up and leave me,
bad things will happen to me (parent).
• -Diffuse identity, impulsive vacillation, self defeating coping
strategies lead to aggressive acting out.
• TREATMENT CONSIDERATIONS
• Higher functioning borderline requires insight oriented
psychotherapy due to regression and acting out
• Confrontational statements should be utilized
• Increasing day to day stable functioning,
• Task oriented group therapy
• Antidepressants
 Cluster B- Narcissistic Personality
Disorder
• Need for admiration and habitually unrealistic
self-expectations.
• The narcissist is impulsive and anxious, has ideas
of grandiosity and “specialness,” becomes quickly
dissatisfied with others, and maintains
superficial, exploitative interpersonal
relationships.
• Under stress and when needs are not met, the
narcissist may become depressed, develop
somatic symptoms, have brief psychotic episodes,
or display extreme rage
 Clinical Presentation
• Behaviouraly, conceited, boastful and snobbish. They appear self assured and
self centered, they tend to dominate conversation, seek admiration, and have
exhibitionistic fashion. They are impatient, arrogant, thin skinned and
hypersensitive.
• Interpersonally, exploitive, use others to indulge themselves and their desires.
Their behavior is socially facile, pleasant. However, they are unable to respond
with true empathy to others. When stressed, they can be disdainful, exploitive,
and generally irresponsible in their behavior.
• Thinking style, Cognitive expansiveness, exaggeration. They tend to focus on
images and themes rather than facts and issues. They distorted facts, engage
in self deception to preserve their own illusions about self and projects on
others.
• Cognitive style, marked by inflexibility. In addition, they have an
exaggerated sense of self-importance and establish unrealistic goals of power,
wealth, and ability. They justify all of this with their sense of entitlement and
exaggerated sense of their own self-importance.

• Affective style, self confidence present in all situation unless shaken. Rage at
criticism, Their feelings toward others shift and vacillate between over
idealization and devaluation, Empathy is superficial, minimal emotional ties or
commitments.
 DSM 5 Characterization
• self-centeredness and grandiosity
• an exaggerated sense of their own abilities and achievements
• constant need for attention, affirmation, and praise
• They believe they are unique or special and should
only associate with others of the same status.
• They are likely to have persistent fantasies about attaining success
and power.
• These individuals can exploit others for personal gain.
• A sense of entitlement and the expectation of special treatment is
common.
• They may come across as snobbish or arrogant.
• They appear to be incapable of showing empathy for others.
• In addition, they can be envious or think that others are envious of
them
 NPD- Biopsychosocial Alderian
conceptualization
• Biologically, Hyper responsive temperaments- viewed by others as special in
terms of looks, talents, or “Promise”.
• Psychologically, “I’m special and unique, and I am
entitled to extraordinary rights and privileges whether I have earned them or
not.” Their world-view is a variant of the theme: “Life is a banquet table to be
sampled at will. People owe me admiration and privilege.” Their goal is:
“Therefore, I’ll expect and demand this specialness.
• Defense mechanism- Rationalization and Projective identification
• Socially, Parental indulgence and overevaluation characterize the
narcissistic personality. The parental injunction was likely to be: “Grow up and
be wonderful—for me.”
– From early age they learn exploitive and manipulative behaviour from their
parents.
– Increased self absorption, illusion of specialness, sense of entitlement

• TREATMENT CONSIDERATION
• Personality restructuring, crisis oriented psychotherapy
• Empathic mirroring or reflection , decrease cognitive distortions, empathy
training, anger management, cognitive restructuring,
• Medication
 Antisocial personality Disorder

• Aggressiveness, fighting, hyperactivity, poor peer relationships,

irresponsibility, lying, theft, truancy, poor school performance,
runaway behavior, inappropriate sexual activity, as well as drug and
alcohol abuse.
• As adults, assaultiveness, self-defeating
impulsivity, hedonism, promiscuity, unreliability, and continued
drug and alcohol abuse may be present.
• Criminality may be involved
• Tend to have abuse parents, neglectful spouse, difficulty in
maintaining intimate relation, maybe convicted, spent time in
prison
• Frequently anxious and depression, shows conversion symptoms
and faciticious
• OFTEN PEAKS IN LATE ADOLESCNECE AND EARLY 20s ,
lessens in late 30s.
• More prevalent in Males than females 4:1
• Psychopathy, sociopathy and antisocial personality engage
in psychopath and sociopath, because interpersonal
deficits, i.e., grandiosity, arrogance, and deceitfulness, as
well as affective deficits, i.e., lack of guilt and empathy.
• Specifically, psychopaths are characterized by a global
empathic deficit.
• In contrast, sociopaths can emotionally attach to
others, and may feel badly when they hurt those
individuals to whom they are attached.
• Yet, sociopaths can lack empathy and attachment toward
society, and are not likely to feel guilt in harming a
stranger or breaking laws.
• As per to the researches, psychopathy is more an innate
and genetic phenomenon were as, sociopathy is more
of environmental factor like poverty, exposure to
violence and neglectful parenting
 Clinical Presentation
• BEHAVIOURALLY, poor job performance, repeated substance abuse,
irresponsible parenting, persistent lying, delinquency, truancy, and
violations of others’ rights, impulsive anger, hostility and cunning,
risk seeking, thrill seeking behaviour.
• INTERPERSONALLY, highly competitive , distrustful, poor losers,
time appears to be slick as well as calculative.
• COGNITIVE styles, impulsive , congnitively inflexible. Because
they are contemptuous of authority, rules, and social expectations,
they easily rationalize their own behavior.
• Their feelings or emotional style are characterized by shallow,
superficial relationships that involve no lasting emotional ties or
commitments.
• They avoid “softer” emotions such as warmth and intimacy because
they regard these as signs of weakness. Guilt is seldom if ever
experienced.
• They are unable to tolerate boredom, depression, or frustration and
subsequently are sensation-seekers
 DSM 5 Characterization
• Disregarding and violating the rights of others.
• They disrespect and disregard laws and social norms, and regularly
engage in acts that are grounds for arrest.
• These individuals
lie, are deceitful, and will take advantage of others for pleasure or for
personal profit.
• They are impulsive and fail to plan ahead.
• They are also irritable and aggressive, which results in physical fights
or assaults.
• It is not surprising that these individuals disregard the safety of others
as well as of themselves.
• Their irresponsibility is demonstrated by their failure to engage in
consistent work behavior and failure to meet financial
obligations.
• Furthermore, their lack of remorse is shown by their indifference
in having
hurt, mistreated, or stolen from others
 Alderian conceptualization -
Biopsychosocial
• Biologically, “Difficult child” temperament
• Unpredictable, withdraw from situations, showed high intensity, and had a
fairly low, discontented mood, decrease in inhibitory centers of central nervous
syste,
• Body types- Endomorphic (Lean) and Mesomorphic (Muscular)
• PSYCHOLOGICALLY, “I am cunning and entitled to get whatever I want.” In other
words, they see themselves as strong, competitive, energetic, and tough. Their
view of life and the world is a variant of the theme: “Life is devious and
hostile, and rules keep me from fulfilling my needs.” Not
surprisingly their life’s goal has a variant of the theme: “Therefore, I’ll bend or
break these rules because my needs come first, and I’ll defend against efforts
to be controlled
or degraded by others.”
• Defense mechanism- Rationalisation and Acting out
• Socially, Hositility and deficient parental modelling, -- parents might have
provided a modeling that child could not or refused to live up to high
standard of parents
• Parental junction--- “The end justifies the means”, Family tends to
be disorganized and disengaged,
• Need to be powerful and fear of being abused and humiliated leads to a denial
of softer emotions plus
 Treatmen
t
• Individual Therapy
• Special residential treatment programs
 Histrionic Personality Disorder
• Histrionic personalities may initially seem
charming, likable, energetic, and seductive,
but as time passes they are likely to be seen
as emotionally unstable, immature, and
egocentric. This personality style and disorder
predominates in females, and presents
with a caricature of femininity in dress
and manner.
 Clinical Presentation of HPD
• Characterized by the following behavioral and
interpersonal style, thinking style, and feeling style.
The behavioral style is characterized as charming,
dramatic, and expressive, while also being demanding,
self- indulgent, and inconsiderate
• Persistent attention-seeking, mood lability,
capriciousness, and superficiality further characterize
their behavior.
• Interpersonally, these individuals tend to be
exhibitionistic and flirtatious in their manner, with
attention-seeking and manipulativeness being
prominent
• he thinking or cognitive style of this personality can
be characterized as impulsive and thematic, rather
than being analytical, precise, and field-independent
• In short, their tendency is to be non- analytic, vague and
field dependent.
• Easily suggestible and rely heavily on hunches
• They avoid awareness of their own dependency and other
self knowledge, and tend to be “other-directed” with
respect to the need for approval from others.
• They can easily dissociate their “real” or inner self from
their public or outer self.
• Their emotional or affective style is characterized by
exaggerated emotional displays and excitability, including
irrational outburst and temper tantrums
• They seek constant reassurance that they are loved, they
respond with only superficial warmth and charm and
are generally emotionally shallow
• They are extremely rejection sensitive
 DSM V Characterization
• Unremitting pattern of attention-seeking and emotionality.
• They tend to be uncomfortable in situations where
they cannot be the center of attention. Their emotional
reactions tend to be shallow and rapidly shifting.
• Typically, they draw attention to themselves with the way
they dress.
• Their manner of speech tends to be impressionistic with few
details.
• These individuals are easily influenced by others or
circumstances.
• They are likely to perceive relationships as more intimate
than they really are.
• They often engage in provocative and inappropriate seductive
sexual behavior
• They are dramatic and overly exaggerate their emotional
expressions
 Biopsychosocial-Alderian
Conceptualization
• Biologically, they are characterized by characterized by a high
energy level and emotional and autonomic reactivity.
• Their temperament then can be characterized as
hyper-responsive and externally oriented for gratification.
• Psychologically, they follow characteristic view of self, world
view and life goal.
• The self-view of the histrionic will be some variant of
the theme: “I am sensitive and everyone should admire and
approve of me.”
• The world- view will be some variant of: “Life makes me
nervous, so I am entitled to special care and consideration.”
• Life goal is some variant of the theme: “Therefore, play to the
audience, and have fun, fun, fun.
• Biological and psychological factors, social factors such as
parenting style and injunction, and family , environmental
factors, influence the development of this personality.
• The parental injunction for the histrionic personality
involves reciprocity: “I’ll give you attention, if you do
X.” A parenting style that involves minimal or
inconsistent discipline helps insure and reinforce the
histrionic pattern.
• Have atleast one manipulative parent who reinforces
the child’s histrionic and attention seeking behaviour.
• Denial of one’s real or inner self, a preoccupation with
externals,
• Need for excitement and attention seeking which leads
to a superficial charm and interpersonal presence. Need
to external approval
• THIS REINFORCES DISSOCIATION AND DENIAL of
the real and inner self from public self and cycle
continues
 Treatmen
t MDD and Bipolar disorder
• This is common under
and is also associated with Social anxiety disorder
and OCD
• Medications,
• Treatment goals- gentleness with strength ,
moderating emotional expression, encouraging
warmth, genuineness and empathy
• Because the histrionic personality can present as
dramatic, impulsive, seductive, and manipulative
with potential for suicidal gestures, the clinician
needs to discuss the matter of limits early in the
course of therapy regarding professional boundaries
and personal responsibilities
 CLUSTER C - AVOIDANT PERSONALITY
DISORDER
• Avoidant personalities are seemingly shy,
lonely, hypersensitive individuals with low
self-esteem. Although they are desperate for
interpersonal involvement, they avoid
personal contact with others because of their
heightened fear of social disapproval and
rejection sensitivity.
 Clinical Presentation
• The Avoidant Personality Disorder is
characterized by the following behavioral and
interpersonal styles, thinking or cognitive
styles, and emotional or affective styles.
• The behavioral style of avoidant personalities
is characterized by social withdrawal, shyness,
distrustfulness, and aloofness. Their behavior
and speech is both controlled and inactive,
apprehensive and arkward
• Interpersonally, they are rejection-sensitive
 DSM-5 Characterization
• According to the DSM5, criteria for diagnosis of avoidant
personality disorder in adults are met when a patient exhibits 4 or
more of the behaviors below. No formal modification has been
made for children
• 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
 biopsychosocial formulation
• Biologically, these individuals commonly were
hyperirritable and fearful as infants, and they
most likely exhibited the “slow to warm”
temperament
• Psychologically, those with avoidant
personalities
typically view themselves as “See, I am
inadequate and frightened of rejection.” They
are
likely to view the world as some variant of the
theme: “Life is unfair—people reject and criticize
me—but, I still want someone to like me.”
• A common defense mechanism of the avoidant
• Socially, predictable patterns of parenting and
environmental factors can be noted for the
avoidant personality disorder. The avoidant
personality is likely to have experienced
parental rejection and/or ridicule. Later,
siblings and peers will likely continue this
pattern of rejection and ridicule. The parental
injunction is likely to have been: “We don’t
accept you, and probably no one else will
either.”
 Treatmen
t
• The goal of therapy is to increase the individual’s
self esteem and confidence in relationship to
others and to desensitize the individual to the
criticism of others.
• Desensitization techniques appear to be much
more useful and expedient in this regard.
• Assertiveness training and shyness training are
reportedly very affective with the Avoidant
Personality pattern
• Comorbidity- Anxiety or Depression
(Medication)
 Cluster C- Dependent personality
disorder
• Characterized by a pervasive pattern of dependent and
submissive behaviours
• Excessively passive, insecure and isolated individuals who
become abnormally dependent on one or more persons.
• Can become controlling, appear hostile, and
even blend into a passive-aggressive
pattern.
• This disorder is more common in females
• Form of submissiveness, while in males the
dependent styles is more likely to be autocratic, such
as when the husband and boss depends on his wife
and secretary to perform essential tasks which he
himself cannot accomplish
• Likely to lead to anxiety and depression when
the dependent relationship is threatened
 Clinical Presentation
• Dependent personalities’ behavioral and interpersonal
styles are characterized by docility, passivity, and non-
assertiveness.
• In interpersonal relations, they tend to be pleasing,
self- sacrificing, clinging, and constantly requiring the
assurance of others.
• Their compliance and reliance on others lead to a subtle
demand that others assume responsibility for major
areas of their lives
• Suggestibility

• The Pollyanna principle (also called Pollyannaism or

positivity bias) is the tendency for people to remember
pleasant items more accurately than unpleasant
ones.
• They tend to minimize difficulties and because
of their naïve behaviour they are persuadable
and easily taken advantage of. In short, their
style of thinking in uncritical and unperceptive
• Their feeling or affective style is characterized
by insecurity and anxiousness. Because they
lack self-confidence, they experience
considerable discomfort at being alone.
• They tend to be preoccupied with the fear of
abandonment and disapproval of others. Their
mood tends to be one of anxiety or
fearfulness, as well as having a somber or sad
quality
 DSM V Characterization
• Characterized by an excessive andnunremitting need to be cared for,
and
• cling to others because of their fear of separation.
• They constantly seek the advice and reassurance of others when
making decisions.
• They want others to take responsibility for most major areas of
their
lives.
• They seldom express disagreement with others for fear they will lose
their support and approval. Because they lack confidence in their
own judgment and ability, they have difficulty starting projects and
doing things on their own.
• These individuals will even engage in actions that are difficult and
unpleasant in order to receive support and caring from others.
Because of unrealistic fears of being unable to take care of
themselves, they feel helpless or uncomfortable when faced with
being alone.
• When a close relationship is about to end, they immediately seek out
another caring and supportive relationship. Finally, they become
preoccupied with fears of being left to take care of themselves
 Biopsychosocial –Alderian
Conceptualization
• Biologically, Low energy level, Melancholic
temperament, as children- fearful, sad, withdrawn,
body types tend to have more endomorphic
• builds
Psychologically, - The self-view of these
tends to be a variant of the theme: “I’m nice, but
individuals
inadequate (or fragile).” Their view of self is self-
effacing, inept, and self-doubting.
• Their view of the world is some variant of the
theme: “Others are here to take care of me,
because I can’t do it for myself.”
• Their life goal is characterized by some variant of
the theme: “Therefore, cling
and rely on others at all cost.
• Social features- overprotective family,
• The parental injunction to the child is “I can’t trust you to
do anything right (or well).”
• Pampered and overprotected
• Engender feelings of unattractiveness, awkwardness,
competitive inadequacy (adolescent and pre adolescent)
• Self deprecation and doubt
• sense of self-doubt,
• an avoidance of competitive
activity; and
• particularly by the availability of self-reliant individuals
who are willing to take care of and make decisions for the
dependent person
• in exchange for the self- sacrificing and docile friendship of
the dependent personality
 Treatmen
t
• Somatization disorders
• Conversion or hypochondriasis
• Experience loss of support which can lead of
PDD and MDD
• Play ‘Sick role’- Factitious disorder
• Long range goal psychotherapy- CBT, MBCT to
be a healthier self
• Challenging own convictions or dysfunctional
beliefs about personal inadequacy
• To increase self reliance, assertiveness
 OCPD
• Described as inhibited, stubborn,
perfectionistic, judgmental,
overconscientious, rigid, and chronically
anxious.
• Characteristically, they are people who avoid
intimacy and experience little pleasure from
life.
• They may be successful, but at the same
time are indecisive and demanding. OFTEN
perceived cold and reserved (Unlike OCD,
itualistic compulsions and obsessions do not
characterize this personality disorder)
 Clinical Presentation
• Behaviorally, this disorder is characterized by
perfectionism. Individuals with this disorder
are likely to be workaholics.
• In addition to dependability, they tend to be
stubborn and possessive.
• They, like passive-aggressive-disordered
individuals, can be indecisive and
procrastinating.
• Interpersonally, these individuals are exquisitely conscious
of social rank and status and modify their behavior
accordingly.
• They tend to be deferential and obsequious to
superiors, and haughty and autocratic to subordinates
and peers.
• They can be doggedly insistent that others do things
their way, without an appreciation or
awareness of how others react to their insistence.
• Thinking style- constricted and rule based.
• They have difficulties in establishing priorities
and perspective
• They are “detail” people and often lose sight of the
larger project.
• In other words, they “can’t see the forest for the trees.”
Their indecisiveness and doubts make decision-
making difficult.
• Their mental inflexibility is matched by their non-
suggestible and unimaginative style, suggesting
they have a restricted fantasy life.
• Like passive-aggressive individuals, the obsessive-
compulsives have conflicts between assertiveness
and defiance, and pleasing and obedience.
• Their emotional style is characterized as grim and
cheerless.
• They have difficulty with the expression of
intimate feelings such as warmth and tenderness.
They tend to avoid the “softer” feelings, although
they may express anger, frustration, and irritability
quite freely.
• This grim, feeling-avoidant demeanor shows itself
in stilted, stiff relationship behaviors.
 DSM V Characterization
• Unremitting pattern of perfectionism, orderliness, and
control, instead of flexibility, openness, and efficiency.
• They are overly preoccupied with details, rules, and
schedules.
• Perfectionism interferes with completing tasks, due
to their overly strict standards.
• They are overly devoted to work and productivity to
the exclusion of leisure activities and friendships.
• They are unable to discard worn-out or worthless
objects that have no sentimental value.
• They will not delegate tasks or work with others unless
it can be on their terms.
• Misers with money and Hoarding traits (Future
catastrophes)
 Biopsychosocial –Alderian
conceptualization
• Biologically, Angedonic temperament
• firstborn children have a greater propensity for
developing a compulsive style than other
siblings
• Psychologically,
• They tend to view themselves with some
variant of the theme: “I’m responsible if something
goes wrong, so I have to be reliable, competent, and
righteous.”
• Their world-view is some variant of the theme: “Life is
unpredictable and expects too much.”
• As such, they are likely to conclude, “Therefore, be in
control, right, and proper at all times.”
• Socially, Parenting and environmental
conditioning
• Parenting style is overcontrolled and
consistent
• Trained as a child to be overly responsible for
their actions and to feel guilty and worthless if
they were not obedient, achievement oriented
or “good”
• Parental injunction “You must do and be better
to be worthwhile”
 Treatmen
• Rat Man
t
(Freud concept)
• Hypnosis
• CBT
• Increased cognitive constriction and increased feeling
expression
• More reasonable balance obtained between thoughts
and feelings
• Insight oriented therapy
• Antidepressants
• Medication is usually not needed unless the person has
anxiety and depression along with this
 References
• American Psychological Association. (2022).
Sleep –Wake disorders. In Diagnostic and
statistical manual of mental disorders (5th
Edition)

• Sperry, L. et. al. (2015). Psychopathology and

Psychotherapy: DSM-5 Diagnosis, case
conceptualization and Treatment. (3rd Edition).
New York: Routledge