Psychology Personality Disorders
by
Edelyn Verona, Sean McKinley, M. Sima Finy
  • LAST REVIEWED: 29 June 2017
  • LAST MODIFIED: 25 October 2017
  • DOI: 10.1093/obo/9780199828340-0082

Introduction

Personality disorders (PDs) are defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; published by the American Psychiatric Association in 2013) as “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, and leads to distress or impairment” (p. 645). Although broad in scope, this definition is meant to distinguish PDs from other psychological disorders that are less clearly related to enduring personality. Indeed, as of 1980, in DSM-III, PDs were introduced in a different “axis” from other disorders, such as mood or anxiety disorders, ensuring that clinicians pay attention to acute disorders as well as personality-based problems in living. The former were classified under Axis I, or “Clinical Disorders,” representing acute manifestations of illness (e.g., schizophrenia, panic disorder), whereas PDs were classified under Axis II (along with mental retardation) in order to capture inflexible personality traits that have become problematic and that require psychological attention. However, with the publication of DSM-5, the multi-axial system has been eliminated in favor of a general scheme that places all disorders (clinical and personality) on the same diagnostic plane. In DSM-5, ten distinct PDs are listed, organized into three clusters: odd or eccentric (paranoid, schizoid, schizotypal); dramatic, emotional, or erratic (antisocial, borderline, narcissistic, histrionic); and anxious or fearful (avoidant, obsessive-compulsive, dependent) disorders. Individuals who show broad dysfunctions in personality that warrant treatment but who do not meet criteria for any specific PD are often classified as “Unspecified Disorder,” which is not in itself a personality disorder, but instead used to enhance specificity of an existing disorder or as a means of attaching a diagnosis to an individual for treatment purposes. Furthermore, a dimensional model of personality disorder, in which symptoms would be identified on a gradient scale of severity rather than a diagnostic checklist, was proposed during the DSM-5 revision process; however, this model was not approved to replace the categorical schema and was instead placed in section III of the manual (entitled “Emerging measures and models”). As of the early 21st century the etiology for PDs is unclear and multidetermined, but specific temperamental (e.g., neuroticism, disinhibition), environmental (e.g., childhood abuse), and biological (e.g., prefrontal cognitive control systems) factors have been most implicated. Specific etiological factors studied in regard to the three PD clusters as well as treatment approaches are reviewed in subsequent sections, with a focus on empirical and scientifically grounded publications.

Overviews, Textbooks, and Historical Perspectives

Several references and textbooks provide comprehensive descriptions of personality disorders (PDs) and can be used as resources for understanding, and guides for treating, these psychiatric conditions. For example, Livesley 2001; Oldham, et al. 2005; Sperry 2016; and Widiger 2012 discuss the etiology, classification, and treatment of PDs. Lenzenweger and Clarkin 2005 describes some of the major theoretical perspectives of personality pathology, and Millon, et al. 2004 applies many of these theoretical perspectives to explain the development of each of the ten DSM-5 PDs. Finally, Alarcón, et al. 1998 considers the role of culture in the development of personality and PDs. These texts are intended for practitioners/clinicians, researchers, and students.

  • Alarcón, Renato D., Edward F. Foulks, and Mark Vakkur. 1998. Personality disorders and culture: Clinical and conceptual interactions. New York: Wiley.

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    One of the first texts to describe the role of social and cultural practices that contribute to personality development and PDs. Explains how cultural concepts and practices can be used to create effective therapeutic interventions, while highlighting the importance of cultural awareness for clinicians/practitioners.

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  • Lenzenweger, Mark F., and John F. Clarkin, eds. 2005. Major theories of personality disorder. 2d ed. New York: Guilford.

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    Provides a historical overview and empirical developments of PD theories of the 20th and early 21st centuries; highlights the importance of viewing these theories as research heuristics. After an initial introduction on the history, classification, and research issues of PDs, each chapter covers one of the major theoretical perspectives (e.g., interpersonal, attachment) of personality pathology.

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  • Livesley, W. John, ed. 2001. Handbook of personality disorders: Theory, research, and treatment. New York: Guilford.

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    Considered by many to be the definitive guide, this text provides a thorough review of PDs. Text is organized into the following sections: “Theoretical Perspectives and Nosological Issues” (classification), “Etiology and Development,” “Diagnosis and Assessment,” “Treatment,” and “Treatment Modalities and Special Issues” (e.g., forensic issues).

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  • Millon, Theodore, Seth Grossman, Carrie Millon, Sarah Meagher, and Rowena Ramnath. 2004. Personality disorders in modern life. 2d ed. Hoboken, NJ: Wiley.

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    Describes the history and theoretical perspectives of personality pathology for the ten DSM-IV PDs and many of their subtypes. The development of each PD is explained in terms of a personality continuum ranging from normal to abnormal. In addition, the assessment and treatment of each PD are discussed.

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  • Oldham, John M., Andrew E. Skodol, and Donna S. Bender, eds. 2005. The American Psychiatric Publishing textbook of personality disorders. Washington, DC: American Psychiatric.

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    One of the most exhaustive reference guides in the field, this text explains what makes personality “disordered.” Organized into the following sections: “Basic Concepts” (e.g., PD classification), “Clinical Evaluation” (e.g., differential diagnosis), “Etiology” (e.g., epidemiology), “Treatment” (e.g., pharmacotherapy), “Special Problems and Populations” (e.g., suicide), and “New Developments and Future Directions” (e.g., translational research).

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  • Sperry, Len. 2016. Handbook of diagnosis and treatment of DSM-5 personality disorders. 3d ed. New York: Routledge.

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    Provides a theoretical overview and discusses intervention strategies, treatment approaches, and empirical findings for the ten DSM-5 PDs. After an introduction to the diagnosis and treatment of PDs, the text is organized by a discussion of each PD.

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  • Widiger, T. 2012. The Oxford handbook of personality disorders. New York: Oxford Univ. Press.

    DOI: 10.1093/oxfordhb/9780199735013.001.0001Save Citation »Export Citation » Share Citation »

    Published shortly before the publication of DSM-5, this book provides a summary of the latest information concerning the diagnosis, assessment, construct validity, etiology, pathology, and treatment of personality disorders. This volume includes chapters related to: continuity and eliminations from DSM-IV-TR to DSM-5, chapters authored by the DSM-5 Personality Disorders Working Group, and controversial areas for the DSM across its many versions (e.g., schizotypal personality disorder, narcissism, depressive personality disorder, dependent personality disorder, and dimensional classification).

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Personality Disorders and Clinical Syndromes

The following references discuss the issues with overlap and distinctions between personality disorders (PDs) and clinical disorders, and how the former moderate the progress and prognosis of the latter. Massion, et al. 2002; Mulder 2002; and Reich 2003 describe treatment outcomes of a clinical disorder when PDs are present. Livesley, et al. 1994; Widiger 2011; and Van Dijk, et al. 2012 question the conceptual and empirical distinctions between PDs and other psychological disorders.

  • Livesley, W. John, Marsha L. Schroeder, Douglas N. Jackson, and Kerry L. Jang. 1994. Categorical distinctions in the study of personality disorder: Implications for classification. Journal of Abnormal Psychology 103.1: 6–17.

    DOI: 10.1037/0021-843X.103.1.6Save Citation »Export Citation » Share Citation »

    A theoretical review and historical retrospective on the classification of PDs, including early use of the term moral insanity to describe psychopathic personality. Examines whether PDs are distinct from each other and from normal personality and analyzes arguments for placing PDs and clinical syndromes on different axes. Available online through purchase.

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  • Massion, Ann O., Ingrid R. Dyck, M. Tracie Shea, Katharine A. Phillips, Meredith G. Warshaw, and Martin B. Keller. 2002. Personality disorders and time to remission in generalized anxiety disorder, social phobia and panic disorder. Archives of General Psychiatry 59.5: 434–440.

    DOI: 10.1001/archpsyc.59.5.434Save Citation »Export Citation » Share Citation »

    This study uses a prospective, naturalistic design to assess the moderating role of PDs on the remission rates in anxiety disorders. Unique in its long follow-up (five years) and large sample as well as assessment of remission across treatment and follow-up periods.

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  • Mulder, Roger T. 2002. Personality pathology and treatment outcome in major depression: A review. American Journal of Psychiatry 159.3: 359–371.

    DOI: 10.1176/appi.ajp.159.3.359Save Citation »Export Citation » Share Citation »

    Meta-analysis examining treatment response in major depression, looking at moderating role of temperament/personality (e.g., neuroticism) on outcomes of treatment. Although two-thirds of the studies that used a gold-standard diagnostic interview reported worse outcomes in those with PDs, studies using random assignment to treatment groups reported no difference in depression outcomes across PD and no-PD groups.

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  • Reich, James. 2003. The effect of Axis II disorders on the outcome of treatment of anxiety and unipolar depressive disorders: A review. Journal of Personality Disorders 17.5: 387–405.

    DOI: 10.1521/pedi.17.5.387.22972Save Citation »Export Citation » Share Citation »

    A qualitative review and commentary attempting to clarify disagreements in findings as to whether PDs predict outcomes of treatment for Axis I disorders. Concludes that personality pathology is a negative predictor of treatment outcome.

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  • Van Dijk, Fiona E., M. Lappenschaar, C. Kan, R. Verkes, and J. Buitelaar. 2012. Symptomatic overlap between attention-deficit/hyperactivity disorder and borderline personality disorder in women: The role of temperament and character traits. Comprehensive Psychiatry 53.1: 39–47.

    DOI: 10.1016/j.comppsych.2011.02.007Save Citation »Export Citation » Share Citation »

    This study examined the role of temperament and character traits in the differentiation of patients with similar attention-deficit/hyperactivity disorder and borderline personality disorder symptom profiles; acknowledging that there is significant symptomatic overlap between the two disorders, the authors found traits consistent with cooccurrences of attention-deficit/hyperactivity disorder and borderline personality disorder (novelty-seeking behaviors).

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  • Widiger, Thomas A. 2011. Personality and psychopathology. World Psychiatry 10.2: 103–106.

    DOI: 10.1002/j.2051-5545.2011.tb00024.xSave Citation »Export Citation » Share Citation »

    Summarizes the three theorized ways in which personality and psychopathology can be related: they can influence the presentation or appearance of one another (pathoplastic), they can share a common, underlying etiology (spectrum), or they can have a causal role in the development or etiology of one another. Considers each of these approaches in terms of their theoretical and clinical implications.

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Controversies and Problems with Personality Disorder Taxonomy

The references in the subsections Taxometric Evidence, Current Problems and Future Dimensional Directions, and Clinical Utility of Dimensional Approach discuss the debates regarding the validity and reliability of personality disorder (PD) diagnoses as well as dimensional and categorical classifications of PDs, debates ongoing in the early 21st century. The PD categories in the Diagnostic and Statistical Manual of Mental Disorders (DSM) have been plagued historically by problems of validity, reliability, and boundary distinctions. Arguments for the shift to dimensional approaches are more obvious in terms of PDs than clinical disorders, because the former are often considered maladaptive variants of normal personality traits; the debate concerning moving to more empirically supported taxonomies continues in the early 21st century (see Widiger and Trull 2007, cited under Current Problems and Future Dimensional Directions), and often takes the form of validating the alternative model included in section III of the DSM-5.

Taxometric Evidence

The following references report on the findings of specific statistical analyses used to evaluate the underlying distribution of a construct as either categorical (yes/no) or dimensional (continuous)—called taxometric analyses. Haslam 2003 supports a taxonic (categorical) structure to narcissistic personality disorder (NPD) and schizotypal PD. However, most of the evidence using cutting-edge procedures supports a dimensional structure of common forms of personality pathology, including Haslam, et al. 2011, in a meta-analysis of taxometric studies of PDs; Marcus, et al. 2006, on antisocial personality disorder (ASPD); and Arntz, et al. 2009, on Cluster C PDs.

  • Arntz, Arnoud, David Bernstein, Dominique Gielen, Myrthe van Nieuwenhuyzen, Krystle Penders, Nick Haslam, et al. 2009. Taxometric evidence for the dimensional structure of Cluster-C, paranoid, and borderline personality disorders. Journal of Personality Disorders 23.6: 606–628.

    DOI: 10.1521/pedi.2009.23.6.606Save Citation »Export Citation » Share Citation »

    A large clinical population was used to consider whether Cluster C PDs are usefully thought of as taxonic. After conducting taxometric analyses, results indicated that all three Cluster C PDs—as well as two other PDs—should be conceptualized dimensionally rather than categorically.

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  • Haslam, Nick. 2003. The dimensional view of personality disorders: A review of taxometric evidence. Clinical Psychology Review 23.1: 75–93.

    DOI: 10.1016/S0272-7358(02)00208-8Save Citation »Export Citation » Share Citation »

    Reviews taxometric evidence for three PDs (schizotypal, borderline, and antisocial), all of which support a taxonic view of these disorders. Available online through purchase.

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  • Haslam, Nick, E. Holland, and P. Kuppens. 2011. Categories versus dimensions in personality and psychopathology: A quantitative review of taxometric research. Psychological Medicine 42.5: 903–920.

    DOI: 10.1017/S0033291711001966Save Citation »Export Citation » Share Citation »

    This reference provides a thorough review of published taxometric research across all DSM-IV-TR disorders (177 articles); although 38.9 percent of findings were taxonic, these were far less prevalent among more recent and methodologically stronger studies. This review suggests that most personality disorders are dimensional in nature, and early influential taxonic findings are likely to have been spurious.

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  • Marcus, David K., Scott O. Lilienfeld, John F. Edens, and Norman G. Poythress. 2006. Is antisocial personality disorder continuous or categorical? A taxometric analysis. Psychological Medicine 36.11: 1571–1581.

    DOI: 10.1017/S0033291706008245Save Citation »Export Citation » Share Citation »

    Using a large sample (N = 1146) of male offenders, the structure of ASPD was found to be dimensional, regardless of whether symptoms are assessed through structured diagnostic interviews or self-report questionnaires.

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Current Problems and Future Dimensional Directions

The classic articles Widiger and Frances 1985 and Grove and Tellegen 1991 provide recommendations for PD research and revising the diagnostic criteria of PDs. Widiger and Trull 2007 and Clark 2007 offer a broad perspective on problems with early-21st-century taxonomies and review debates regarding moving to a more dimensional system. Widiger 2011 expresses frustration with the decision to retain a categorical diagnostic model in the DSM-5, while Dell-Osso, et al. 2010 and O’Connor 2002 report further evidence for the dimensionality of early-21st-century measures of PD pathology.

  • Clark, Lee Anna. 2007. Assessment and diagnosis of personality disorder: Perennial issues and an emerging reconceptualization. Annual Review of Psychology 58:227–257.

    DOI: 10.1146/annurev.psych.57.102904.190200Save Citation »Export Citation » Share Citation »

    Reviews problems regarding the assessment and diagnosis of PDs, suggests certain assessment approaches and measures that can replace the current DSM system, and proposes an assessment model of PDs that would distinguish acute symptoms/dysfunction from basic temperament (the latter being the stable part of PDs).

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  • Dell’Osso, Bernardo, H. Berlin, M. Serati, and A. Altamura. 2010. Neuropsychobiological aspects, comorbidity patterns and dimensional models in borderline personality disorder. Neuropsychobiology 61.4: 169–179.

    DOI: 10.1159/000297734Save Citation »Export Citation » Share Citation »

    Reviews the updated literature on the main neuropsychobiological aspects of borderline personality disorder and their relation to clinical symptoms, comorbidity patterns, and dimensional models. Specifically, the authors link borderline personality disorder to several dimensional conceptualizations of personality disorder (addictive spectrum, affective spectrum, obsessive-compulsive spectrum, and trauma spectrum disorders).

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  • Grove, William M., and Auke Tellegen. 1991. Problems in the classification of personality disorders. Journal of Personality Disorders 5.1: 31–41.

    DOI: 10.1521/pedi.1991.5.1.31Save Citation »Export Citation » Share Citation »

    Authors urge PD researchers to focus on “basic” PD questions (as opposed to more-applied questions), to incorporate normal personality research findings into their work, and to use appropriate statistics. The use of self- and informant-report PD measures is encouraged, so that researchers can examine agreement/discrepancies from different sources.

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  • O’Connor, Brian P. 2002. The search for dimensional structure differences between normality and abnormality: A statistical review of published data on personality and psychopathology. Journal of Personality and Social Psychology 83.4: 962–982.

    DOI: 10.1037/0022-3514.83.4.962Save Citation »Export Citation » Share Citation »

    Examined the factor structure of measures of normal personality or psychopathology between clinical and nonclinical samples. Analyses of inventories of normal personality versus psychopathology yielded a similar number of dimensions both in clinical and nonclinical samples.

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  • Widiger, Thomas A. 2011. The DSM-5 dimensional model of personality disorder: Rationale and empirical support. Journal of Personality Disorders 25.2: 222–234.

    DOI: 10.1521/pedi.2011.25.2.222Save Citation »Export Citation » Share Citation »

    In this somewhat heated article, Widiger expresses frustration at the DSM-5 Work Group’s proposal to construct a cumbersome six-dimensional model of personality disorder that excludes normative personality traits, is inconsistent with the research on the dimensionality of PDs, and is thoroughly distinguished from the predominantly agreed-upon dimensional model of personality structure; furthermore, it was not even included in the main diagnostic section II, but relegated to section III as a model requiring further research. Future directions for revisions to the DSM are discussed.

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  • Widiger, Thomas A., and Allen Frances. 1985. The DSM-III personality disorders: Perspectives from psychology. Archives of General Psychiatry 42.6: 615–623.

    DOI: 10.1001/archpsyc.1985.01790290097011Save Citation »Export Citation » Share Citation »

    Provides recommendations for revising Axis II of the DSM-III, which include adopting the prototypal model of categorization, using behavioral indicators of personality traits, identifying prototypic acts, specifying behaviors necessary for aggregation across time/situations, adopting a dimensional model of classification, and revising the diagnostic criteria to include the interpersonal circumplex. Available online through purchase.

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  • Widiger, Thomas A., and Timothy J. Trull. 2007. Plate tectonics in the classification of personality disorder: Shifting to a dimensional model. American Psychologist 62.2: 71–83.

    DOI: 10.1037/0003-066X.62.2.71Save Citation »Export Citation » Share Citation »

    Reviews limitations of DSM-IV classification system (e.g., excessive cooccurrence across PDs, unclear diagnostic boundaries, limited research base). Argues for shifting to dimensional classification of PDs, in particular, for the five-factor model of personality, which would allow for coverage of a range of maladaptive personality functioning. Available online through purchase.

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Clinical Utility of Dimensional Approach

Some authors are trying to address concerns about the clinical utility of moving to a dimensional classification system and whether normal personality dimensions can capture all facets of pathological personality. Skodol, et al. 2005 provides evidence that dimensional representations of DSM-IV PDs can capture functional impairment. Verheul 2005 argues for the clinical utility of dimensional approaches, and Samuel and Widiger 2006 reports on empirical evidence for the utility of a personality-based approach to PDs, relative to the DSM-IV system. More recently, Zimmerman, et al. 2012 found that low-severity levels of borderline personality disorder can be detected reliably, substantiating the clinical utility of dimensional personality models.

  • Samuel, Douglas B., and Thomas A. Widiger. 2006. Clinicians’ judgments of clinical utility: A comparison of the DSM-IV and five-factor models. Journal of Abnormal Psychology 115.2: 298–308.

    DOI: 10.1037/0021-843X.115.2.298Save Citation »Export Citation » Share Citation »

    Assessed clinical utility of both the five-factor model (FFM) and the DSM criteria of PDs. Experienced psychologists rate the FFM approach as having better clinical utility than the DSM categories (e.g., easier to apply the system, better for communicating with client and other professionals). Available online through purchase.

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  • Skodol, Andrew E., John M. Oldham, Donna S. Bender, Ingrid R. Dyck, Robert L. Stout, Leslie C. Morey, et al. 2005. Dimensional representations of DSM-IV personality disorders: Relationships to functional impairment. American Journal of Psychiatry 162.10: 1919–1925.

    DOI: 10.1176/appi.ajp.162.10.1919Save Citation »Export Citation » Share Citation »

    Assessed clinical utility in regard to whether the DSM-IV system of PDs captures variance in functional impairment. Found that dimensional representations of the DSM-IV PDs were more predictive of functional impairment in social or occupational domains, compared with scores on inventories of general personality functioning. Supports the clinical use of dimensional representations of the DSM-IV PDs.

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  • Verheul, Roel. 2005. Clinical utility of dimensional models for personality pathology. Journal of Personality Disorders 19.3: 283–302.

    DOI: 10.1521/pedi.2005.19.3.283Save Citation »Export Citation » Share Citation »

    Argues that dimensional measurements of PDs can be more clinically useful than the DSM-IV categories, including in regard to validity and clinical utility. Contends that arguments of clinical utility should not impede changes in future versions of the DSM, but that categorical decisions will need to be maintained for other reasons (e.g., communication with insurance companies).

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  • Zimmerman, Mark, I. Chelminski, D. Young, K. Dalrymple, and J. Martinez. 2012. Does the presence of one feature of borderline personality disorder have clinical significance? Implications for dimensional ratings of personality disorders. Journal of Clinical Psychiatry 73.1: 8–12.

    DOI: 10.4088/JCP.10m06784Save Citation »Export Citation » Share Citation »

    The authors evaluated 3,200 psychiatric outpatients with semistructured interviews for DSM-IV Axis I and II disorders, using the 1,976 patients meeting only 0 or 1 DSM-IV criterion for borderline personality disorder. They found that the reliability of determining if a patient was rated with 0 or 1 criterion for borderline personality disorder was good (Kappa index = 0.70). They surmised that these findings suggest a clinical justification for using dimensional models of personality disorders for diagnostic purposes (meeting even 1 criterion, versus no criterion, was significantly more associated with clinical disorders, suicide attempts/ideation, etc.).

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Etiological Processes in Personality Disorder Clusters

Although the scientific study of certain personality disorders (PDs), especially borderline and antisocial, has blossomed since the 1980s, empirical studies on other PDs are rare. The references that follow represent reviews and empirical papers elaborating on risk factors or etiological processes associated with each of the PD clusters for which evidence exists in the literature.

Cluster A Personality Disorders

Cluster A PDs (the “odd, eccentric” cluster) include paranoid, schizoid, and schizotypal PDs. Surprisingly, there is a dearth of texts or research on Cluster A PDs. Most research on Cluster A disorders has focused on schizotypal PD, which is because of the strong association that has been established among schizotypal PD, schizotypy as a precursor to schizophrenia, and schizophrenia-spectrum disorders (Chemerinski, et al. 2013; Esterberg, et al. 2010; Lener, et al. 2014; Raine, et al. 2007). Indeed, Raine 2006 argues that schizotypal personality research promises “critically important insights into the etiology and ultimate prevention of schizophrenia” (p. 291). Despite this, Cluster A “schizophrenia-related personality disorders” are presumed to share similar characteristics and genetic and environmental risk factors (Cohen, et al. 2010; Esterberg, et al. 2010), including childhood neglect (Lenzenweger 2010; Natsuaki, et al. 2009).

  • Chemerinski, E., J. Triebwasser, P. Roussos, and L. J. Siever. 2013. Schizotypal personality disorder. Journal of Personality Disorders 27.5: 652–679.

    DOI: 10.1521/pedi_2012_26_053Save Citation »Export Citation » Share Citation »

    Results of this study indicated that patients with schizotypal personality disorder and those with severe chronic schizophrenia share similar deficits in areas such as cognition and attention, potentially because of similar neurodevelopmental processes. However, it has been shown that schizotypal patients are not as badly affected by these deficits, and tend to be more resistant to psychosis as well.

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  • Cohen, Alex S., Lindsay C. Emmerson, Monica C. Mann, Courtney B. Forbes, and Jack J. Blanchard. 2010. Schizotypal, schizoid and paranoid characteristics in the biological parents of social anhedonics. Psychiatry Research 178.1: 79–83.

    DOI: 10.1016/j.psychres.2008.07.018Save Citation »Export Citation » Share Citation »

    Results show that the biological parents of socially anhedonic probands had elevated rates of Cluster A PDs compared with the parents of control probands. These findings support the hypothesis that social anhedonia is a marker of genetic vulnerability to Cluster A PDs.

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  • Esterberg, Michelle L., Sandra M. Goulding, and Elaine F. Walker. 2010. Cluster A personality disorders: Schizotypal, schizoid and paranoid personality disorders in childhood and adolescence. In Special section: Measurement and assessment of child and adolescent personality pathology. Edited by Jennifer L. Tackett. Journal of Psychopathology and Behavioral Assessment 32.4: 515–528.

    DOI: 10.1007/s10862-010-9183-8Save Citation »Export Citation » Share Citation »

    Excellent review of the limited literature on Cluster A PDs in childhood and adolescence (although controversy remains regarding the diagnosis of PDs in general in youth). The authors discuss differential diagnosis for Cluster A PDs, how to measure Cluster A disorders in youth, and the development and course of these disorders. Available online through purchase.

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  • Lener, M. S., E. Wong, C. Y. Tang, et al. 2014. White matter abnormalities in schizophrenia and schizotypal personality disorder. Schizophrenia Bulletin 41.1: 300–310.

    DOI: 10.1093/schbul/sbu093Save Citation »Export Citation » Share Citation »

    Results of this study indicated that both schizotypal personality disorder and schizophrenia patients have white matter abnormalities in frontotemporal regions of the brain. More specifically, schizophrenia patients displayed greater disruption of white matter connectivity in the temporal lobe and cingulum regions, and schizotypal patients displayed greater disruption of white matter connectivity in the corpus callosum. It was concluded that overall, white matter dysconnectivity (associated with onset of psychosis) is less severe in schizotypal personality disorder, and this may provide and explanation for the decreased intensity of psychosis in schizotypal patients.

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  • Lenzenweger, M. F. 2010. A source, a cascade, a schizoid: A heuristic proposal from The Longitudinal Study of Personality Disorders. In Special issue: Developmental cascades: Part 2. Edited by Ann S. Masten and Dante Cicchetti. Development and Psychopathology 22.4: 867–881.

    DOI: 10.1017/S0954579410000519Save Citation »Export Citation » Share Citation »

    Suggests that the absence of an early childhood relationship characterized by a rich degree of psychological proximal process predicts impairment in the actualization of the affiliation system (which is under substantial genetic influence). This affiliation system impairment later predicts schizoid PD symptoms in emerging adulthood.

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  • Natsuaki, Mitsaki. N., Dante Cicchetti, and Fred A. Rogosch. 2009. Examining the developmental history of child maltreatment, peer relations, and externalizing problems among adolescents with symptoms of paranoid personality disorder. Development and Psychopathology 21.4: 1181–1193.

    DOI: 10.1017/S0954579409990101Save Citation »Export Citation » Share Citation »

    Findings suggest that children who manifested elevated paranoid PD symptoms in adolescence were more likely to have a history of childhood maltreatment. Additionally, children who manifested elevated paranoid PD symptoms in adolescence displayed a faster growth rate for peer bullying and externalizing problems in childhood.

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  • Raine, Adrian. 2006. Schizotypal personality: Neurodevelopmental and psychosocial trajectories. Annual Review of Clinical Psychology 2:291–326.

    DOI: 10.1146/annurev.clinpsy.2.022305.095318Save Citation »Export Citation » Share Citation »

    Argues that genetic and early environmental factors act together to alter brain structure and function throughout development, which results in disturbances to basic cognitive and affective processes that give rise to the three building blocks of schizotypy: cognitive-perceptual, interpersonal, and disorganized features. Neurodevelopmental schizotypy and pseudoschizotypy are also discussed. Available online through purchase.

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  • Raine, Adrian, Todd Lencz, and Sarnoff A. Mednick, eds. 2007. Schizotypal personality. Cambridge, UK, and New York: Cambridge Univ. Press. Provides a comprehensive overview of schizotypal PD.

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    Describes family genetic research, neurodevelopment (e.g., schizotypal PD characteristics associated with second-trimester disturbances of neural development), assessment (e.g., schizotypal status as a developmental stage of risk for schizophrenia), categorical versus dimensional approaches, psychophysiology, psychopharmacology, neuropsychology, and neuroscience of schizotypal PD.

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Cluster B Personality Disorders

Referred to as the erratic and dramatic cluster, Cluster B includes Borderline Personality Disorder (BPD), Antisocial Personality Disorder (ASPD), Narcissistic Personality Disorder (NPD), and Histrionic Personality Disorder (HPD). As is evident from the references cited in those subsections, most of the research on Cluster B has focused on BPD and ASPD, since individuals with these two disorders highly populate community mental health and forensic settings, respectively.

Borderline Personality Disorder

The references cited here highlight two of the most studied etiological processes in BPD. In particular, Bornovalova, et al. 2013 and Bradley, et al. 2005 address the role of childhood history of maltreatment in understandings of BPD. Brain-functioning abnormalities in emotion and cognitive control systems are addressed in other articles, with Hazlett, et al. 2007 looking at affective abnormalities and Posner, et al. 2002 covering cognitive system functioning. Brendel, et al. 2005 and Krause-Utz, et al. 2014 summarize neuroimaging evidence for several abnormalities in brain systems governing emotional and behavioral control in BPD.

Antisocial Personality Disorder

The study of antisocial syndromes spans many decades (Cloninger, et al. 1978). More-recent focus on ASPD is on its overlap with other the externalizing spectrum disorders, a group of related syndromes marked by impulsivity, which include ASPD, childhood conduct problems, and substance use (Iacono and Malone 2011; Krueger, et al. 2002). Other studies discuss distinctions between ASPD and psychopathy (Venables, et al. 2014), genetic and environmental influences (Burt, et al. 2007; Checknita, et al. 2015), and brain abnormalities related to the prefrontal cortex in ASPD (Barkataki, et al. 2006).

  • Barkataki, Ian, Veena Kumari, Mrigendra Das, Pamela Taylor, and Tonmoy Sharma. 2006. Volumetric structural brain abnormalities in men with schizophrenia or antisocial personality disorder. Behavioural Brain Research 169.2: 239–247.

    DOI: 10.1016/j.bbr.2006.01.009Save Citation »Export Citation » Share Citation »

    Structural abnormalities in temporal brain regions, but not prefrontal areas, were observed in ASPD but not in schizophrenia. There was some overlap in brain abnormalities across ASPD and schizophrenia, including increases in putamen volume, especially when both syndromes involve violence. Available online through purchase.

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  • Burt, S. Alexandra, Matt McGue, Latanya A. Carter, and William G. Iacono. 2007. The different origins of stability and change in antisocial personality disorder symptoms. Psychological Medicine 37.1: 27–38.

    DOI: 10.1017/S0033291706009020Save Citation »Export Citation » Share Citation »

    Biometric analyses of twin data revealed that genetic factors account for stability of antisocial symptoms from adolescence to adulthood, and environmental influences account for changes in symptoms across this period.

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  • Checknita, D., et al. 2015. Monoamine oxidase A gene promoter methylation and transcriptional downregulation in an offender population with antisocial personality disorder. The British Journal of Psychiatry 206.3: 216–222.

    DOI: 10.1192/bjp.bp.114.144964Save Citation »Export Citation » Share Citation »

    Aimed at understanding the role of the monoamine oxidase A (MAOA) gene in regulating serotonin in an offender population with ASPD, compared with a healthy non-incarcerated control population. Results indicate that an epigenetically altered MAOA promoter in those predisposed to ASPD may contribute to a downregulation of MAO activity, which leads to serotonin dysregulation in ASPD sufferers.

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  • Cloninger, C. Robert, Karl O. Christiansen, Theordore Reich, and Irving I. Gottesman. 1978. Implications of sex differences in the prevalences of antisocial personality, alcoholism, and criminality for familial transmission. Archives of General Psychiatry 35.8: 941–951.

    DOI: 10.1001/archpsyc.1978.01770320035002Save Citation »Export Citation » Share Citation »

    Reports on various models to account for sex differences in the prevalence of antisocial syndromes, with familial and nonfamilial models best representing sex differences in antisocial personality and alcoholism, respectively. Gender roles seem to suppress the manifestation of antisocial personality in women with genetic liability. Available online through purchase.

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  • Iacono, William G., and Stephen M. Malone. 2011. Developmental endophenotypes: Indexing genetic risk for substance abuse with the P300 brain event-related potential. Child Development Perspectives 5.4: 239–247.

    DOI: 10.1111/j.1750-8606.2011.00205.xSave Citation »Export Citation » Share Citation »

    This review article provides a detailed overview of how the brain P300 response serves as an index of genetic risk for substance abuse and related externalizing disorders. The P300 response is highly heritable and broadly associated with characteristics of externalizing disorder, including disruptive behaviors in childhood and later antisociality. Additionally, findings show that P300 developmental trajectories may be highly informative as measures of genetic risk for antisocial behavior in adulthood.

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  • Krueger, Robert F., Brian M. Hicks, Christopher J. Patrick, Scott R. Carlson, William G. Iacono, and Matt McGue. 2002. Etiologic connections among substance dependence, antisocial behavior, and personality: Modeling the externalizing spectrum. Journal of Abnormal Psychology 111.3: 411–424.

    DOI: 10.1037/0021-843X.111.3.411Save Citation »Export Citation » Share Citation »

    Conceptualizes antisocial personality symptoms as part of a broader dimension of externalizing vulnerability, with the common variance shared by substance dependence, antisocial personality, and disinhibited personality traits being highly heritable. Available online through purchase.

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  • Venables, N. C., J. R. Hall, and C. J. Patrick. 2014. Differentiating psychopathy from antisocial personality disorder: A triarchic model perspective. Psychological Medicine 44.5: 1005–1013.

    DOI: 10.1017/S003329171300161XSave Citation »Export Citation » Share Citation »

    This study used the triarchic theory of psychopathy to clarify the boundaries between psychopathy and ASPD, two highly related yet distinct personality constructs. Authors found that boldness (fearless dominance) contributed incrementally (above disinhibition and meanness) to prediction of psychopathy (particularly interpersonal traits) but not ASPD. Results suggest that bold interpersonal competence is central to diagnostic conceptions of psychopathy and serves to distinguish psychopathy from ASPD, a more behaviorally based disorder.

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Narcissistic Personality Disorder

The literature on NPD tends to be theoretical rather than empirical, with a few exceptions. For example, Caligor, et al. 2015 addresses refinements in diagnostic criteria and subtypes of NPD. Sylvers, et al. 2008 describes a distinct psychophysiological profile for NPD, relative to ASPD, and Schoenleber, et al. 2011 presents evidence for overlaps in facets of NPD and psychopathic personality. Most of the empirical advances in the area of narcissism have come from research in the personality literature, with Morf and Rhodewalt 2001 providing a theoretical framework for understanding vulnerable and grandiose traits in narcissism, and Konrath, et al. 2006 examining links between grandiose traits and aggression propensity.

  • Caligor, Eve, Kenneth N. Levy, and Frank E. Yeomans. 2015. Narcissistic personality disorder: Diagnostic and clinical challenges. American Journal of Psychiatry 172.5: 415–422.

    DOI: 10.1176/appi.ajp.2014.14060723Save Citation »Export Citation » Share Citation »

    Provides a current overview of the diagnostic and clinical challenges present when treating an individual with NPD. Covers definitions, core psychological features, and the subtypes of narcissism (grandiose, vulnerable, and high-functioning).

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  • Konrath, Sara, Brad J. Bushman, and W. Keith Campbell. 2006. Attenuating the link between threatened egotism and aggression. Psychological Science 17.11: 995–1001.

    DOI: 10.1111/j.1467-9280.2006.01818.xSave Citation »Export Citation » Share Citation »

    Across two experiments, showed that individuals high on narcissistic traits reduced the level of aggression they enacted toward a provocateur when the narcissists believed they had something in common with the target of their aggression. Implications relate to strategies for reducing ego-threat aggression by building connections between adversaries (e.g., empathy).

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  • Morf, Carolyn C., and Frederick Rhodewalt. 2001. Unraveling the paradoxes of narcissism: A dynamic self-regulatory processing model. Psychological Inquiry 12.4: 177–196.

    DOI: 10.1207/S15327965PLI1204_1Save Citation »Export Citation » Share Citation »

    Theoretical paper that attempts to reconcile the grandiose and vulnerable symptoms of narcissism into one self-regulatory model, underscoring the notion that the interpersonal behaviors of narcissists are pursued to maintain their desired self-identities.

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  • Schoenleber, Michelle, Naomi Sadeh, and Edelyn Verona. 2011. Parallel syndromes: Two dimensions of narcissism and the facets of psychopathic personality in criminally involved individuals. Personality Disorders: Theory, Research, and Treatment 2.2: 113–127.

    DOI: 10.1037/a0021870Save Citation »Export Citation » Share Citation »

    Provided further validity of distinctions between grandiose and vulnerable subtypes of narcissistic traits in a clinical-forensic sample via associations with different facets of psychopathy and external criteria. Finds that vulnerable narcissism is associated with more-impulsive/antisocial traits and psychopathology, whereas grandiose narcissism related to a deceitful interpersonal style and unprovoked aggression. Available online through purchase.

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  • Sylvers, Patrick, Nicholas Brubaker, S. Amanda Alden, Patricia A. Brennan, and Scott O. Lilienfeld. 2008. Differential endophenotypic markers of narcissistic and antisocial personality features: A psychophysiological investigation. Journal of Research in Personality 42.5: 1260–1270.

    DOI: 10.1016/j.jrp.2008.03.010Save Citation »Export Citation » Share Citation »

    Presents evidence of different psychophysiological profiles for ASPD and NPD symptoms assessed in college students. Antisocial features were related to decreased skin conductance and heightened cardiac response to threat, but narcissistic features were related only to negative responses to happy stimuli. Available online through purchase.

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Histrionic Personality Disorder

Empirical work on HPD is rare, with existing work (most of which is not recent) focusing on sexual behaviors (Apt and Hurlbert 1994), epidemiology (Nestadt, et al. 1990), and relationship to Big Five personality traits (Furnham 2014) and ASPD (Cale and Lilienfeld 2002). Empirical research on etiology of HPD is not available as of the early 21st century.

  • Apt, Carol, and David Farley Hurlbert. 1994. The sexual attitudes, behavior, and relationships of women with histrionic personality disorder. Journal of Sex and Marital Therapy 20.2: 125–133.

    DOI: 10.1080/00926239408403423Save Citation »Export Citation » Share Citation »

    Given the sexualized descriptions of HPD, the study compared the sexual attitudes and behaviors among women recruited from a marital enrichment workshop for military families, who either had HPD or did not have this diagnosis. The former group showed more sexual dysfunction and preoccupation, and, surprisingly, less assertiveness in regard to sex.

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  • Cale, Ellison M., and Scott O. Lilienfeld. 2002. Histrionic personality disorder and antisocial personality disorder: Sex-differentiated manifestations of psychopathy? Journal of Personality Disorders 16.1: 52–72.

    DOI: 10.1521/pedi.16.1.52.22557Save Citation »Export Citation » Share Citation »

    Showed that HPD and antisocial personality features are moderately related. However, despite previous theory and evidence indicating that HPD and antisocial personality may be sex-differentiated manifestations of psychopathy, results did not consistently replicate such assertions.

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  • Furnham, A. 2014. A bright side, facet analysis of histrionic personality disorder: The relationship between the HDS colourful factor and the NEO-PI-R facets in a large adult sample. The Journal of Social Psychology 154.6: 527–536.

    DOI: 10.1080/00224545.2014.953026Save Citation »Export Citation » Share Citation »

    This study validated previous findings on HPD and the Big Five personality traits using a large sample size (N = 5,000) and a novel measure of HPD (Hogan’s Development Survey), showing that personality traits are predictably correlated with key personality disorders. They found that HPD individuals tend to be high on Extraversion and Openness but also Stable and Disagreeable. At the Facet level, it was observed that these individuals tend to also be Assertive and Immodest.

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  • Nestadt, G., A. J. Romanoski, R. Chahal, A. Merchant, M. F. Folstein, E. M. Gruenberg, et al. 1990. An epidemiological study of histrionic personality disorder. Psychological Medicine 20.2: 413–422.

    DOI: 10.1017/S0033291700017724Save Citation »Export Citation » Share Citation »

    Found 2 percent rates of HPD in the population, with equal prevalence in men and women (despite previous claims of sex specificity). The clinical picture associated with HPD in this community sample, involving interpersonal dysfunction, depression, and medical concerns, substantiates the validity of the diagnosis.

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Cluster C Personality Disorders

Cluster C PDs—avoidant, dependent, and obsessive-compulsive PDs—have been termed the anxious, fearful disorders. Summarized in this section are some of the limited existing resources that focus on Cluster C PDs. Although the three Cluster C PDs are distinct diagnoses, research suggests that they likely share a common latent dimension (Fossati, et al. 2006); thus, there is support for their inclusion in the same PD cluster. However, other research suggests that these disorders are distinguishable, because there appear to be relative differences in heritability (Reichborn-Kjennerud, et al. 2007). In addition, Eskedal and Demetri 2006 also addresses the etiology and maintenance of Cluster C PDs more broadly, with a discussion of different treatment approaches; Isomura, et al. 2015 discusses familial risk and heritability of avoidant personality disorder compared to social anxiety disorder. Other research has considered the impact of emotion-related constructs in Cluster C PDs, suggesting that their development and maintenance may be strongly influenced by particular emotions (Schoenleber and Berenbaum 2010; Steenkamp, et al. 2015). Speaking to broader issues in personality pathology, Viinamäki, et al. 2003 demonstrated that the presence of Cluster C PDs had a detrimental influence on treatment outcomes among individuals with major depressive disorder.

  • Eskedal, Glen A., and Jamie M. Demetri. 2006. Etiology and treatment of Cluster C personality disorders. Journal of Mental Health Counseling 28.1: 1–17.

    DOI: 10.17744/mehc.28.1.7yjq6tabcexb1a6jSave Citation »Export Citation » Share Citation »

    Describes the biological predispositions, environmental influences, and self-maintenance functions of avoidant, dependent, and obsessive-compulsive PDs. Provides an overview of how cognitive-behavioral, group, and psychodynamic approaches might be used for treating each Cluster C PD.

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  • Fossati, Andrea, Theodore P. Beauchaine, Federica Grazioli, Serena Borroni, Ilaria Carretta, Carola De Vecchi, et al. 2006. Confirmatory factor analyses of DSM-IV Cluster C personality disorder criteria. Journal of Personality Disorders 20.2: 186–203.

    DOI: 10.1521/pedi.2006.20.2.186Save Citation »Export Citation » Share Citation »

    Results of a factor analysis support the DSM-IV Cluster C PD criteria; in other words, avoidant, dependent, and obsessive-compulsive PDs share a common latent dimension. However, these three dissociable PDs should be considered as distinct diagnoses along a common latent continuum.

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  • Isomura, K., M. Boman, C. Rück, et al. 2015. Population-based, multi-generational family clustering study of social anxiety disorder and avoidant personality disorder. Psychological Medicine 45.8: 1581–1589.

    DOI: 10.1017/S0033291714002116Save Citation »Export Citation » Share Citation »

    This study aimed to provide unbiased estimates of familial risk and heritability of social anxiety disorder and avoidant personality disorder. Overall, the authors found that social anxiety disorder clusters in families primarily due to genetic factors; they also found that social anxiety disorder and avoidant personality disorder are etiologically related and may represent different expressions of the same vulnerability. Interestingly, they also found strong marital concordance in avoidant personality disorder, meaning that these individuals tend to mate with one another.

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  • Reichborn-Kjennerud, Ted, Nikolai Czajkowski, Michael C. Neale, Ragnhild E. Ørstavik, Svenn Torgersen, Kristian Tambs, et al. 2007. Genetic and environmental influences on dimensional representations of DSM-IV Cluster C personality disorders: A population-based multivariate twin study. Psychological Medicine 37.5: 645–653.

    DOI: 10.1017/S0033291706009548Save Citation »Export Citation » Share Citation »

    Results suggest that Cluster C PDs are moderately heritable; common genetic and individual environmental factors explained a substantial proportion of the variance in avoidant and dependent PDs. However, obsessive-compulsive PD was found to be etiologically distinct.

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  • Schoenleber, Michelle, and Howard Berenbaum. 2010. Shame aversion and shame-proneness in Cluster C personality disorders. Journal of Abnormal Psychology 119.1: 197–205.

    DOI: 10.1037/a0017982Save Citation »Export Citation » Share Citation »

    Hypothesizing that shame is particularly important, study showed that shame aversion and shame-proneness predicted Cluster C PDs over and above trait positive and negative affect. Importantly, shame-proneness significantly predicted these disorders only when shame aversion was elevated. Results also suggest a role for implicit shame–pain memory associations in dependent PD.

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  • Steenkamp, Maria M., Michael K. Suvak, Benjamin D. Dickstein, M. Tracie Shea, and Brett T. Litz. 2015. Emotional functioning in obsessive-compulsive personality disorder: Comparison to borderline personality disorder and healthy controls. Journal of Personality Disorders 29.6: 794–808.

    DOI: 10.1521/pedi_2014_28_174Save Citation »Export Citation » Share Citation »

    Compared to healthy controls, participants with obsessive-compulsive personality disorder reported significantly higher levels of negative affectivity, anger, emotional intensity, and emotion regulation difficulties. When compared to borderline personality disorder, obsessive-compulsive personality disorder participants scored generally lower on these emotional dimentions (placing them between borderline and healthy controls) and were similar to borderline personality disorder on only one variable: problems with goal-directed behavior when upset. Results suggest that obsessive-compulsive personality disorder may be characterized by notable difficulties in several emotional domains, relative to healthy controls.

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  • Viinamäki, H., A. Tanskanen, H. Koivumaa-Honkanen, K. Haatainen, K. Honkalampi, R. Antikainen, et al. 2003. Cluster C personality disorder and recovery from major depression: 24-month prospective follow-up. Journal of Personality Disorders 17.4: 341–350.

    DOI: 10.1521/pedi.17.4.341.23971Save Citation »Export Citation » Share Citation »

    Compared clients with major depressive disorder (MDD) with those with MDD and a Cluster C PD. Results indicated that treatment outcomes were poorer for individuals with comorbid diagnoses. The additional presence of Cluster C symptoms decreased the likelihood of successful sustained remission of MDD symptoms following treatment.

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Psychopathic Personality Disorder

Psychopathy (“psychopathic personality”) is a PD composed of several maladaptive personality traits (e.g., interpersonal and affective deficits, superficial charm, lack of empathy, impulsivity, antisocial lifestyle). Although the diagnosis is not included in the DSM, it has garnered substantial research attention. Studies on etiology have focused on emotional and cognitive deficits associated with psychopathy (Newman, et al. 2010; Patrick, et al. 1993; Sadeh and Verona 2012). The early-21st-century clinical conceptualization of psychopathy is credited to Cleckley’s seminal case studies in The Mask of Sanity (Cleckley 1982; originally published in 1941); however, the empirical conceptualization is often credited to the widespread use of the four-factor (previously two-factor) Hare Psychopathy Checklist—Revised (Hare 1991 work is “The Hare Psychopathy Checklist—Revised: Manual” by Robert Hare.” North Tonawanda, NY: Multi-Health Systems; see Hare and Neumann 2008). Nevertheless, there have been several proposed theoretical models of psychopathy (Patrick 2006), including a triarchic conceptualization (Patrick, et al. 2009), which provides a framework for the neurobiological and developmental processes that contribute to different manifestations of psychopathy (Blonigen, et al. 2005). Although there are varying conceptualizations of psychopathy, Crego and Widiger 2014 notes that the measures that assess psychopathy from these different perspectives have high convergent validity on overlapping items and good discriminant validity on their differing aspects. Furthermore, Lilienfeld, et al. 2012 discusses the potentially adaptive nature of the psychopathy construct and the notion of “successful” psychopathy. Finally, although psychopathy is not recognized as a PD in the DSM-5, it is included as a specifier to ASPD in section III of the manual; Crego and Widiger 2014 discusses this addition and the implications of including fearlessness, boldness, and invulnerability into the conceptualization in terms of convergence across measures of psychopathy.

  • Blonigen, Daniel M., Brian M. Hicks, Robert F. Krueger, Christopher J. Patrick, and William G. Iacono. 2005. Psychopathic personality traits: Heritability and genetic overlap with internalizing and externalizing psychopathology. Psychological Medicine 35.5: 637–648.

    DOI: 10.1017/S0033291704004180Save Citation »Export Citation » Share Citation »

    The results of a twin study suggest a genetic influence on the psychopathic traits of fearless dominance and impulsive antisociality, as measured by the Multidimensional Personality Questionnaire. Fearless dominance was associated with reduced genetic risk for internalizing psychopathology, and impulsive antisociality was associated with increased genetic risk for externalizing psychopathology.

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  • Cleckley, Hervey. 1982. The mask of sanity. Rev. ed. Mosby Medical Library. St. Louis, MO: Mosby.

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    Originally published in 1941. Unquestionably the most influential work on psychopathy; often cited as the basis for modern conceptualizations and measures of psychopathy. Through descriptions of his clinical interviews with institutionalized psychopathic individuals, Cleckley argues that individuals with psychopathy have severe underlying pathology “masked” by an outward appearance of a normally functioning individual.

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  • Crego, Cristina, and Thomas A. Widiger. 2014. Psychopathy, DSM-5, and a caution. Personality Disorders: Theory, Research, and Treatment 5.4: 335–347.

    DOI: 10.1037/per0000078Save Citation »Export Citation » Share Citation »

    In response to the inclusion of the triarchic conceptualization of psychopathy as a specifier to antisocial personality disorder in section III of the DSM-5, this study sought to test the convergent and discriminant validity of the Psychopathic Personality Inventory—Revised (PPI-R), the Triarchic Psychopathy Measure (TriPM), the Elemental Psychopathy Assessment (EPA), and the Personality Inventory for DSM-5 (PID-5) with respect to their relationships with one another and with traditional measures of psychopathy and ASPD. Results indicated good convergent and discriminant validity across measures, but the authors caution against reliance on reverse-coded items for the assessment of components of psychopathy.

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  • Hare, Robert D., and Craig S. Neumann. 2008. Psychopathy as a clinical and empirical construct. Annual Review of Clinical Psychology 4:217–246.

    DOI: 10.1146/annurev.clinpsy.3.022806.091452Save Citation »Export Citation » Share Citation »

    Argues that although early-21st-century conceptualizations of psychopathy have “drifted” from the clinical profiles of Cleckley 1982, they are better informed by empirical research on the integration of structural, genetic, developmental, personality, and neurobiological research findings than by rigid adherence to early clinical conceptualizations.

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  • Lilienfeld, Scott O., I. D. Waldman, K. Landfield, A. L. Watts, S. Rubenzer, and T. R. Faschingbauer. 2012. Fearless dominance and the U.S. presidency: Implications of psychopathic personality traits for successful and unsuccessful political leadership. Journal of Personality and Social Psychology 103.3: 489–505.

    DOI: 10.1037/a0029392Save Citation »Export Citation » Share Citation »

    This study looked at psychopathic traits in forty-two US presidents up to and including George W. Bush. Fearless Dominance, which reflects the boldness associated with psychopathy, was associated with better overall performance in office; in contrast, Impulsive Antisociality was generally unassociated with presidential performance, although it was linked to some indicators of negative performance (e.g., tolerating unethical behavior in subordinates, negative character). These positive findings with Fearless Dominance suggest that certain features of psychopathy are linked to successful interpersonal behavior.

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  • Newman, Joseph P., John J. Curtin, Jeremy D. Bertsch, and Arielle R. Baskin-Sommers. 2010. Attention moderates the fearlessness of psychopathic offenders. Biological Psychiatry 67.1: 66–70.

    DOI: 10.1016/j.biopsych.2009.07.035Save Citation »Export Citation » Share Citation »

    Consistent with Joe Newman’s response modulation hypotheses, showed that psychopathic offenders were deficient in fear processing only when attention was directed away from threat, but otherwise, fear responses were intact.

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  • Patrick, Christopher J., ed. 2006. Handbook of psychopathy. New York: Guilford.

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    Considered the definitive guide of the psychopathic personality. The contents are as follows: “Theoretical and Empirical Foundations” (e.g., dual-deficit model of psychopathy), “Issues in Conceptualization and Assessment” (e.g., disaggregating psychopathy), “Etiological Mechanisms” (e.g., genetic and environmental influences), “Psychopathy in Specific Subpopulations” (e.g., women), “Clinical and Applied Issues” (e.g., risk for criminal recidivism), and “Conclusions and Future Directions.”

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  • Patrick, Christopher J., Margaret M. Bradley, and Peter J. Lang. 1993. Emotion in the criminal psychopath: Startle reflex modulation. Journal of Abnormal Psychology 102.1: 82–92.

    DOI: 10.1037/0021-843X.102.1.82Save Citation »Export Citation » Share Citation »

    Although nonpsychopathic individuals and individuals with some psychopathic features showed higher defensive responses to negative images, assessed using fear-potentiated startle, this effect was absent in psychopathic individuals. Differences in startle modulation are related to affective features of psychopathy, but not to antisocial behavior. Results suggest abnormalities in processing emotional stimuli in psychopathy.

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  • Patrick, Christopher J., Don C. Fowles, and Robert F. Krueger. 2009. Triarchic conceptualization of psychopathy: Developmental origins of disinhibition, boldness, and meanness. In Special issue: Precursors and diverse pathways to personality disorder in children and adolescents: Part 1. Edited by Dante Cicchetti and Nicki R. Crick. Development and Psychopathology 21.3: 913–938.

    DOI: 10.1017/S0954579409000492Save Citation »Export Citation » Share Citation »

    Introduces the triarchic model of psychopathy, which encompasses the phenotypic components of disinhibition, boldness, and meanness. These three phenotypic constructs are discussed in terms of etiologic and developmental pathways.

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  • Sadeh, Naomi, and Edelyn Verona. 2012. Visual complexity attenuates emotional processing in psychopathy: Implications for fear-potentiated startle deficits. Cognitive Affective Behavioral Neuroscience 12:346–360.

    DOI: 10.3758/s13415-011-0079-1Save Citation »Export Citation » Share Citation »

    Study examined the convergence of fearlessness and response modulation models of psychopathy. Results indicated that interpersonal-affective traits of psychopathy are associated with deficient defensive fear reactivity to only high-complexity unpleasant pictures, implicating the interplay of attention and emotional systems as deficient in psychopathy.

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Treatment Approaches

Empirically supported treatments do not abound for personality disorders (PDs), with traditional treatments for these syndromes focused on long-term psychodynamic systems of change, especially for borderline personality and narcissistic personality disorders (NPDs; Kohut 1971, Millon and Grossman 2005). Only one of the newer cognitive and behavioral treatments has received broad acclaim by clinical scientists for showing effectiveness in randomized controlled trials: dialectical behavior therapy (DBT; Linehan 1993; Linehan, et al. 2015). Other approaches are beginning to build a scientific base, including newer dynamic treatments (Leichsenring and Leibing 2003), symptom-targeted medication strategies (Nelson, et al. 2015), and schema therapy (Farrell and Shaw 2012). Finally, Olver and Wong 2009 and Polaschek and Daly 2013 provide evidence that psychopathic youth and adults may be amenable to treatment.

  • Farrell, Joan M., and Ida A. Shaw. 2012. Group schema therapy for borderline personality disorder: A step-by-step treatment manual with patient workbook. Chichester, UK: Wiley.

    DOI: 10.1002/9781119943167Save Citation »Export Citation » Share Citation »

    This book represents the first treatment manual for group schema therapy (GST); group-based schema therapy is a cost-effective alternative technique with the potential to assist in the public health program of making evidence-based borderline personality treatment widely available. As in individual schema therapy, the focus is on core schemas that relate to the origins of personality disorder.

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  • Kohut, H. 1971. The analysis of the self: A systematic approach to the psychoanalytic treatment of narcissistic personality disorders. New York: International Universities.

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    Clarifies psychoanalytic terminology and treatment approaches in regard to narcissism, mirroring, and idealization. Focuses on the therapy relationship between client and therapist to achieve personality change in the client.

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  • Leichsenring, Falk, and Eric Leibing. 2003. The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: A meta-analysis. American Journal of Psychiatry 160:1223–1232.

    DOI: 10.1176/appi.ajp.160.7.1223Save Citation »Export Citation » Share Citation »

    A meta-analysis of treatment studies for personality disorders, showing that psychodynamic treatments do as well as, and sometimes better than, cognitive behavioral treatments. Studies of psychodynamic treatments tended to be slightly longer treatments, and fewer were randomized.

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  • Linehan, Marsha. 1993. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.

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    Textbook and manual for applying DBT with borderline personality and parasuicidal clients. Includes the theoretical basis of the treatment as well as structural and stylistic strategies, targets of treatment, and a team approach to system of care.

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  • Linehan, Marsha M., Kathryn E. Korslund, and Melanie S. Harned. 2015. Dialectical behavioral therapy for high suicide risk in individuals with borderline personality disorder: A randomized clinical trial and component analysis. JAMA Psychiatry 72.5: 472–482.

    DOI: 10.1001/jamapsychiatry.2014.3039Save Citation »Export Citation » Share Citation »

    This study sought to evaluate the importance of the skills training component of DBT by comparing it against other conditions that contained the additional components of the therapy (case management, individual therapy plus activities, and standard DBT) in a randomized clinical trial of BPD patients. The authors found that interventions that include DBT skills training are more effective than DBT without skills training, and standard DBT may be superior in some cases.

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  • Millon, Theodore, and Seth D. Grossman. 2005. Psychotherapy for the narcissistic personality disorder. In Oxford textbook of psychotherapy. Edited by Glenn O. Gabbard, Judith S. Beck, and Jeremy Holmes, 279–289. New York: Oxford Univ. Press.

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    Discussion of the putative intrapersonal and interpersonal dynamics of narcissism, psychodynamic and cognitive behavioral approaches to treatment, and an integrated treatment model with suggestions on how therapists can approach treatment with such clients. Descriptive case studies are included.

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  • Nelson, Katharine J., Alexandra Zagoloff, Sandra Quinn, Heather E. Swanson, Claire Garber, and S. Charles Schultz. 2015. Borderline personality disorder: Treatment approaches and perspectives. Clinical Practice 11.3: 341–349.

    DOI: 10.2217/cpr.14.24Save Citation »Export Citation » Share Citation »

    These authors suggest that, in addition to evidence-based psychotherapies (such as DBT and schema therapy), early evidence exists for use of medications in a symptom-targeted manner (particularly mood stabilizers and antipsychotics). However, the authors caution against the use of benzodiazepines or anything with a high risk of toxicity due to the high suicidal behavior risk in BPD patients.

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  • Olver, Mark E., and Stephen C. P. Wong. 2009. Therapeutic responses of psychopathic sexual offenders: Treatment attrition, therapeutic change, and long-term recidivism. Journal of Consulting and Clinical Psychology 77.2: 328–336.

    DOI: 10.1037/a0015001Save Citation »Export Citation » Share Citation »

    Sex offender treatment study compared those with psychopathy and no psychopathy on treatment outcomes. Although psychopaths were more likely to drop out, those showing therapeutic improvement were less likely to recidivate. Provides hope for treatment of psychopathic behaviors. Available online through purchase.

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  • Polaschek, Devon L. L., and Tadhg E. Daly. 2013. Treatment and psychopathy in forensic settings. Aggression and Violent Behavior 18.5: 592–603.

    DOI: 10.1016/j.avb.2013.06.003Save Citation »Export Citation » Share Citation »

    This review paper examines past and recent research on psychopathy and treatment, concluding that some newer, well-designed studies contradict the notion that psychopaths are not amenable to treatment; furthermore, these suggest there may be grounds for optimism when considering the treatability of psychopathy. Although there is no doubt that psychopathic offenders present a greater challenge in treatment settings, well-conceived programs for higher-risk offenders can reduce recidivism in highly psychopathic offenders; techniques include providing separate interventions for these individuals (as they can disrupt group settings with other low-level offenders) and providing an intervention intensity associated with the degree of risk for the individual.

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