This assignment will involve the selection a current event from the news (a valid news website – properly formatted in APA) and then applying it to a concept from your course textbook.You will discuss
218 12 Personality Disorders criStina creGo and thomaS a. W idiGer In 1980, the American Psychiatric Association (APA) pub – lished the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980), which introduced the innovative multiaxial classification system. Axis II was devoted primarily to personality dysfunction, owing to the prevalence of maladaptive personality traits in general clinical practice, the substantial impact that these traits can have on the course and treatment of other mental dis – orders, and the tendency of clinicians to miss comorbid maladaptive personality functioning as their attention is drawn to concerns regarding anxiety, depression, sub- stance usage, or other form of psychopathology (Frances, 1980). This multiaxial system has been instrumental in the increased recognition of personality disorders within clin- ical practice (Loranger, 1990) and research (Blashfield & Intoccia, 2000). The multiaxial system, however, has been deleted in DSM-5 (American Psychiatric Association, 2013). No explanation for this decision was provided by the APA. However, a commonly expressed concern with respect to the multiaxial system was that few clinicians were actually using it, at least the components for indicat- ing presence of a medical disorder, level of functioning, and social stressors (Frances, First, & Pincus, 1995). DSM-5 includes 10 personality disorders, organized into three clusters: (a) paranoid, schizoid, and schizotypal (the odd-eccentric cluster); (b) antisocial, borderline, histri- onic, and narcissistic (dramatic-emotional-erratic cluster); and (c) avoidant, dependent, and obsessive-compulsive (anxious-fearful cluster). These diagnoses and their cri – terion sets are identical to those included in the prior edi- tions, DSM-IV-TR (American Psychiatric Association, 2000) and DSM-IV (American Psychiatric Association, 1994). Proposed for DSM-5 were major revisions to the personality disorders such as use of prototype narratives, self-interpersonal impairment criteria for each personality disorder, deletion of half of the disorders, and a shift from categorical to dimensional classification. However, because of the magnitude of the proposed changes, vocal opposition to them, and the inadequate documentation of their empiri – cal support, none of them was approved (Skodol, Morey, Bender, & Morey, 2013; Widiger, 2013). In this chapter, we begin with a discussion of personality disorders in general, followed by a discussion of the proposals that were made for DSM-5, and the five-factor model (FFM) of personal – ity disorder (Widiger & Costa, 2013) that is closely aligned with one of the proposals. We then discuss five specific personality disorders (antisocial, narcissistic, borderline, schizotypal, and dependent) including how they are under – stood from the perspective of the FFM. Personality Disorder in General Virtually all persons, including everyone with psycho – logical problems, will have a characteristic manner of thinking, feeling, behaving, and relating to others that would have been present prior to the onset of their anxi- ety, mood, substance use or other mental disorder. For many of these persons, these personality traits will be so maladaptive that they would constitute a personality dis – order, defined in DSM-5 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, is stable over time, and leads to distress or impairment” (American Psychiatric Association, 2013, p. 645). It is estimated that 10–15% of the general population would meet criteria for one of the 10 DSM-5 personality Maddux, J. E., & Winstead, B. A. (Eds.). (2015). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from apus on 2022-05-26 02:09:20. Copyright © 2015. Taylor & Francis Group. All rights reserved. 219 disorders (Torgersen, 2012). The prevalence of person- ality disorders within clinical settings is estimated to be well above 50% (Zimmerman & Mattia, 2001). As many as 60% of inpatients within some clinical settings are diagnosed with borderline personality disorder (American Psychiatric Association, 2013; Hooley, Cole, & Gironde, 2012). The prevalence of personality disorders, however, is generally underestimated in clinical practice, owing to a lack of time to provide sufficiently systematic or com- prehensive evaluations of personality functioning (Miller, Few, & Widiger, 2012) and perhaps also to a reluctance to diagnose personality disorders because insurance compa – nies may consider them to be untreatable (Zimmerman & Mattia, 1999). 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 (Millon, 2011). Nevertheless, much has been written on the treatment of personality disorder (e.g., Beck, Freeman, Davis, & Associates, 1990; Clarkin, Fonagy, & Gabbard, 2010; Critchfield & Benjamin, 2006; Gunderson & Gabbard, 2000; Livesley, 2003; Magnavita, 2010; Young, Klosko, & Weishaar, 2003) and there is empirical sup – port for clinically and socially meaningful changes in response to psychosocial and pharmacologic treatments (Magnavita, 2010). The development of an ideal or fully healthy personality structure is unlikely to occur through the course of treatment, but given the considerable social, public health, and personal costs associated with some of the personality disorders, such as antisocial and border- line, even moderate adjustments to personality function – ing can represent substantial social and clinical benefits. DSM-5 Personality Disorder Proposals The major innovation of DSM-III was the inclusion of specific and explicit criterion sets to facilitate the obtain – ment of reliable diagnoses (Spitzer, Williams, & Skodol, 1980). However, proposed for DSM-5 was a return to the method used in DSM-II (American Psychiatric Association, 1968), in which clinicians would match their global perception of a patient to a paragraph description, considering the narrative “as a whole rather than count – ing individual symptoms” (Westen, Shedler, & Bradley, 2006, p. 847). Gestalt matching to paragraph narratives is preferred by clinicians, probably because it is much eas – ier and quicker than having to systematically assess each individual diagnostic criterion (Spitzer, First, Shedler, Westen & Skodol, 2008). However, this proposal met with considerable objection (Pilkonis, Hallquist, Morse, & Stepp, 2011; Widiger, 2011; Zimmerman, 2011), due largely to the weak empirical support for its reliability and validity. The proposal was subsequently abandoned by the Personality and Personality Disorders Work Group (PPDWG). An additional DSM-5 proposal was to revise the defi – nition and diagnostic criteria for each respective per- sonality disorder to incorporate psychodynamic clinical theory concerning impairments in the perception of the self (identity and self-direction) and interpersonal relat – edness (empathy and intimacy) (Skodol, 2012). These features were derived from psychoanalytic theory con- cerning pathology of the self (Livesley & Jang, 2000). Empirical support for this proposal, however, was limited and largely indirect (see Bender, Morey, & Skodol, 2011). In addition, the APA is shifting toward a neurobiological model of psychopathology (Kupfer & Regier, 2011) and it is likely that this proposal was not well received. A further proposal for DSM-5 was to delete half of the diagnostic categories, largely to address the problematic diag – nostic co-occurrence (Skodol, 2012). Originally slated for deletion were the narcissistic, dependent, paranoid, schizoid, and histrionic personality disorders. Narcissistic, however, was saved from the chopping block, due in large part to criti – cal reviews that documented its empirical support (Pincus, 2011; Miller, Widiger, & Campbell, 2010; Ronningstam, 2011). The empirical support for the deletion of the others, however, was also questioned (Mullins-Sweatt, Bernstein, & Widiger, 2012). All of the DSM-IV personality disorders were eventually retained in DSM-5. Questions remain, how – ever, concerning the extent of empirical support for histri – onic (Blashfield, Reynolds, & Stennett, 2012), paranoid and schizoid personality disorder (Hopwood & Thomas, 2012). The Chair and Vice Chair of the DSM-5 Task Force indicated that the primary contribution of DSM-5 would be a shift toward a dimensional model of classification (e.g., Regier, 2008; Regier, Narrow, Kuhl, & Kupfer, 2010). The Nomenclature Work Group of a DSM-5 research planning conference, charged with address – ing fundamental assumptions of the diagnostic system, concluded that it will be “important that consideration be given to advantages and disadvantages of basing part or all of DSM-V on dimensions rather than categories” (Rounsaville et al., 2002, p. 12). They suggested that a dimensional model be developed in particular for the per – sonality disorders. “If a dimensional system of personality performs well and is acceptable to clinicians, it might then be appropriate to explore dimensional approaches in other domains” (Rounsaville et al. 2002, p. 13). A subsequent DSM-5 research planning conference was devoted to doc – umenting research supporting this shift for the personality disorders section (Widiger & Simonsen, 2005). This was followed by a third DSM-5 research planning conference that was devoted to proposals to shift the entire manual to a dimensional model, including the personality disorders (Krueger, Skodol, Livesley, Shrout, & Huang, 2008). The DSM-5 dimensional trait model for personality dis – orders consisted initially of 37 traits. The list of 37 traits was first reduced to 25, on the basis of a factor analysis, while maintaining the original trait assignments (American Maddux, J. E., & Winstead, B. A. (Eds.). (2015). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from apus on 2022-05-26 02:09:20. Copyright © 2015. Taylor & Francis Group. All rights reserved. Personality Disorders Cristina Crego and Thomas A. Widiger 220 Psychiatric Association, 2011). The trait assignments were then subsequently revised again. The list of 25 traits was retained, but there were shifts in how they were assigned (American Psychiatric Association, 2012; Skodol, 2012). The final proposals by the PPDWG included a five-domain, 25-maladaptive trait model, that could be used by itself to describe a patient and was also part of the diagnostic crite – rion sets for the traditional personality disorder categories (Krueger et al., 2011). The five broad domains were negative affectivity, detachment, psychoticism, antagonism, and dis- inhibition. The proposal was approved by the DSM-5 Task Force but rejected by a DSM-5 scientific oversight com – mittee and the APA Board of Trustees. The rationale for this rejection is unclear. No report by the oversight committee has been provided. The dimensional trait proposal was embedded within other major proposals, including the addition of psycho – dynamically oriented deficits in self and interpersonal relatedness to the diagnostic criterion sets (Skodol, 2012). This aspect of the proposal did not appear to have much empirical support. There is a considerable body of research to support the dimensional trait proposal. However, very little of this research was actually presented to the over – sight committee. The report to the oversight committee was confined largely to studies authored by work group members (Blashfield & Reynolds, 2012), failing to cite a considerable body of additional research (Widiger, Samuel, Mullins-Sweatt, Gore, & Crego, 2012). For example, it was important for the dimensional trait proposal to be “accept – able to clinicians” (Rounsaville et al., 2002, p. 13). There have been a number of studies documenting empirically that clinicians prefer the dimensional trait model over the existing diagnostic categories (e.g., Glover, Crego et al., 2012; Lowe & Widiger, 2009; Samuel & Widiger, 2006), but this research was not included within the PPDWG lit – erature review (American Psychiatric Association, 2012). Included instead were the studies that suggested a lack of support by clinicians for such a shift (i.e., Rottman, Ahn, Sanislow, & Kim, 2009; Spitzer et al., 2008). In any case, it was clear that there was considerable opposition to the pro – posal by well-known and well-regarded personality disor – der clinicians (e.g., Gunderson, 2010; Shedler et al., 2010). The dimensional trait proposal, however, is included within Section 3 of DSM-5, for emerging models and measures. The introduction to DSM-5 explicitly acknowl – edges the failure of the categorical model: “the once plausible goal of identifying homogeneous populations for treatment and research resulted in narrow diagnostic categories that did not capture clinical reality, symptom heterogeneity within disorders, and significant sharing of symptoms across multiple disorders” (p. 12). It is further asserted that dimensional approaches will “supersede cur – rent categorical approaches in coming years” (p. 13). Five-Factor Model of Personality Disorder This chapter describes a dimensional trait model con- ceptualization of the DSM-5 personality disorders that is conceptually and empirically aligned with the DSM-5 dimensional trait proposal included within Section 3 of the DSM-5. The model provided in this chapter is the FFM of general personality structure developed within psy – chology (Widiger & Costa, 2013). Five broad domains of personality functioning have been identified empirically through the study of the languages of a number of differ – ent cultures (John, Naumann, & Soto, 2008). Language can be understood as a sedimentary deposit of the obser – vations of persons over the thousands of years of the language’s development and transformation. The most important domains of personality functioning would be those with the greatest number of terms to describe and differentiate their various manifestations and nuances, and the structure of personality would be evident in the empirical relationship among the trait terms (Goldberg, 1993). Such lexical analyses of languages have typically identified five fundamental dimensions of personality: neuroticism (or negative affectivity) versus emotional sta – bility, introversion versus extraversion, closedness versus openness to experience, antagonism versus agreeableness, and conscientiousness (constraint) versus disinhibition. The five domains of the FFM align well with the five included in Section 3 of DSM-5. As stated in DSM-5, the “five broad domains [of DSM-5] are maladaptive variants of the five domains of the extensively validated and rep – licated personality model known as the ‘Big Five,’ or the Five Factor Model of personality” (American Psychiatric Association, 2013, p. 773). FFM neuroticism aligns with DSM-5 negative affectivity, FFM introversion aligns with DSM-5 detachment, FFM openness (or unconventional – ity) aligns with DSM-5 psychoticism; FFM antagonism aligns with DSM-5 antagonism, and FFM low conscien – tiousness aligns with DSM-5 disinhibition. Each of the five broad domains of the FFM can be differentiated further in terms of underlying facets. For example, the facets of antagonism versus agreeableness include suspiciousness versus trusting gullibility, callous tough-mindedness versus tender-mindedness, confidence and arrogance versus modesty and meekness, exploita – tion versus altruism and sacrifice, oppositionalism and aggression versus compliance, and deception and manipu- lation versus straightforwardness and honesty (Costa & McCrae, 1992). Figure 12.1 indicates how each of the 25 maladaptive traits (as well as the 12 additional traits that were deleted from the proposal) included in Section 3 of DSM-5 would be organized with respect to the FFM. Each of the DSM-5 personality disorders can be read – ily understood as maladaptive and/or extreme variants of the FFM domains and facets (Lynam & Widiger, 2001; Samuel & Widiger, 2004). For example, DSM-5 obses – sive-compulsive personality disorder (OCPD) is primarily a disorder of maladaptively extreme conscientiousness, including the FFM facets of deliberation (OCPD rumina- tion), self-discipline, achievement-striving (OCDP work- aholism), dutifulness (OCPD over-conscientiousness, scrupulousness about matters of ethics and morality), order (OCPD preoccupation with details), and competence Maddux, J. E., & Winstead, B. A. (Eds.). (2015). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from apus on 2022-05-26 02:09:20. Copyright © 2015. Taylor & Francis Group. All rights reserved. Separation InsecurityAttention-Seeking Cognitive and Pe rceptual Dy sregulation Dissociation Pr oneness Submissiveness Risk Aversion Perfectionism (High) Conscientiousness (Low) (High) Agr eeableness (Low) (High) Openness (Low) (High) Extr aversion (Low) (High) Neuroticism (Low) Callousness Anhedonia Social Withdr awal Restricted Affectivity Intimacy Avoidance Deceitfulness Manipulativeness SuspiciousnessAg gression Distractibility Irresponsibility Emotional Lability Pessimism Depressivity Guilt/Shame Anxiousness Self-Harm Hostility Low Self- esteem Unusual Beliefs and Experiences Social Detachment Eccentricity Orderliness Rigidity Persev eration Risk Taking Impulsivity Grandiosity Oppositionality Figure 12.1 DSM-5 traits arranged with respect to the five-factor model of personali ty. Note: Traits in blue are from the original 37 trait proposal but hav e since been removed from the DSM-5 Section 3 trait model (a 37th trait, unusual perceptions, does not appear in the figure because it was folded into cognitive-perceptual dysregulation). Maddux, J. E., & Winstead, B. A. (Eds.). (2015). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from apus on 2022-05-26 02:09:20. Copyright © 2015. Taylor & Francis Group. All rights reserved. Cristina Crego and Thomas A. Widiger 222 (OCPD perfectionism). The FFM description also goes beyond the DSM-IV-TR, now DSM-5, diagnostic crite – ria by including high anxiousness (excessive worry), low excitement-seeking (risk aversion), and closed minded – ness to feelings (constricted), values (dogmatism), and actions (inflexibility; Samuel, Riddell, Lynam, Miller, & Widiger, 2012). Table 12.1 indicates how each of the DSM-5 personality disorders can be understood from the perspective of the FFM. Existing measures of the FFM can in fact be used to provide valid assessments for most of the DSM-5 personality disorders (Miller, 2012). However, measures to assess the DSM-5 personality dis – orders from the perspective of the FFM, such as the Five- Factor Borderline Inventory (Mullins-Sweatt et al., 2012) have also been developed (Widiger, Lynam, Miller, & Oltmanns, 2012). There are a number of advantages to a FFM of personal – ity disorder approach (Crego & Widiger, 2015; Widiger & Trull, 2007). The dimensional trait model addresses the many fundamental limitations of the categorical system (e.g., heterogeneity within diagnoses, inadequate cover – age, lack of consistent diagnostic thresholds, and exces – sive diagnostic co-occurrence). It provides a description of abnormal personality functioning within the same model and language used to describe general personality structure, allowing for a more comprehensive system that would enable clinicians to identify personality strengths as well as deficits. It would transfer to the psychiatric nomenclature a wealth of knowledge concerning the ori – gins, development, universality, and stability of personal – ity structure (Widiger & Trull, 2007). Finally, it would represent a significant step toward a rapprochement and integration of psychiatry with psychology. Empirical sup – port for the integration of the DSM-IV-TR (and DSM-5) personality nomenclature with the FFM is summarized by Clark (2007), Widiger, Samuel et al. (2012), and Widiger and Costa (2012). Five Personality Disorders and Their Five-Factor Formulations Space limitations prohibit a detailed coverage of all 10 DSM-5 personality disorders; neither would that seem worthwhile because some of them have an uncertain future (Skodol, 2012). However, the five discussed herein are not entirely the same as the five originally proposed for retention in DSM-5. We discuss the five personality dis – orders for which there has been the most research: antiso – cial, borderline, narcissistic, schizotypal, and dependent. The narcissistic and dependent were slated for deletion, whereas the avoidant and obsessive-compulsive were to be retained. However, there is arguably more research to sup – port the validity and clinical utility of the narcissistic and dependent than for OCPD or avoidant (Mullins-Sweatt, Bernstein et al., 2012). For each of the five diagnoses cho – sen for this chapter, we describe what is known about their etiology, pathology, differential diagnosis, comorbidity, course, and treatment. We also indicate how each of them can be understood from the perspective of the FFM and how this conceptualization can help to address one or more issues that have been problematic for that personal- ity disorder. Antisocial Personality Disorder Antisocial personality disorder (ASPD) has been included within every edition of the DSM. One might even characterize ASPD as the prototypic personality disorder as the term “psychopath” originally referred to all cases of personality disorder (Schneider, 1923). The term “psychopathy” now refers to a particularly severe variant of ASPD (Derefinko & Widiger, 2013). Much of the current research on ASPD is being conducted with regard to this more severe variant, as assessed, for instance, by the Psychopathy Checklist- Revised (PCL-R; Hare, 2003; Hare, Neumann, & Widiger, 2012). Definition DSM-5 defines ASPD as a pervasive pattern of disregard for and violation of the rights of others. Its primary diagnostic criteria include criminal activity, deceitfulness, impulsivity, recklessness, aggressiveness, irresponsibility, and indifference to the mistreatment of others. DSM-5 ASPD overlaps substantially with PCL-R psychopathy. The primary differences are the inclusion of glib charm, arrogance, lack of empathy, and shallow affect within the PCL-R, and the requirement within DSM-5 for the evidence of conduct disorder within childhood (Widiger, 2006). More recent formulations of psychopa – thy have extended its description to include such traits as fearlessness (Malterer, Lilienfeld, Neumann, & Newman, 2010), boldness (Patrick, Fowles, & Krueger, 2009), dom – inance, and invulnerability (Lynam et al., 2011). Etiology and Pathology Twin, family, and adoption studies have provided substantial support for a genetic contribution to the etiology of the criminal, delinquent tendencies of persons meeting criteria for ASPD, account- ing for approximately 50% of the variance in antisocial behavior (Waldman & Rhee, 2006). Exactly what is inherited in ASPD, however, is not known. It could be an impulsivity, an antagonistic callousness, or an abnormally low anxiousness, or all of these dispositions combined. Numerous environmental factors have also been impli- cated. Shared, or common, environmental influences account for 15–20% of variation in antisocial behav – ior (Rhee & Waldman, 2002). Not surprisingly, shared environmental factors such as low family income, inner- city residence, poor parental supervision, single-parent households, rearing by antisocial parents, delinquent siblings, parental conflict, harsh discipline, neglect, large family size, and young mother have all been implicated (Farrington, 2006). Nonshared environmental influences (30%) comprise the remaining variance not accounted for by the genetic (50%) or shared environmental (20%) Maddux, J. E., & Winstead, B. A. (Eds.). (2015). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from apus on 2022-05-26 02:09:20. Copyright © 2015. Taylor & Francis Group. All rights reserved. TABLE 12.1 DSM-5 Personality Disorders from the Perspective of the Five-Factor Model of General Personality Functioning AntisocialNarcissistic BorderlineSchizotypal DependentParanoidSchizoid Histrionic AvoidantObsessive-compulsive Neuroticism (vs. emotional stability) Anxiousness (vs. unconcerned) Fearlessness Social anxiousness Separation insecurity Evaluation apprehension Excessive worry Angry hostility (vs. dispassionate) Anger Reactive anger Dysregulated rage Vengeful Depressiveness (vs. optimistic) Despondence Pessimism Self-consciousness (vs. shameless) Glib charmShame Indifference Self- disturbance Social discomfort Shamefulness Mortified Impulsivity (vs. restrained) Behavioral dysregulation Vulnerability (vs. fearless) InvincibilityNeed for admiration Affective dysregulation Helplessness Neediness for attention, rapidly shifting emotions Extraversion (vs. introversion) Warmth (vs. coldness) Intimacy needs ReservedSocial anhedonia Intimacy seeking Detached coldness Gregariousness (vs. withdrawal) Exhibitionism Social withdrawalAloof Social withdrawal Attention seeking Social withdrawal Dominance (vs. submissiveness) Domineering Authoritative Timidity Timidity Activity (vs. passivity) Inactive Excitement-seeking (vs. lifeless) Thrill-seeking LifelessFlirtatious Risk aversion Positive emotionality (vs. anhedonia) Physical anhedonia Melodramatic emotionality Joylessness Openness (vs. closedness) Fantasy (vs. concrete) Grandiose fantasies Dissociative tendencies Aberrant perceptions Romantic fantasies Aesthetics (vs. disinterest) Feelings (vs. alexithymia) AlexithymicTouchy feely Constricted Actions (vs. predictable) Odd-eccentric Inflexibility Ideas (vs. closed-minded) Aberrant ideas Values (vs. dogmatic) DogmaticDogmatism Agreeableness (vs. antagonism) Trust (vs. mistrust) Cynicism SuspiciousnessGullibility Suspicious Suggestibility Straightforwardness (vs. deception) Manipulation Manipulation Manipulative Circumspect Altruism (vs. exploitative) ExploitativeEntitlement Selflessness Compliance (vs. aggression) AggressiveOppositionalSubservience Combative Modesty (vs. arrogance) Arrogance Arrogance Self-effacing VainTimorous Tender-mindedness (vs. tough-minded) Callous Lack of empathy Conscientiousness (vs. disinhibition) Competence (vs. laxness) IneptitudePerfectionism Order (vs. disorderly) Disorderliness Fastidious Dutifulness (vs. irresponsibility) Lax Punctilious Achievement striving (vs. lackadaisical) Acclaim-seeking Workaholism Self-discipline (vs. negligence) Unreliable Negligence Doggedness Deliberation (vs. rashness) RashRashness Impressionistic thinkingRuminative deliberation Maddux, J. E., & Winstead, B. A. (Eds.). (2015). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from apus on 2022-05-26 02:09:20. Copyright © 2015. Taylor & Francis Group. All rights reserved. Cristina Crego and Thomas A. Widiger 224 influences. Nonshared environmental factors may include delinquent peers, individual social and academic experi – ences, or sexual, physical abuse (Moffitt, 2005). The interactive effects of genetic and environmental influences are difficult to tease apart though, and create confusion about what these estimates mean in terms of causation. For example, the individual who is genetically predisposed to antisocial behavior will elicit experiences that can in turn contribute to the development of antisocial behavior, such as peer problems, academic difficulty, and harsh discipline from parents. In other words, the person genetically disposed to antisocial behavior can help create an environment that would reinforce antisocial behavior. In addition, antisocial individuals receive their genes from antisocial parents who had also likely modeled delinquent and irresponsible behavior. In sum, it can be difficult to disentangle what is really genetic and what is really envi – ronmental. Studies that explicitly address these issues have found that environmental factors continue to play an important part in the etiology of antisocial behavior beyond genetic factors alone. For instance, after control – ling for the genetic component of physical maltreatment, Jaffee, Caspi, Moffitt, and Taylor (2004) found that the environmental etiological effect of physical maltreatment remained. Considerable research effort has been focused on the pathology of psychopathy. This extensive research base indicates that many deficits can be involved, leading to a very complex picture. Historically, the psychopathic individual was said to suffer from “superego lacunae” or a “semantic dementia” (Cleckley, 1941) that involved a deficit of conscience or, more generally, a deficient pro – cessing of feelings and emotion. Laboratory research is now providing support for this theoretical model in stud – ies assessing the psychopath’s autonomic reaction to emo – tional words and fearful images (Blackburn, 2006). Many psychophysiological deficits have also been asso – ciated with psychopathy, including for example a low level of physiological arousal and/or fear response (Fowles & Dindo, 2006). Support for this hypothesis has included abnormally low physiological responses (reduced skin conductance) to a conditioned stimulus paired with electric shock, indicating that the psychopath may not develop the expected anticipatory arousal from threat of physical pun – ishment. Additional autonomic arousal assessments include low resting heart rate levels and startle response deficits (Derefinko & Widiger, 2015). There is also the suggestion that persons with ASPD may have abnormally low levels of anxiousness. Some distress-proneness (FFM anxious – ness or neuroticism) and attentional self-regulation (FFM constraint or conscientiousness) may be necessary in order to develop an adequate sense of guilt or conscience. Normal levels of neuroticism will promote the internalization of a conscience by associating wrongdoing or misbehavior with distress and anxiety, and the temperament of self-regulation will help modulate impulses into socially acceptable chan – nels (Fowles & Kochanska, 2000). Cognitive functioning deficits have also been impli- cated. The psychopath’s notorious failure to accurately anticipate negative consequences suggests a cognitive deficit (Hiatt & Newman, 2006). Existing research indi – cates that the psychopath experiences stable deficits in the cognitive domains of attention and response modulation (Gao, Glenn, Schug, Yang, & Raine, 2009). According to this research, psychopaths continue to engage in behaviors that are initially interpreted as positively reinforcing, even when additional information is presented indicating sub – stantial overall costs (Newman & Lorenz, 2003). Differential Diagnosis ASPD is most closely associated with narcissistic personality traits, the differentiation of which will be discussed later in this chapter. At times, ASPD may be difficult to differentiate from a substance dependence disorder because many persons with ASPD develop a substance-related disorder, and many persons with substance dependence engage in antisocial acts. However, the requirement that conduct disorder be pres – ent prior to the age of 15 will usually assure the onset of ASPD prior to the onset of a substance-related disorder. If both were evident prior to the age of 15, then it is likely that both disorders are now present and both diagnoses should be given (Widiger, 2006). Often, ASPD and sub – stance-dependence will interact, exacerbating each other’s development. Epidemiology The National Institute of Mental Health Epidemiologic Catchment Area study estimated that 3% of males and 1% of females meet criteria for ASPD. Subsequent studies have replicated this rate, but it has also been suggested that this finding may have underestimated the prevalence in males, owing to a failure to consider the full range of ASPD features. Other estimates have been as high as 6% in males (Kessler et al., 1994). Within prison and forensic settings, the rate of ASPD has been estimated to be as high as 50% in males (Hare et al., 2012). However, the ASPD criteria may inflate the prevalence within such settings, owing to the emphasis on overt acts of crimi- nality, delinquency, and irresponsibility. More specific criteria for psychopathy provided by the PCL-R (Hare, 2003) obtain a more conservative estimate of 20–30% of male prisoners by placing relatively less emphasis on the history of criminal behavior and more emphasis on per – sonality traits associated with this criminal history (e.g., callousness and arrogance). ASPD is much more common in men than in women (Verona & Vitale, 2006). A sociobiological explanation for the differential sex prevalence is the presence of a genetic advantage for social irresponsibility, infidelity, superfi – cial charm, and deceit in men but not women. These traits may be related to reproductive success for men (having more offspring) but also contribute to a higher likelihood of developing features of ASPD (Derefinko & Widiger, in press). Maddux, J. E., & Winstead, B. A. (Eds.). (2015). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from apus on 2022-05-26 02:09:20. Copyright © 2015. Taylor & Francis Group. All rights reserved. 225 Course ASPD is the only personality disorder for which much is known about childhood antecedents. Approximately 40% of the children diagnosed with DSM-5 conduct disorder grow up to meet criteria for ASPD, particularly those with childhood onset of con – duct disorder and/or have callous-unemotional traits. The presence of conduct disorder is in fact essentially required for the diagnosis of ASPD (American Psychiatric Association, 2013). There are also compelling data to indicate that ASPD is a relatively chronic disorder which persists in adulthood, although research suggests that as the person reaches middle to older age, the frequency of criminal acts decreases. Nevertheless, the core personality traits may remain largely stable (Hare et al., 2012). Five Factor Model Reformulation ASPD can be under – stood primarily as excessive, maladaptively low con – scientiousness and high antagonism (see Table 12.1). Specifically, these individuals would be described as aimless, unreliable, lax, negligent, and hedonistic (low in the facets of self-discipline and deliberation), as well as manipulative, exploitative, aggressive, and ruthless (low in straightforwardness, altruism, compliance, and tender- mindedness). Additional facets of the FFM would be seen in prototypic cases of ASPD-psychopathy, including low anxiousness (fearlessness), low self-consciousness (glib charm), low vulnerability (invincibility), high impulsiv – ity, high angry hostility, high dominance, and high thrill- seeking (Derefinko & Lynam, 2013). An ongoing issue surrounding the diagnosis of ASPD has been the failure to include all of the personality traits of psychopathy identified originally by Cleckley (1941), emphasizing instead those traits that could most easily be identified by objectively observed behaviors (e.g., irre – sponsible and/or illegal acts). An advantage of the FFM conceptualization is that it includes all of the traits that are common to both ASPD and the PCL-R, including decep – tion, exploitation, aggression, irresponsibility, negligence, rashness, angry hostility, impulsivity, excitement-seeking, and assertiveness (see Table 12.1) as well as the traits that are unique to the PCL-R, including glib charm (low self- consciousness), arrogance, and lack of empathy (tough- minded callousness). In addition, the FFM includes those traits of psychopathy that were emphasized originally by Cleckely (1941) but were not included in either the DSM-5 or the PCL-R (i.e., low anxiousness or fearless – ness). Considerable evidence supports the FFM concep – tualization of ASPD (Lynam & Widiger, 2007a). Miller (2012) has shown that the extent to which an individual’s FFM profile matches the FFM profile for a prototypic case of psychopathy can even be used as a quantita – tive indication of the likelihood that a person would be diagnosed as psychopathic. A self-report measure of ASPD-psychopathy from the perspective of the FFM (the Elemental Psychopathy Assessment) was developed by Lynam et al. (2011). An FFM conceptualization of ASPD also provides some clarity in regards to the often discussed but poorly understood concept of the “successful psychopath” (Hall & Benning, 2006). Systematic research has been con – fined largely to the study of the “unsuccessful” psycho – path, which typically means the incarcerated criminal. However, there is considerable social and theoretical interest in understanding the psychopath who is indeed exploitative, callous, and ruthless, but either manages never to get arrested or convicted, or who pursues a white- collar career that only flirts with the edges of the legal sys – tem (Hall & Benning, 2006). From the perspective of the FFM, these persons share many of the traits of the proto – typic psychopath (i.e., high fearlessness, high in assertive – ness and gregariousness, and high in the exploitativeness, deceptiveness, and callousness of antagonism), but are high rather than low in the facets of conscientiousness (Mullins-Sweatt, Glover, Derefinko, Miller, & Widiger, 2010). Such persons would be even more dangerous than most of the incarcerated psychopaths because they share the disposition to engage in behavior harmful to others, but also possess the traits (deliberation, competence, and self-discipline) that contribute to a more “success – ful” criminal career. A potential case illustration of such a “successful” psychopath is provided by the infamous serial killer, Theodore Bundy. As stated in Samuel and Widiger’s paper regarding Bundy’s FFM ratings: Perhaps the most noteworthy finding from the FFM rat- ings was his generally high ratings on the domain of conscientiousness. In contrast with the impulsive, under – controlled behavior that one would typically expect from an antisocial criminal, Bundy was described as being competent, orderly, achievement oriented and deliberate. Perhaps it was his characteristic style of careful planning and deliberate execution that enabled Bundy to avoid cap – ture and arrest for so many years. (Samuel & Widiger, 2007) Researchers have been attempting to identify the single, core pathology of psychopathy for many years, and a variety of compelling but inconsistent models have been proposed. These alternative conceptualizations can be integrated and their inconsistencies addressed by the FFM (Derefinko & Lynam, 2013). Their apparent inconsist – ency may reflect that each alternative model of pathology is focusing on a different facet or even a different domain of the FFM. For example, poor fear conditioning and elec – trodermal hypoarousal (Fowles & Dindo, 2006) would be placing particular emphasis on the low neuroticism (i.e., low anxiousness or low vulnerability). Lack of response modulation, or an inability to refrain from acting on first impulse (Hiatt & Newman, 2006) would involve the dis – inhibition of low conscientiousness. A deficit in empathy or the processing of affective language (Blackburn, 2006) can be understood in terms of the antagonism facet of cal – lous tough-mindedness. In sum, the personality profile for the prototypic psychopath involves a constellation Maddux, J. E., & Winstead, B. A. (Eds.). (2015). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from apus on 2022-05-26 02:09:20. Copyright © 2015. Taylor & Francis Group. All rights reserved. Personality Disorders Cristina Crego and Thomas A. Widiger 226 of personality traits that together provides a virulent and at times even lethal mix (i.e., high antagonism, low con – scientiousness, low vulnerability, low anxiousness, high assertiveness, high gregariousness, and high excitement- seeking). Researchers though are approaching this constellation like the blind men from Indostan, each inter – preting the location of the elephant upon which they are laying their hands in a much different manner, depending upon which component of the FFM is the focus of their attention (Lynam & Widiger, 2007a). Treatment ASPD is considered to be the most difficult personality disorder to treat (Gunderson & Gabbard, 2000; Hare et al., 2012). Individuals with ASPD can be seduc – tively charming and may declare a commitment to change, but they often lack sufficient motivation. Their declarations of desire to change might even be dishonest. They will also fail to appreciate the future costs associated with antisocial acts (e.g., imprisonment and lack of meaningful interper – sonal relationships), and may stay in treatment only as required by an external source, such as a parole. Residential programs that provide a carefully controlled environment of structure and supervision, combined with peer confron – tation, have been recommended (Gunderson & Gabbard, 2000). However, it is unknown what benefits may be sus – tained after the ASPD individual leaves this environment. During inpatient treatment individuals with ASPD may manipulate and exploit staff and fellow patients. Studies have indicated that outpatient therapy is not likely to be suc – cessful, although the extent to which persons with ASPD are entirely unresponsive to treatment may have been some – what exaggerated (Salekin, 2002). Rather than attempting to develop a sense of conscience in these individuals, thera – peutic techniques should perhaps be focused on rational and utilitarian arguments against repeating past mistakes. These approaches would focus on the tangible, material value of prosocial behavior (Young et al., 2003). Narcissistic Personality Disorder Narcissistic personality disorder (NPD) was first included within the APA diag – nostic manual in DSM-III. Its inclusion “was suggested by an increasing psychoanalytic literature and by the iso – lation of narcissism as a personality factor in a variety of psychological studies” (Frances, 1980, p. 1053). However, it was not included in the 10th edition of the World Health Organization’s International Classification of Diseases (ICD-10; World Health Organization, 1992) despite its presence in the DSM since 1980, as it has been perceived internationally as largely an American concept. It was at one point slated for deletion in DSM-5 (Skodol, 2012). Definition NPD is defined in DSM-5 as a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration or adulation, and lack of empathy. Its pri – mary diagnostic criteria include a grandiose sense of self-importance, preoccupation with success, power, brilliance, or beauty, the belief that one is special and can only be understood by high status individuals, a demand for excessive admiration, a strong sense of entitlement, an exploitation of others, a lack of empathy, and arrogance (American Psychiatric Association, 2000). There has been some concern, however, that the DSM-5 criterion set may place too much emphasis on a grandiose narcissism, which can be associated with suc – cess in work and career, failing to adequately recognize a vulnerable narcissism indicated by a need for admiration, self-devaluation, and feelings of vulnerability, humili – ation or rage in response to criticism or rebuke (Miller et al., 2010; Pincus & Lukowitsky, 2010). It is suggested that narcissistic persons fluctuate between states of gran – diosity and vulnerability, and when in the latter state will not appear at all arrogant, grandiose, or conceited. Etiology and Pathology There has been little systematic research on the etiology of NPD. Twin studies have sup – ported heritability for narcissistic personality traits (South, Reichborn-Kjennerud, Eaton, & Krueger, 2012), although given the trait complexity of narcissism (Glover, Miller, Lynam, Crego, & Widiger, 2012; Pincus & Lukowitsky, 2010; Ronningstam, 2005), it is not entirely clear what precisely is being inherited. The predominant models for the etiology of NPD have been largely social learn – ing or psychodynamic (Ronningstam, 2005). One model proposes that NPD develops through an excessive ideal – ization by parental figures, which is then incorporated by the child into his or her self-image (Horton, 2011). NPD may also develop through unempathic, neglectful, incon- sistent, or even devaluing parental figures who have failed to adequately mirror a child’s natural need for idealiza – tion (Millon, 2011). The child may find that the attention, interest, and perceived love of a parent are contingent largely on achievements or successes. They might then develop the belief that their own feelings of self-worth are dependent upon a continued recognition of such achieve – ments, status, or success by others. The character armor of arrogant self-confidence would mask a vulnerability and at times rage over the feeling of having been so neglected, and perhaps even mistreated and devalued, as a child. Conflicts and deficits with respect to self-esteem are central to the pathology of NPD (Ronninstam, 2005), and there is considerable empirical support for this model in studies published within the general personality literature (Miller et al., 2010; Morf & Rhodewalt, 2000; Pincus & Lukowitsky, 2010). Individuals with NPD must continu – ally seek and obtain signs and symbols of recognition to compensate for conscious or perhaps even unconscious feelings of inadequacy. Narcissism is not simply arro – gant self-confidence as it is more highly correlated with an instability in self-confidence rather than a consistently high self-confidence. Individuals with NPD may at times claim that it is not narcissism if they are in fact brilliant, talented, and successful. However, the pathology would Maddux, J. E., & Winstead, B. A. (Eds.). (2015). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from apus on 2022-05-26 02:09:20. Copyright © 2015. Taylor & Francis Group. All rights reserved. 227 still be evident by an excessive need for the recognition and acknowledgment of their achievements. Differential Diagnosis Narcissistic personality disor- der overlaps substantially with ASPD (Widiger, 2006). Prototypic cases of NPD and ASPD will share the features of lack of empathy, exploitation of others, and arrogance. However, persons with NPD are generally seeking recogni – tion, fame, and success, whereas antisocial persons are gen – erally seeking material benefits. Persons with ASPD will also be generally more impulsive and disinhibited than indi – viduals with NPD. Individuals with ASPD will also lack the vulnerability that can be evident in some persons with NPD. Epidemiology NPD is among the least frequently diag- nosed personality disorders within clinical settings, with estimates of prevalence as low as 2% (American Psychiatric Association, 2013). A curious finding is that many commu – nity studies that have used a semistructured interview have not even been able to identify one single case, despite the substantial amount of research on maladaptive narcissistic personality traits within community and college samples (Miller et al., 2010; Morf & Rhodewalt, 2001; Ronningstam, 2005). NPD is perhaps one of the more difficult personality disorders to assess, as persons are reluctant to acknowledge arrogance, sense of entitlement, lack of empathy, and con – ceit (Cooper, Balsis, & Oltmanns, 2012). DSM-5 NPD is diagnosed more frequently in males (American Psychiatric Association, 2013), consistent with the finding within gen – eral personality research that men tend to be, on average, more arrogant than women (Lynam & Widiger, 2007b). Course This disorder does not generally abate with age and may even become more evident into middle or older age. Persons with this disorder might be seemingly well adjusted and even successful as a young adult, having experienced substantial achievements in education, career, and perhaps even within relationships (Ronningstam, 2005). However, narcissistic personality traits are associated with relation – ship failure (Miller et al., 2010). Relationships with col – leagues, peers, and intimates can become strained over time as the lack of consideration for and even exploitative use of others becomes cumulatively evident. Successes might also become more infrequent with age as the inability to accu – rately perceive or address criticism and setback contributes to a mounting number of defeats. Persons with NPD may at times not recognize their pathology until they have had a substantial number of setbacks, or they have finally rec – ognized that the excessive importance they have given to achievement, success, and status has led to an emptiness and loneliness in their older age (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2005). Five Factor Model Reformulation One of the facets of FFM antagonism is arrogance, the central trait of NPD (American Psychiatric Association, 2013; Millon, 2011). However, as indicated in Table 12.1, additional traits of narcissism can also be described in terms of the FFM. An advantage of the FFM dimensional classification is the ability to distinguish between arrogant persons who are high versus low in neuroticism (Campbell & Miller, 2013; Glover, Miller et al., 2012). A longstanding con – cern within the clinical literature on NPD is the distinc – tion between individuals with NPD who are consistently self-confident, arrogant, and conceited (described as the arrogant or grandiose narcissist; Ronningstam, 2005; Pincus & Lukowitsky, 2010) versus the person with NPD who is quite insecure and self-conscious (referred to as the vulnerable narcissist). The dimensional perspective of the FFM would not suggest the creation of artifactual subtypes of this diagnostic category to distinguish such persons but would simply describe the extent to which a person who is high in arrogance is also low in the anx – iousness, self-consciousness, and vulnerability facets of neuroticism. Further distinctions would be provided by the extent to which the person is low in extraversion (the shy narcissist) versus high in extraversion (the outgoing, interpersonally engaging narcissist), or high in conscien – tiousness (the narcissist who is relatively successful in school, college, and career). Glover, Miller et al. (2012) developed a measure of NPD from the perspective of the FFM titled the Five Factor Narcissism Inventory (FFNI). Treatment Persons rarely seek treatment for their narcis – sistic personality traits. Individuals with NPD enter treat- ment seeking assistance for another mental disorder, such as substance abuse (secondary to career stress), mood disorder (secondary to career setback), or even something quite specific, such as test anxiety. One may at times have persons with NPD seeking treatment for a growing sense of discontent and futility with their lives (Ronningstam, 2005). Once an individual with NPD is in treatment, he or she will have difficulty perceiving the relationship as collaborative and will likely attempt to dominate, impress or devalue the therapist. They can idealize their therapists (to affirm that the therapist is indeed of sufficient status or quality to be treating them) but they may also devalue the therapist to affirm to themselves a sense of superiority . How best to respond is often unclear as the establish – ment and maintenance of rapport will be an immediate and ongoing issue. It may at times be preferable to simply accept the praise or criticism, whereas at other times it is preferable to confront and discuss the motivation for the devaluation (or the idealization). Therapists must be care – ful not to become embroiled within intellectual conflicts and competitions. Individuals with NPD can be acutely aware of the self-esteem conflicts of their therapist, and it is best for the therapist to model a comfortable indiffer – ence to losing disputes or conflicts. Borderline Personality Disorder Borderline personality disorder (BPD) was a new addition to DSM-III (American Psychiatric Association, 1980; Spitzer, Endicott, & Gibbon, 1979). However, it has since become the single Maddux, J. E., & Winstead, B. A. (Eds.). (2015). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from apus on 2022-05-26 02:09:20. Copyright © 2015. Taylor & Francis Group. All rights reserved. Personality Disorders Cristina Crego and Thomas A. Widiger 228 most frequently diagnosed (Gunderson, 2001) and studied (Blashfield & Intoccia, 2000) personality disorder. Definition BPD is a pervasive pattern of impulsivity and instability in interpersonal relationships, affect, and self-image (American Psychiatric Association, 2013). Its primary diagnostic criteria include frantic efforts to avoid abandonment, unstable and intense relationships, impulsivity (e.g., substance abuse, binge eating, or sexual promiscuity), recurrent suicidal thoughts and gestures, self-mutilation, and episodes of rage and anger. Etiology and Pathology There are studies supportive of BPD as a disorder with a distinct genetic disposition but many studies have also suggested a shared genetic asso- ciation with mood and impulse control disorders (South et al., 2012). There is also substantial empirical support for a childhood history of physical and/or sexual abuse, paren – tal conflict, loss, and neglect (Silk, Wolf, Ben-Ami, & Poortinga, 2005). Past traumatic events are present in many (if not most) cases of BPD, contributing to the comorbidity with post-traumatic stress and dissociative disorders (Gunderson, 2001; Hefferman & Cloitre, 2000). BPD is perhaps best understood as an interaction of an emotionally unstable temperament with a cumulative and evolving series of intensely pathogenic relationships (Gunderson, 2001; Widiger, 2005). The pathogenic mechanisms of BPD are addressed in numerous theories. Most concern issues of abandon – ment, separation, and/or exploitative abuse. Persons with BPD will often describe quite intense, disturbed, and/or abusive relationships with the significant persons of their past (Gunderson, 2001). The development of malevo – lent perceptions and expectations of others is not sur – prising (Ornduff, 2000). These malevolent expectations and lingering feelings of bitterness and rage, along with an impairment in the ability to regulate affect (Linehan, 1993), may contribute to the perpetuation of intense, hos – tile, and unstable relationships. Differential Diagnosis Most persons with BPD develop quite a number of other mental disorders, including mood, dissociative, eating, substance use, and anxiety disorders (Hooley et al., 2012). It can be difficult to differentiate BPD from these disorders if the assessment is confined to current symptomatology (Gunderson, 2001). The diagnostic criteria for BPD require that the symptomatology be evident since adolescence, which should differentiate BPD from other mental disorders in most cases. If a chronic mood disorder is present, then the additional features of transient, stress- related paranoid ideation, dissociative experiences, impul – sivity, and anger dyscontrol of BPD should be emphasized in the diagnosis (Gunderson, 2001). Epidemiology It is estimated that 1–2% of the gen – eral population would meet the DSM-5 criteria for BPD (Torgersen, 2012). BPD is the most prevalent personality disorder within most clinical settings (Hooley et al., 2012). Approximately 15% of all inpatients (51% of inpatients with a personality disorder) and 8% of all outpatients (27% of outpatients with a personality dis- order) will meet criteria for BPD. Approximately 75% of persons diagnosed with BPD are female (Lynam & Widiger, 2007b). Course Individuals with BPD are likely to report having been emotionally unstable, impulsive, and angry as chil – dren, however there is little longitudinal research on the childhood antecedents of BPD (De Fruyt & De Clercq, 2012). As adolescents, their intense affectivity and impul- sivity may contribute to involvement with rebellious groups, along with the development of a variety of other psychological disorders, including eating, substance, and mood disorders. BPD is at times diagnosed in children and adolescents but considerable caution should be used when doing so, as some of the symptoms of BPD (e.g., identity disturbance, hostility, and unstable relationships) could be confused with a normal adolescent rebellion or identity crisis (Gunderson, 2001). As adults, persons with BPD may be repeatedly hos – pitalized, owing to their affect and impulse dyscontrol, psychotic-like and dissociative symptoms, suicidal behav – ior, and non-suicidal self-injurious behavior (Gunderson, 2001). Persons with BPD are said to be manipulative with respect to their suicidal gestures, threats, and attempts, but the risk of death from suicide in people who suffer from BPD is actually high (Hooley et al., 2012).The risk of suicide is increased with a comorbid mood disorder and substance-related disorder. It is estimated that 3–10% of persons with BPD will have committed suicide by the age of 30 (Gunderson, 2001). Intimate relationships tend to be unstable and explosive, and employment history is gener – ally poor. As the person reaches the age of 30, affective lability and impulsivity may begin to diminish (Skodol et al., 2005; Zanarini et al., 2005). These symptoms may lessen earlier if the person becomes involved with a sup – portive and patient sexual partner. Some, however, may obtain stability by abandoning the effort to obtain a rela – tionship, opting instead for a lonelier but less volatile life. Five Factor Model Reformulation BPD is primarily com- posed of excessively high negative affectivity. In par – ticular, these individuals are at the very highest range of anxiousness, angry hostility, depressiveness, impulsive- ness, and vulnerability (see Table 12.1). Clients who have BPD will also likely be low in the agreeableness facets of trust and compliance, and low on the conscientiousness facets of order and deliberation (Trull & Brown, 2013). The FFM conceptualization of BPD is helpful in explaining its substantial prevalence within clinical set – tings and its excessive diagnostic comorbidity. A diag – nostic category defined primarily by all of the facets of neuroticism (i.e., vulnerability to stress, impulse Maddux, J. E., & Winstead, B. A. (Eds.). (2015). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from apus on 2022-05-26 02:09:20. Copyright © 2015. Taylor & Francis Group. All rights reserved. 229 dyscontrol, despondence, rage, and other components of negative affectivity) will be highly prevalent within clini- cal settings. In addition, most of the other DSM-5 per – sonality disorders include at least some components of neuroticism. Lynam and Widiger (2001) demonstrated that much of the diagnostic co-occurrence of BPD with other personality disorders is explained by common facets of neuroticism. Mullins-Sweatt, Edmundson et al., (2012) developed a measure of BPD from the perspective of the FFM titled the Five Factor Borderline Inventory. Treatment Clients with BPD form relationships with therapists that are similar to their other significant rela- tionships; that is, the therapeutic relationship can often be tremendously unstable, intense, and volatile. Ongoing consultation with colleagues is recommended to address potential negative reactions toward the client (e.g., dis – tancing, rejecting, or abandoning the patient in response to feelings of anger or frustration) as well as positive reactions (e.g., fantasies of being the therapist who in fact rescues or cures the patient, or romantic, sexual feel – ings in response to a seductive patient). Sessions should emphasize the building of a strong therapeutic alliance, monitoring self-destructive and suicidal behaviors, vali – dation of suffering and abusive experience (but also help – ing the client take responsibility for actions), promotion of self-reflection rather than impulsive action, and setting limits on self-destructive behavior (Gunderson, 2001). The tendency of borderline patients to engage in “split – ting” (polarization of an emotional response) should also be carefully monitored and addressed (e.g., devaluation of prior therapists, coupled with idealization of current therapist). The APA (2001) has published practice guidelines for the psychotherapeutic and pharmacologic treatment of persons with BPD. Because patients with BPD can pres – ent with significant suicide risk, a thorough evaluation of the potential for suicidal ideation and activity should have the initial priority (Hooley et al., 2012). There is empirical support for both psychodynamic and cognitive-behavioral treatments of BPD (American Psychiatric Association, 2001). The most common version of the former approach is mentalization-based treatment (Bateman & Fonagy, 2012). This treatment uses many structured techniques to help persons with BPD to “mentalize,” or stand outside their feelings and more accurately observe the feelings within themselves and others. The most common form of cognitive-behavioral BPD treatment is dialectical behav – ior therapy (DBT; Lynch, Trost, Salsman, & Linehan, 2007). The dialectical component of DBT was derived largely from Zen Buddhist principles of overcoming suf- fering through acceptance (Linehan, 1993). Mastery of conflict is achieved in part through no longer struggling or fighting adversity; pain is overcome when it is accepted as an inevitable, fundamental part of life. This principle is taught in part through the meditative technique of mind – fulness, in which one attempts to empty one’s mind of all thoughts, but accepts whenever and wherever the mind naturally travels. DBT initially focuses on reducing self- harm and para-suicidal behaviors that are disruptive to treatment. Contracts may be implemented, wherein time with the therapist is limited secondary to treatment disrup – tive behavior. This can even go so far as to include sus – pension of treatment secondary to suicidal behavior. After mastery of treatment disruptive behavior, DBT teaches coping skills focused on emotional control and interper- sonal relatedness. Individuals in DBT attend regular ses- sions with an individual therapist and discuss problems in applying the new skills. These sessions are augmented with a didactic skills-training group. Schizotypal Personality Disorder Schizotypal personal- ity disorder (STPD) was a new addition to DSM-III. Its diagnostic criterion set was developed originally from studies of biological relatives of persons diagnosed with schizophrenia (Spitzer et al., 1979). Definition STPD is characterized by a pervasive pattern of social and interpersonal deficits marked by an acute dis – comfort with close relationships, eccentricities of behav – ior, and cognitive-perceptual aberrations. Diagnostic criteria for STPD include odd beliefs, magical thinking, social withdrawal, unusual perceptual experiences, odd speech, inappropriate or constricted affect, social anxiety, and social withdrawal (American Psychiatric Association, 2013). Etiology and Pathology STPD is not included within the personality disorder section of the ICD-10; it is clas – sified instead as a form of schizophrenia (World Health Organization, 1992). There is compelling empirical sup – port for a genetic association of STPD with schizophrenia (Kwapil & Barrantes-Vidal, 2012) which is not surpris – ing given that the diagnostic criteria were obtained from the observations of biological relatives of persons with schizophrenia (Miller, Useda, Trull, Burr, & Minks- Brown, 2001). A predominant model for the psychopathology of STPD is deficits or defects in the attention and selection processes that organize a person’s cognitive-perceptual evaluation of and relatedness to his or her environment (Raine, 2006). These deficits may lead to discomfort within social situations, misperceptions and suspicions, and a coping strategy of social isolation. Correlates of central nervous system dysfunction seen in persons with schizophrenia have been observed in STPD laboratory studies, including performance on tests of visual and audi – tory attention (e.g., backward masking and sensory gating tests) and smooth pursuit eye movement (Parnas, Licht, & Bovet, 2005). This dysfunction may be the result of dysregulation along dopaminergic pathways, which could be serving to modulate the expression of an underlying schizotypal genotype. Maddux, J. E., & Winstead, B. A. (Eds.). (2015). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from apus on 2022-05-26 02:09:20. Copyright © 2015. Taylor & Francis Group. All rights reserved. Personality Disorders Cristina Crego and Thomas A. Widiger 230 Differential Diagnosis An initial concern for many cli – nicians when confronted with a person with STPD is whether the more appropriate diagnosis might be schizo – phrenia. Persons with severe variants of STPD can closely resemble persons within the prodromal (or residual) phase of schizophrenia (American Psychiatric Association, 2013). A differentiation of the two conditions can be guided in part by age of onset and whether there is a recent deterioration in functioning. Persons with STPD will have evidenced their social anxiety, social withdrawal, magi- cal thinking, odd behavior, and perceptual aberrations since childhood, and will not typically be characterized by any recent deterioration in functioning. Longitudinal follow-up would provide the conclusive differentiation, as a prodromal phase of schizophrenia will eventually be fol – lowed by an active psychotic episode. The close relationship of STPD to the phenomenology, genetics, and pathology of schizophrenia has suggested that perhaps it should in fact be classified in future edi – tions of the Diagnostic Manual as a variant of schizophre – nia rather than a personality disorder (Skodol, 2012). In DSM-5, STPD is included in both the personality disor – ders and the schizophrenia spectrum sections. However, contrary to conceptualizing STPD as a form of schizo – phrenia is that STPD is much more comorbid with other personality disorders than with psychotic disorders, per – sons with STPD very rarely develop schizophrenia, and schizotypal symptomatology is evident within the general population in persons with no apparent genetic relation- ship to schizophrenia (Raine, 2006). Epidemiology STPD may occur in as much as 3% of the general population although most studies with semi – structured interviews have suggested a somewhat lower percent (Torgersen, 2012). STPD might occur somewhat more often in males (Parnas et al., 2005; Raine, 2006). Course There is insufficient research to describe the child – hood precursors of adult STPD (De Fruyt & De Clercq, 2012). There are, however, retrospective reports of neuro – developmental abnormalities in infancy and childhood for persons diagnosed with STPD (Raine, 2006; Parnas et al., 2005). During childhood they would be expected to have appeared peculiar and odd to their peers, and may have been teased or ostracized. Achievement in school might be impaired, and they may have been heavily involved in esoteric fantasies and peculiar interests. As adults, they may drift toward esoteric, fringe groups that support their magical thinking and aberrant beliefs. These activities can provide structure for some persons with STPD, but they can also contribute to a further loosening and deteriora – tion if there is an encouragement of aberrant experiences. The symptoms of STPD do not appear to remit with age (Miller et al., 2001; Raine, 2006). The course appears to be relatively stable, with some proportion of schizotypal persons remaining marginally employed, withdrawn, and transient throughout their lives. Schizotypal symptoms, as measured in scales assessing cognitive-perceptual aberrations, magical thinking, and social and physical anhedonia, have been studied longitudinally in a number of community samples, and the findings to date do not suggest any meaningful likelihood of the development of schizophrenia (Gooding, Tallent, & Matts, 2005). Five Factor Model Reformulation The FFM conceptu- alization of STPD views it as a disorder of introversion (social withdrawal), neuroticism (anxiousness), and mal – adaptive openess. Key to STPD are the magical ideation, cognitive-perceptual aberrations, and eccentric behaviors, which are considered within the FFM of personality disor – der to be maladaptive variants of openness to ideas, fanta- sies, and actions (Edmundson & Kwapil, 2013). FFM openness has obtained weak relationships with schizotypal thinking in some studies (Krueger et al., 2011; Watson, Clark, & Chmielewski, 2008). Recent studies, however, have reported a convergence of FFM openness with the cognitive and perceptual aberrations of schizotypy (De Fruyt et al., 2013; Gore & Widiger, 2013; Thomas et al., 2013). The existence of the relation – ship appears to depend on how both schizotypal think – ing and FFM openness are conceptualized and assessed (Chmielewski, Bagby, & Markon, 2014; Gore & Widiger, 2013). Traditional measures of FFM openness empha- size a healthy psychological functioning, with items con- cerning aspects of self-realization and self-actualization. However, other measures of openness include as well aspects of unconventionality and peculiarity. Edmundson et al. (2011) developed a measure of STPD from the per- spective of the FFM titled the Five Factor Schizotypal Inventory. Treatment Persons with STPD may seek treatment for anxiousness, perceptual disturbances, or depression. Treatment of persons with STPD should be cognitive, behavioral, supportive, and/or pharmacologic, as they will often find the intimacy and emotionality of reflective, exploratory psychotherapy to be too stressful and they have the potential for psychotic decompensation. Persons with STPD will often fail to consider their social isolation and aberrant cognitions and perceptions to be particularly problematic or maladaptive. They may consider themselves to be simply eccentric, creative, or nonconformist. Rapport can be difficult to develop, as increasing familiarity and intimacy may only increase their level of discomfort and anxiety (Millon, 2011). They are unlikely to be responsive to informality or playful humor. The sessions should be well structured, to curb loose and tangential ideation. Practical advice is usually helpful and often necessary (Kwapil & Barrantes-Vidal, 2012). The therapist should serve as the patient’s counselor or guide to more adaptive decisions with respect to everyday problems (e.g., finding an apartment, interviewing for a job, and personal appear- ance). Persons with STPD should also receive social skills Maddux, J. E., & Winstead, B. A. (Eds.). (2015). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from apus on 2022-05-26 02:09:20. Copyright © 2015. Taylor & Francis Group. All rights reserved. 231 training directed at their awkward and odd behavior, man- nerisms, dress, and speech. Specific, concrete discussions on what to expect and do in various social situations (e.g., formal meetings, casual encounters, and dates) should be provided.Most of the systematic empirical research on the treat – ment of STPD has been confined to pharmacologic inter – ventions. Low doses of neuroleptic medications (e.g., thiothixene) have shown some effectiveness in the treat- ment of schizotypal symptoms, particularly the percep- tual aberrations and social anxiousness (Silk & Feurino, 2012)). Group therapy has also been recommended for persons with STPD but only when the group is highly structured and supportive (Millon, 2011). The emotional intensity and intimacy of unstructured groups will usually be too stressful. Schizotypal patients with predominant paranoid symptoms may even have difficulty in highly structured groups. Dependent Personality Disorder A diagnosis of depen – dent personality disorder (DPD) was, technically speak – ing, a new addition to DSM-III, in that it had not been included within the prior edition of the Diagnostic Manual. However, a diagnosis of passive-dependent personality trait disturbance was included within the first edition. The diagnosis, however, was slated for deletion in DSM-5 (Skodol, 2012), despite there being a considerable body of research to support the validity and clinical importance of dependent personality traits (Bornstein, 2012b; Gore & Pincus, 2013; Mullins-Sweatt, Bernstein et al., 2012). Fortunately, this disorder was retained because all of the proposals for DSM-5 were rejected, including the pro – posal to delete half of the personality disorders. Definition DPD involves a pervasive and excessive need to be taken care of that leads to submissiveness, clinging, and fears of separation (American Psychiatric Association, 2013; Bornstein, 2005). Its primary diagnos- tic criteria include extreme difficulty making decisions without others’ input, need for others to assume respon – sibility for most aspects of daily life, difficulty disagree – ing with others, inability to initiate projects due to lack of self-confidence, and going to excessive lengths to obtain the approval of others. Etiology and Pathology Insecure interpersonal attach – ment is considered to be central to the etiology and pathol – ogy of DPD (Bornstein, 2005; Luyten & Blatt, 2013). Insecure attachment and helplessness may be generated through a parent–child relationship, perhaps by a cling – ing parent or by continued infantilization during a time in which individuation and separation normally occurs (Bornstein, 2012a). However, the combination of an anx – ious and/or inhibited temperament with inconsistent or overprotective parenting may also generate and exacer – bate dependent personality traits (Bornstein, 2005; Luyten & Blatt, 2013). Unable to generate feelings of security and confidence for themselves, dependent persons may rely on a parental figure for constant reassurance of their worth. Eventually, persons with DPD may come to believe that their self-worth is defined by their importance to another person. Differential Diagnosis Excessively dependent behavior may be seen in persons who have developed debilitat – ing mental and physical conditions, such as agoraphobia, schizophrenia, severe injuries, or dementia. However, a diagnosis of DPD requires the presence of the depen – dent traits since late childhood or adolescence (American Psychiatric Association, 2013). One can diagnose the presence of a personality disorder at any age during a person’s lifetime, but if (for example) a DPD diagnosis is given to a person at the age of 75, this presumes that the dependent behavior was evident since the age of approxi – mately 18 (i.e., predates the onset of a comorbid physical impairment or disability secondary to aging; Oltmanns & Balsis, 2011). Epidemiology DPD is one of the more prevalent per- sonality disorders and is estimated to occur in 5–30% of patients and 2–4% of the general community (Torgersen, 2012). Longitudinal studies have indicated that dependent personality traits are a risk factor for the development of depression in response to interpersonal loss (Gore & Pincus, 2013; Hammen, 2005). Course To the extent that independent responsibility and initiative are required, job functioning will be impaired or unsatisfactory. Individuals with DPD are prone to mood disorders throughout life, particularly major depression and dysthymia, and to anxiety disorders, particularly ago – raphobia, social phobia, and panic disorder (Bornstein, 2005). There is also a considerable body of research to indicate significant social and personal costs for depen- dent personality traits, including increased risk for suicide, victimization, and excessive health care use (Bornstein, 2012b). The self-esteem of a person with DPD is said to depend substantially on the maintenance of a supportive and nurturant relationship (Bornstein, 2005; Luyten & Blatt, 2013), yet these intense needs for reassurance can have the paradoxical effect of driving the needed person away. The dependent person’s worst fears are then realized (i.e., he or she is abandoned and alone), and his or her sense of self- worth, meaning, or value is then furthered injured, perhaps even crushed by the rejection (Shahar, Joiner, Zuroff, & Blatt, 2004). The dependent person might then indis – criminately select a readily available but unreliable (and perhaps even abusive) person simply to be with someone (Widiger & Presnall, 2012). This partner would again reaffirm the worst fears through the abuse, derogation, and denigration (i.e., conveying to the dependent person that he or she is indeed undesirable and unlovable and that the relationship is again tenuous). Maddux, J. E., & Winstead, B. A. (Eds.). (2015). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from apus on 2022-05-26 02:09:20. Copyright © 2015. Taylor & Francis Group. All rights reserved. Personality Disorders Cristina Crego and Thomas A. Widiger 232 Research on the relationship of dependency to depres- sion, however, is not without fundamental concerns (Coyne, Thompson, & Whiffen, 2004). In theory, dependent per – sonality traits contribute to the instability of intimate and supportive relationships through the expression of exces – sive needs for reassurance and/or a premorbid emotional instability and pathogenic cognitions that contribute to intense feelings of helplessness and neediness. However, it is also possible that the emotional instability and pathologic attitudes are themselves the result of unstable interpersonal relationships. Dependency is a personality disposition that is seen much more often in women than in men (Lynam & Widiger, 2007b). A provocative reformulation of depen – dency in women is that the apparent feelings of insecurity may say less about the women than the persons with whom the women are involved. “Men and women may differ in what they seek from relationships, but they may also dif – fer in what they provide to each other” (Coyne & Whiffen, 1995, p. 368). In other words, “women might appear (and be) less dependent if they weren’t involved with such unde – pendable men” (Widiger & Anderson, 2003, p. 63). Five Factor Model Reformulation Dependent personality is characterized in terms of the FFM by maladaptively high levels of agreeableness (meek, gullible, & compliant) and the neuroticism facets of anxiousness, self-consciousness, and vulnerability (see Table 12.1). Researchers have indeed veri- fied an association between the FFM domain of agreeableness and dependent personality disorder symptomatology (Gore & Pincus, 2013; Lowe, Edmundson, & Widiger, 2009). A controversial issue in the diagnosis of DPD has been its differential sex prevalence (Oltmanns & Powers, 2012). DPD is diagnosed much more frequently in females (American Psychiatric Association, 2013) and some have argued that this may reflect a masculine bias toward what constitutes a personality disorder and/or a failure of males to acknowledge the presence of dependency needs (Bornstein, 2005). One difficulty in resolving this issue is the absence of any gold standard or even theoretical basis for hypothesizing, let alone determining, whether there should in fact be a differential sex prevalence rate. Understanding the DSM-5 personality disorders from the perspective of the FFM, however, does provide a theo- retical basis for gender difference expectations (Lynam & Widiger, 2007b). Researchers have consistently found that women tend to score higher than men on the domains of agreeableness and neuroticism (Costa & McCrae, 1992). Costa, Terracciano, and McCrae (2001) found these dif – ferences to be consistent across 26 cultures, ranging from very traditional (Pakistan) to modern (Netherlands). Thus, to the extent that DPD is a maladaptive variant of FFM agreeableness and neuroticism, one should then expect to obtain a differential sex prevalence rate. This is not to suggest, however, that no gender bias operates in clinical assessments. Studies have indicated that some self-report inventories are providing gender biased assessments of DPD (Lindsay, Sankis, & Widiger, 2000). The Millon Clinical Multiaxial Inventory-III (MCMI- III; Millon, Millon, Davis, & Grossman, 2009) and the Minnesota Multiphasic Personality Inventory-2 (Colligan, Morey, & Offord, 1994) are two of the more commonly used measures of personality disorder, and these measures include gender-related items that are keyed in the direction of adaptive rather than maladaptive functioning. An item need not assess for dysfunction to contribute to a valid assessment of personality disorders. For example, items assessing for gregariousness can identify histrionic persons, items assessing for confidence can identify narcissistic persons, and items assessing conscientiousness can iden – tify obsessive-compulsive persons (Millon, 2011). Items keyed in the direction of adaptive rather than maladaptive functioning can also be helpful in countering the tendency of some respondents to deny or minimize personality dis- order symptomatology. However, these items will not be useful in differentiating abnormal from normal personality functioning and they will contribute to an over-diagnosis of personality disorders in normal or minimally dysfunctional populations, as seen, for example, in MCMI-III assess – ments in student counseling centers, child custody disputes, and personnel selection (Widiger & Boyd, 2009). Gore, Presnall, Miller, Lynam, & Widiger (2012) developed a measure of DPD from the perspective of the FFM titled the Five Factor Dependency Inventory. Treatment There are no empirically validated treatments for DPD. Treatment recommendations are based essen – tially on anecdotal clinical experience. Persons with DPD will often be in treatment for one or more other mental disorders, particularly a mood (depressive) or an anxiety disorder. These individuals will tend to be very agreeable, compliant, and grateful, at times to excess (Bornstein, 2005, 2012b). Many individuals with DPD will find that the therapeutic relationship itself satisfies their need for support and concern and may then desist from seeking a partner. The client may be compliant and agreeable in order to be a patient that the therapist would continue to treat. Therapists should be careful to neither unwittingly encourage a compliant submissiveness, nor to reject the client in order to be rid of their clinging dependency. An important component of treatment can be a thor – ough exploration of the need for support and its root causes. Cognitive-behavioral techniques can be useful to address feelings of inadequacy and helplessness, and to provide training in assertiveness and problem-solving techniques (Leahy & McGinn, 2012). Group therapy may be useful for persons with DPD, providing interpersonal feedback and modeling autonomous behavior. DPD is not known to respond to pharmacotherapy. Conclusions Maladaptive personality traits will often impair or impede the treatment of other mental disorders and should often be the focus of clinical treatment. Reviews of practitioners’ Maddux, J. E., & Winstead, B. A. (Eds.). (2015). Psychopathology : Foundations for a contemporary understanding. Taylor & Francis Group. Created from apus on 2022-05-26 02:09:20. Copyright © 2015. Taylor & Francis Group. All rights reserved. 233 clinical records suggest, however, that personality disor- ders are not being diagnosed as frequently as they in fact occur, perhaps because the clinician’s attention is being drawn to a mood, anxiety, substance use, or other form of psychopathology that has captured his or her immediate attention. It can be difficult to obtain insurance coverage for the treatment of a personality disorder due to the inac – curate assumption that they are not in fact treatable. This is regrettable because some maladaptive personality traits (e.g., borderline and antisocial) have substantial social and public health care costs. Section 3 of DSM-5, for emerging models and mea – sures, includes a five-domain, 25-trait dimensional model of personality disorder that is closely aligned, both con – ceptually and empirically with the FFM of general person – ality structure. The FFM offers a compelling alternative to the categorical diagnosis of personality disorders provided in DSM-5. Advantages of understanding personality dis- orders in terms of this dimensional model are the provi – sion of more specific descriptions of individual patients (including adaptive as well as maladaptive personality functioning), the avoidance of arbitrary categorical dis – tinctions, and the ability to bring to bear the extensive amount of research on the heritability, temperament, development, and course of general personality func- tioning to an understanding of personality disorders. It is unclear what role the FFM, or dimensional personality trait models in general, will play in future editions of the DSM, It is evident that the classification of psychopathol – ogy is shifting toward dimensional models (Regier, 2008), but there remains considerable opposition to this shift, including even for the personality disorders (Gunderson, 2010; Shedler et al., 2010). 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