Chapter 16 Personality disorders covered in this chapter can be found in both Sections II and III of the DSM-5. We first discuss personality disorders found in Section II, which lists all current diagnostic criteria and codes being used by clinicians. Following this brief description, we explain the proposed model for diagnosing and conceptualizing personality disorders found in Section III of the DSM-5 titled Emerging Measures and Models. We explain the reasoning behind this newly proposed approach, describe various viewpoints regarding the new model, and list practice implications for counselors regarding these proposed changes. Counselors currently in practice should note this model has not been adopted into the general nomenclature system. Currently, this new approach only serves the purpose of stimulating future research endeavors and generating discussion about a dimensional versus hybrid (i.e., containing both categorical and dimensional criteria) approach to personality dysfunction. Readers will find this discussion useful because we anticipate that the diagnostic criteria for personality disorders will soon be replaced. With the exception of adding diagnostic information related to culture (Peluso, 2013), there were very minor changes to the Personality Disorders chapter within the DSM-5. Therefore, we have chosen to cover these disorders in less detail, providing readers with a short description of each disorder that includes essential features, special and general cultural considerations, and common differential diagnoses. We wish to emphasize that counselors who currently understand personality disorder nomenclature as presented in the DSM-IV-TR only need to be concerned with very minor, mostly semantic, changes to this section of the DSM-5. Personality disorders permeate an individual’s internal and external presentation, are typically rigid and uncompromising, have an onset prior to early adulthood, are chronic dysfunctions (as opposed to episodic), and are very slow to change (APA, 2013a; Durand & Barlow, 2010; Paris, 2013). The disorders discussed in this chapter fall within 10 distinct types: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive. All of these disorders share common biological etiology (i.e., inherited traits) and are grouped according to symptomatology. Cluster A disorders are characterized by odd, eccentric thinking or behavior; Cluster B by dramatic, overly emotional thinking or behaviors; and Cluster C by anxious, fearful, or obsessive thinking and behavior (APA, 2013a). Note There is no empirical evidence supporting the clustering system used by the APA in the DSM-5. This system was maintained in the DSM-5 for the purpose of clinical utility and to be used in research and academic settings. Disorders found within the Personality Disorders chapter of the DSM-5 are characterized by persistent maladaptive patterns of behavior, cognition, affect, and interpersonal functioning that deviate from one’s cultural norms (APA, 2013a). These traits have a significant negative impact on the client’s life, limiting his or her ability to function in essential areas such as work, home, or school. Lifetime prevalence of personality disorders is estimated at 15% (APA, 2013a). However, some claim this number is drastically inflated and merely a product of poorly constructed diagnostic criteria (Paris, 2013). The APA (2013a) defines personality disorder 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. (p. 645) This definition seems to have an inherent message that personality disorders are permanent and thus resistant to treatment (Paris, 2013). Individuals diagnosed with personality disorders are generally stereotyped as difficult, unlikable, and extremely challenging (Comer, 2013; Frances, 2013; Nietzel, Speltz, McCauley, & Bernstein, 1998). Although we agree this population is challenging to treat, we side with Paris (2013), who challenged the claim that treatment for these disorders is ineffective. These disorders have been misunderstood primarily because of their complexity; differentiating between normal personality functioning and pathological personality functioning is a complicated task. Critics of the DSM-IV-TR (and subsequently DSM-5) nosology have claimed the current categorical diagnoses within this chapter are just as confusing as the definition. Clinicians maintain there is significant overlap and comorbidity between the 10 personality disorder categories (Paris, 2013; Rosenbaum & Pollock, 2002). There is also considerable heterogeneity within diagnostic classifications, as evidenced by some diagnoses that require only five of 10 criteria (Paris, 2013). Finally, clinical utility has traditionally been difficult, as evidenced by overuse of the personality disorder NOS diagnosis (Pagan, Oltmanns, Whitmore, & Turkheimer, 2005; Rosenbaum & Pollock, 2002). Adding to this challenge is evidence that these disorders typically respond better to psychotherapeutic treatment than to psychotropic medication (Mercer, Douglass, & Links, 2009; Olabi & Hall, 2010). Because research points to the therapeutic alliance as the primary predictor of positive client outcomes (Bachelor, 2013; Lambert & Barley, 2001; Strunk, Brotman, & DeRubeis, 2010), it is difficult for many within the mental health field to conceptualize that counseling is a more effective treatment modality. Aside from the therapeutic alliance, empirical evidence is limited as to the efficacy of different treatment approaches; thus, treatment decisions are typically arbitrary (Rosenbaum & Pollock, 2002). These controversies fueled the DSM-5 Personality and Personality Disorders Work Group to present a new model for diagnosing personality disorders. The final model, discussed in more detail toward the end of this chapter, proposed a hybrid categorical and dimensional approach. The original proposal, a strictly dimensional model, scored trait dimensions as a way to reduce ambiguous boundaries. Only measuring deviations from normal functioning or “amplifications of normal personality profiles” (Paris, 2013, p. 157), this model was rejected. A second model by the work group was proposed, but this model was also rejected because the new approach minimized personality disorder categories and lacked empirical validation (Paris, 2013). As a result, only minor changes were made to the Personality Disorders chapter of the DSM-5, and a proposed model for diagnosing personality disorders is now included within Section III of the DSM-5. Before discussing this proposed model and future implications for counselors, we briefly review changes from DSM-IV-TR to DSM-5. The major change to personality disorders within the DSM-5 results from the collapse of the multiaxial system into one axis. As a result, personality disorders are not differentiated from other disorders as they have been in the past. The APA (2013d) reported the former distinction as artificial and stated that there are no basic differences between Axis I and Axis II disorders (also see Grohol, 2013). Furthermore, whereas a dimensional approach is applied to other disorders in the manual, personality disorders have not been changed to match this philosophical shift and are still represented categorically (Peluso, 2013). Other changes within these disorders involve subtle changes regarding culture. More predominantly featured in the DSM-5 is emphasis on cultural factors. For example, antisocial personality disorder tends to be overdiagnosed among individuals of lower socioeconomic status. Acculturation problems may look diagnostically similar to avoidant personality disorder. Finally, high level of productivity and a strong focus on work is a cultural trend within some cultures and could potentially be characteristic of some obsessive-compulsive personality disorder. Including this information in the DSM-5 can help counselors avoid misdiagnosis and allow for better representation of cultural issues that are not pathological (Peluso, 2013). Personality disorders are marked by a significant cultural deviation in the pattern of actions and internal focus and require that the individual experience problems in at least two of four areas (APA, 2013a). These areas include a pattern of cognitive distortions as related to perceptions of self, others, and the external world; affective or emotional responses that can be intense, inappropriate, and vary widely in nature; intense difficulty with interpersonal interactions; and impulse control impairment. The patterns associated with personality disorders exist in nearly all aspects of clients’ lives and vary little in the application to their life roles and relationships (APA, 2013a; Comer, 2013; Nietzel et al., 1998). The onset usually begins in adolescence or early adulthood and results in clinically significant distress and impairment in multiple areas of functioning (APA, 2013a). Furthermore, as with other disorders, the symptoms of personality disorders cannot be attributed to any other disorder or the effects of medication or a medical condition (APA, 2013a). It is important to note that the diagnosis must be given only when a stable, long-term pattern of these behaviors has been established. However, in terms of diagnosing, counselors will not typically be the primary mental health provider assigning a personality disorder diagnosis to a client. Because personality disorders represent a persistent, marked change from the client’s cultural patterns and norms, it is imperative that counselors understand the client’s culture, cultural origin, and cultural expectations, including customs, habits, religion, and political views. Additionally, gender is an important consideration in diagnosing, and counselors should carefully watch for gender bias (Durand & Barlow, 2010). For example, antisocial personality disorder is more prevalent in men than in women; however, borderline, histrionic, and dependent personality disorders tend to be diagnosed, perhaps overdiagnosed, more often in women than in men. Again, counselors are encouraged to diagnose in an ethical manner consistent with the ACA Code of Ethics (ACA, 2014). Because personality disorders are lifelong, pervasive disorders rather than brief changes in personality, counselors need to ensure that the symptoms observed are not related to a change in personality related to substance use, medications, or another medical condition. Counselors should also note the overlap in symptoms among the personality disorders as well as significant comorbidity within this diagnostic class (Durand & Barlow, 2010). Within each disorder, we discuss the distinctive elements in detail to make differentiating these a bit easier. The defining characteristics of paranoid personality disorder include a mistrust and suspicion of other people and their motives that begin in early adulthood and persist across multiple aspects of the individual’s life (APA, 2013a; Durand & Barlow, 2010). The mistrust must be manifested in at least four areas, including constant suspicion that others are planning to trick, harm, or exploit the individual; an inability to trust or believe in the loyalty of friends; and/or difficulty confiding in people because of fear that what is shared will be used against the individual. An individual with paranoid personality disorder may have a pervasive pattern of not forgiving others, perceive threats or insults in normal events or conversations, believe that others are engaging in assaults on his or her character and feel the need to attack in response, and chronically believe that his or her spouse or partner is unfaithful (APA, 2013a). It is important for counselors to ensure that the symptoms associated with paranoid personality disorder do not only occur during psychosis, a manic episode, or an episode of major depression with psychotic features and that the symptoms are not a result of another medical condition, medications, or substance use (APA, 2013a). Individuals with this disorder will have relationship difficulties and often seem to be argumentative, hostile, aloof, or cold toward others. Family and partner relationship difficulties are not uncommon, as individuals diagnosed with paranoid personality disorder are often extremely self-reliant, controlling, and suspicious. Furthermore, these individuals are not likely to seek treatment and, when they do, have even more difficulty engaging in a trusting relationship with a therapist (Durand & Barlow, 2010). Paranoid personality disorder occurs more in men than in women (Durand & Barlow, 2010), and it is estimated that about 4.4% of the population has this disorder (APA, 2013a). Symptoms of this disorder should not be confused with reactions related to the experience of disenfranchised or oppressed groups, such as minorities, immigrants, or refugees. Individuals with a family history of psychotic disorders or those who have unique experiences such as being incarcerated are more susceptible to being diagnosed with paranoid personality disorder (Durand & Barlow, 2010). Note Throughout this chapter, readers will notice that most personality disorders occur more frequently in men than in women. However, gender bias in diagnosing personality disorders is not uncommon (Durand & Barlow, 2010; Ford & Widiger, 1989). Although prevalence information regarding gender is important, counselors should carefully consider the client’s diagnostic profile and watch for gender bias. Paranoid personality disorder should not be confused with the symptoms of psychotic disorders such as schizophrenia. This diagnosis should be given only if the symptoms occur before psychotic symptoms and continue after psychosis abates. If this occurs, paranoid personality disorders should be listed with the word premorbid following the diagnosis. It is important to note that there is a strong comorbidity among personality disorders, and counselors must carefully screen to ensure that another personality disorder, such as schizotypal, is not warranted (APA, 2013a; Durand & Barlow, 2010). Individuals with schizoid personality disorder have little to no interest in relationships, even family relationships (APA, 2013a; Durand & Barlow, 2010; Kosson et al., 2008). They may prefer to engage in activities by themselves, have few or no friends, rarely experience pleasure in activities, and may have little to no interest in sex or intimate relationships. They may have difficulties experiencing emotions or emotional reactions and appear cold or indifferent to others and to assessments of others, such as encouragement or criticism. The symptoms of this disorder should not occur exclusively during a psychotic episode such as those associated with schizophrenia, nor should they be better attributed to ASD (APA, 2013a). Finally, the symptoms of this disorder must impair the individual’s functioning significantly for a diagnosis to be made. Appearing first in childhood, schizoid personality disorder often results in severe impairment in social, socioeconomic, and occupational functioning. Although it is estimated that 3.1% of the population has this disorder (APA, 2013a), these individuals will not typically seek treatment (Durand & Barlow, 2010; Martens, 2010). Furthermore, it can be argued that schizoid personality disorder receives the least attention of all the personality disorders, both clinically and empirically (Kosson et al., 2008). In terms of treatment, Parpottas (2012) claimed that when this disorder is conceptualized from an attachment theory lens, CBT partnered with a psychodynamic perspective may be the best approach. Parpottas argued that the role of the counselor is crucial because individuals experiencing this disorder need a model for interpersonal relationships. Additionally, counselors should be aware that individuals with this disorder may experience brief psychotic episodes when under stress or duress (APA, 2013a). Relatively uncommon in clinical settings, schizoid personality disorder tends to occur more in men than in women (APA, 2013a). Cultural context is essential in the formation of peer relationship and social and behavioral characteristics. Therefore, counselors should carefully consider the client’s cultural background when diagnosing schizoid personality disorder, because certain cultures emphasize defensive behaviors or detachment (Martens, 2010). Caldwell-Harris and Ayçiçegi (2006) researched autonomy and interdependence among individuals within individualist (i.e., Boston, Massachusetts) and collectivist (i.e., Istanbul, Turkey) cultures. The authors found that individuals who expressed personality characteristics outside their normative cultural group were at risk of psychiatric symptoms that correlated with symptoms of schizoid personality disorder. Of course, having personal attributes that are inconsistent with the values of society is not associated with psychiatric symptoms. However, these results do illustrate that counselors must be very careful, not only when diagnosing schizoid personality disorder but also when assessing clients for all types of personality dysfunction. Finally, special consideration should also be given to individuals who have changed cultures, such as immigrants, or who experience issues with acculturation (APA, 2013a). When considering a diagnosis of schizoid personality disorder, counselors should be sure that the symptoms are not related to substance use, medications, or another medical condition such as those that affect the central nervous system (APA, 2013a). Moreover, this disorder should not be diagnosed when the symptoms only occur as a part of psychosis. If there is psychosis, schizoid symptoms should precede this and continue after the episode has resolved in order to be diagnosed. If this does occur, the diagnosis should be written with the word premorbid at the end. It is easy to confuse symptoms of other personality disorders and ASD with schizoid personality disorder (APA, 2013a). Careful screening over a period of time is crucial for an accurate diagnosis to be made. Schizotypal personality disorder is pervasive and includes bizarre ideation and social constriction or avoidance (APA, 2013a; Paris, 2013). The symptoms of schizotypal personality disorder appear similar in many ways to schizophrenia. Some consider schizotypal personality disorder a milder, nonpsychotic form of schizophrenia; however, manifestations of this disorder do not typically include positive symptoms of hallucinations or delusions (Paris, 2013; Ripoll et al., 2013). Schizotypal personality disorder is characterized by discomfort with any type of close relationships, bizarre or distorted cognitions, and strange behaviors (Comer, 2013). This pattern, which often begins during early adulthood, may include sensations of an external presence, odd physical awareness, magical thinking, or the belief that one’s powers may control the behavior of others (APA, 2013a; Comer, 2013; Paris, 2013). Individuals diagnosed with schizotypal personality disorder often think unrelated events pertain to them personally. Individuals with schizotypal personality disorder exhibit paranoia, flat affect, and odd communication patterns such as loose associations, and they usually have an eccentric appearance (Comer, 2013; Nietzel et al., 1998; Ripoll et al., 2013). Although not formally considered a schizophrenia spectrum disorder, these disorders are actually cross-listed in the DSM-5. The primary reason is because of symptom similarity and because clients diagnosed with schizotypal personality disorder have the same biological markers as those with schizophrenia (Paris, 2013). However, because schizotypal personality disorder is not a precursor to schizophrenia, it has been retained in the Personality Disorders chapter of the DSM-5. Individuals diagnosed with schizotypal personality disorder do not have many close friends and continue to be paranoid even when a close relationship does exist (APA, 2013a; Comer, 2013). For example, these individuals tend to appear socially anxious even around family. If symptoms of this disorder only occur as part of depression, bipolar, or schizophrenia disorders, then it is not a true schizotypal personality disorder. If it is diagnosed before the onset of schizophrenia, the word premorbid should follow the diagnosis (APA, 2013a). However, as stated previously, schizotypal personality disorder is not a precursor to schizophrenia (Paris, 2013). Schizotypal personality disorder occurs in about 3.9% in the general population (APA, 2013a), and individuals with it often present for treatment because of depression or anxiety (Comer, 2013; Nietzel et al., 1998). Because they have difficulty with interpersonal relationships and have few friends, they may feel intensely lonely. Individuals with schizotypal personality disorder are often unemployed or underemployed; have challenges living independently; and experience issues with working memory, attentiveness, inhibition, and abstract thought processing (McClure, Harvey, Bowie, Iacoviello, & Siever, 2013). Comorbidity is not unusual; there is considerable overlap with other personality disorders (APA, 2013a; Rosenbaum & Pollock, 2002), and more than half of the individuals diagnosed with this disorder have also experienced a major depressive episode (Comer, 2013). Whereas antipsychotic medication has been given in low doses with some success, CBT is frequently used to address unusual or inappropriate thoughts and behaviors (Comer, 2013). Beliefs or behaviors that appear bizarre or outside the norm should always be evaluated within the context of the individual’s cultural and religious beliefs. Counselors must fully understand the impact of family, religion, and culture on behavior before making this diagnosis. For example, speaking in tongues, belief in the afterlife, and phenomenon such as voodoo are not considered schizotypal symptoms if these beliefs and behaviors are within the client’s cultural context (Peluso, 2013). As with most Cluster A personality disorders, there is evidence that this disorder occurs more in men than in women (APA, 2013a). Finally, individuals who have family members with a history of schizophrenia are more likely to be diagnosed with schizotypal personality disorder (Durand & Barlow, 2010). Schizotypal personality disorder should not be diagnosed if the symptoms can be better explained by use of substances or medications or by a medical condition (APA, 2013a). Whereas some individuals with schizotypal personality disorder experience brief moments of psychosis when under stress, this personality disorder should not be confused with delusional, psychotic, depressive, or bipolar disorders. Counselors should look for symptoms that are pervasive and begin before or continue after other types of episodes, such as mania and psychosis. In children, symptoms of a communication disorder or ASD may appear similar to schizotypal personality disorder (APA, 2013a). A thorough assessment over a period of time is necessary to ensure an accurate diagnosis is made. Often referred to as “psychopathy,” “sociopathy,” or “dissocial” personality disorder (APA, 2013a, p. 659), antisocial personality disorder is characterized by a complete disregard for the feelings, rights, and concerns of others, often resulting in harm to self or others and/or incarceration (Comer, 2013). Individuals with this disorder will have at least three of the following symptoms: illegal behaviors, chronic lying, a lack of regard for personal or others’ safety, aggressive behavior frequently leading to fights, a pattern of impulsivity and lack of forethought, problems working and/or meeting financial responsibilities, and chronic indifference to the feelings of others without regret or remorse (APA, 2013a; Comer, 2013; Durand & Barlow, 2010; Frances, 2013). Individuals diagnosed with antisocial personality disorder often receive pleasure from their destructive behavior, such as feeling pleasure when deceiving others. These symptoms cannot be attributed to substance use, another medical condition, or medication use, nor can they occur solely during a psychotic or manic episode. Behaviors must occur before 18 years of age and must be preceded by symptoms of conduct disorder occurring before age 15 (APA, 2013a). Conduct disorder with onset in childhood is nearly a universal occurrence (Paris, 2013). Antisocial personality disorder is characterized by deceitfulness, manipulation, anger, irresponsibility, and reckless decision making followed by hazardous behavior (Paris, 2013). Counselors often find that individuals with antisocial personality disorder are often charming, self-assured, and manipulative, particularly in close personal or sexual relationships (Durand & Barlow, 2010). Because of the high rates of criminal activity and incarceration associated with antisocial personality disorder, most of the research on this disorder is conducted on inmates, former inmates, or parolees (Frances, 2013). It is estimated that as many as 30% of those incarcerated have antisocial personality disorders (Comer, 2013). Because of this, and also because of the lack of remorse associated with this disorder, it is unlikely that counselors will see these individuals present voluntarily; most counselors will work with these individuals as a result of court mandate. Furthermore, rates of alcohol and drug use can be very high in this population (Comer, 2013). In general, counseling and therapeutic interventions for this disorder are extremely challenging, largely because these individuals do not see the need to change (Comer, 2013; Paris, 2013). Motivational interviewing or cognitive treatments have been used to increase awareness of behavioral impact. Finally, counselors need to be cognizant of the propensity for violence and suicide in this population and conduct risk and suicide assessments as needed (Frances, 2013). Although general population estimates for this disorder range from 0.2% to 3.3%, rates are consistently much higher in the male population than in the female population, perhaps as high as four to one (APA, 2013a; Comer, 2013). These rates tend to increase in urban populations and with lower socioeconomic status and sociocultural variables. Although the diagnosis cannot be made prior to age 18, symptoms seem to decrease in later life, with criminal activity in particular decreasing after the age of 40 (APA, 2013a; Comer, 2013; Frances, 2013; Paris, 2013). Substance use disorder can be difficult to differentiate from antisocial personality disorder, but symptoms of antisocial personality disorder should begin in younger years, often preceding the substance use (APA, 2013a). When these are co-occurring, they can be diagnosed simultaneously. Symptoms of antisocial personality disorder must occur prior to or outside of a manic or psychotic episode for this diagnosis to be given. There may be overlap with the symptoms of other personality disorders, particularly other Cluster B personality disorders. Antisocial personality disorder can be differentiated by the lack of empathy, aggression, impulsivity, and manipulation of others purely for personal gains (Comer, 2013; Frances, 2013). However, if criteria are met for more than one disorder, counselors may diagnose all applicable disorders (APA, 2013a). Finally, it is important to note the difference between committing a crime and having antisocial personality disorder. Criminal behavior is only one symptom of this disorder, and at least three other symptoms must be met, in addition to age requirements, to make this diagnosis. First noted in the DSM-III
Looking Ahead:
Personality Disorders
Major Changes From DSM-IV-TR to DSM-5
Essential Features
Special Considerations
Cultural Considerations
Differential Diagnosis
301.0 Paranoid Personality Disorder (F60.0)
Essential Features
Special Considerations
Cultural Considerations
Differential Diagnosis
301.20 Schizoid Personality Disorder (F60.1)
Essential Features
Special Considerations
Cultural Considerations
Differential Diagnosis
301.22 Schizotypal Personality Disorder (F21)
Essential Features
Special Considerations
Cultural Considerations
Differential Diagnosis
301.7 Antisocial Personality Disorder (F60.2)
Essential Features
Special Considerations
Cultural Considerations
Differential Diagnosis
301.83 Borderline Personality Disorder (F60.3)
Essential Features
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
