622 CHAPTER 13
SUMMING UP
Summary of Diagnosing
Personality Disorders
A personality disorder is characterized by mal-
adaptive personality traits that begin by young
adulthood and continue through adult-
hood; these traits are relatively infl exible, are
expressed across a wide range of situations,
and lead to distress or impaired functioning.
A personality disorder affects three areas of
functioning: affect, behavior (including social
behavior), and cognition. The diagnostic cri-
teria for personality disorders were based on
the assumptions that the maladaptive person-
ality traits begin in childhood and are stable
throughout life. These assumptions led to
the disorders being placed on a separate axis
(Axis II) of DSM-IV-TR. Subsequent research
indicates that some Axis I disorders begin in
childhood and that symptoms of personality
disorders may improve over time.
Personality disorders may be assessed
through diagnostic interviews, personality in-
ventories, or questionnaires. The clinician may
make the diagnosis based on the pattern of
the patient’s behavior and, given the prepon-
derance of interpersonal problems that arise
with personality disorders, may also rely on
supplemental reports from family or friends.
In DSM-IV-TR, personality disorders are
grouped into three clusters: Cluster A, charac-
terized by odd or eccentric behaviors related to
features of schizophrenia; Cluster B, character-
ized by dramatic and erratic behaviors and prob-
lems with emotional regulation; and Cluster C,
characterized by anxious or fearful behaviors.
The category of personality disorders in DSM-IV-
TR has been criticized on numerous grounds.
The neuropsychosocial approach explains
how personality disorders develop by high-
lighting the interactions among three sorts of
factors: the effects of genes on temperament
and the interaction of temperament, operant
conditioning, dysfunctional beliefs, and inse-
cure attachment that can result from childhood
abuse or neglect. Treatments for personality
disorders include medications for comorbid
symptoms, CBT or psychodynamic therapy,
and family education and therapy, as well as
couples, interpersonal, and group therapy.Thinking like a clinician
V.J. was 50 years old, never married, and had
never been very successful professionally. Hewas a salesman, and changed companies ev-
ery few years, either because he was passed
over for a promotion and quit, or because he
didn’t like the new rules—or the way that the
rules were enforced—at the job. He’d been
in love a few times, but it never worked out.
He chalked it up to diffi culty fi nding the right
woman. He had some friends, but they were
really people he’d known over the years and
saw occasionally. Most of his positive social
interactions happened in chat rooms or via
e-mail, not face to face.
Is there anything about the informa-
tion presented that would lead you to won-
der whether he might have a personality
disorder—if so, what was the information?
(And if not, why not?) Based on what you have
read, how should mental health clinicians go
about determining whether V.J. might have a
personality disorder or whether his personal-
ity traits are in the normal range? Do you agree
with the way that DSM-IV-TR goes about classi-
fying personality disorders—why or why not?Summary of
Odd/Eccentric
Personality Disorders
The essential feature of paranoid personality
disorder is a persistent and pervasive mistrust
and suspiciousness, which is accompanied by
a bias to interpret other people’s motives as
hostile. Although paranoid personality disorder
and paranoid schizophrenia both involve suspi-
cious beliefs, people with the personality dis-
order have some capacity to evaluate whether
their suspicions are based on reality; they also
tend to be suspicious about people they know.
In contrast, the beliefs of people with paranoid
schizophrenia are delusional, and they perceive
threats as coming from strangers or objects.
Schizoid personality disorder is character-
ized by a restricted range of emotions in social
interactions and few—if any—close relation-
ships; people with this disorder have poor
social skills. They report rarely experiencing
strong emotions, and they prefer to be—and
function best when—isolated from others.
Schizotypal personality disorder is
marked by eccentric thoughts, perceptions,
and behaviors, as well as by having very few
close relationships. This personality disorder
is characterized by three groups of symptoms:cognitive-perceptual, interpersonal, and dis-
organized. Schizotypal personality disorder
is viewed as a milder form of schizophrenia.
Many of the factors that give rise to schizo-
phrenia also appear to give rise to schizotypal
personality disorder: genes and the prenatal
environment; problems with attention, mem-
ory, and executive function as well as an im-
paired theory of mind; and physical abuse or
neglect in childhood, insecure attachment,
and discrimination.
Paranoid, schizoid, and schizotypal per-
sonality disorders are on the spectrum of
schizophrenia-related disorders, and close
relatives of people with any of these odd/ec-
centric personality disorders are more likely
to have schizophrenia. Schizotypal personal-
ity disorder involves neurological abnormali-
ties that are less severe than those associated
with schizophrenia.
People with odd/eccentric personality dis-
orders are reluctant participants in treatment.
Treatment may address fundamental issues,
such as isolation and suspiciousness. Treat-
ment for schizotypal personality disorder may
include antipsychotic medication (although
at lower doses than used for psychotic dis-
orders), CBT, social skills training, and family
therapy.Thinking like a clinician
Shawna has few friends; most of the time she’s
quiet and shy, avoiding eye contact. Occasion-
ally, she mentions that her troubles—work,
social, and fi nancial—are because of the radi-
ation coming out of the computer. She says it
with a straight face, but it’s hard to tell whether
she’s joking. When asked whether she’s being
serious, she reluctantly says that she’s not,
but it’s not clear whether she’s being honest.
If you were asked to determine whether she
has a personality disorder, what kinds of ques-
tions would you ask? Based on what you have
read, what types of answers would distinguish
somewhat quirky behavior from the truly odd
behavior that characterizes a Cluster A per-
sonality disorder? If you determined that her
behavior was odd enough to merit a diagno-
sis of a Cluster A (odd/eccentric) personality
disorder, what would you look for in order to
decide which of those disorders might be the
best diagnosis? Could Shawna have more than
one personality disorder? If not, why not? And
if so, what might her other symptoms be?hospitalizations and outpatient therapy, Reiland tried various medications, settling
on antidepressants that she gradually stopped before her therapy ended.
Her treatment was successful. She wrote her memoir 8 years after her therapy
ended; she developed and sustained the ability to regulate her moods, to control her
impulses, and to have productive and enjoyable relationships.