Choose and read any one case study from Chapter 13 (Personality Disorders) in the most current version of DSM in Action.
Research the specific personality disorder from your chosen case study.
Create a 10-15-slide PowerPoint presentation about your selected case study.
Include the following in your presentation:
A brief description of the selected case study
Explanation and rationale for the Personality Disorder Diagnosis using the latest version of the DSM as a reference.
Information on the course of treatment for the disorder.
CHAPTER
13 Personality Disorders
S O P H IA F . D Z I E G I E L E W S K I A N D G E O R G E A . J A C I N T O
INTRODUCTION
This chapter provides information about adults
who suffer from the mental disorders known as
the personality disorders. Several epidemiological
studies in the United States and abroad with
different populations provide consistent estimations of persons diagnosed with a personality
disorder (cited by Lenzenweger, 2008). The
mean prevalence rate for any personality disorder
is estimated at 10.56% (Lenzenweger, 2008). This
figure suggests that 1 in 10 people have a diagnosable personality disorder, but the actual criteria
and treatment options remain controversial.
These illnesses relate directly to an individual’s
personality, which defines the basic core of his or
her self-identity, and how the world is interpreted, influencing all interactions that result.
Our personality creates the basic defining characteristic from which all responses and behaviors
result (Barnhill, 2014). When inflexible and pervasive, these enduring patterns of behavior can
cause troubled and disturbed relations that touch
every aspect of a person’s life. Personality functioning affects the development of individual
talents and responses, as well as close relationships
with others. The link between developing these
disorders and how exhibiting these problematic
behaviors affect the family system is not well
known. As individuals develop, there does appear
to be a correlation with early separation and loss,
parental neglect, and other types of family dysfunction, although most professionals agree this
467
factoralone couldnotaccountforthedevelopment
of personality disorders (Sherry, Lyddon, &
Henson, 2007). There also appears to be a strong
correlation between substance use and personality
disorders, so much so that some practitioners
believe that when a personality disorder is assessed,
so should the possibility of a substance-related
disorder (McMain & Ellery, 2008).
This chapter has a brief overview of each
disorder and a case example that provides specific
treatment planning and intervention-related
applications. A lack of understanding of the symptoms related to having a loved one who suffers
from a personality disorder can disturb family
relationships and thereby alienate support systems
critical to enhanced functioning. This chapter
highlights the guidelines for using the Diagnostic
and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5; American Psychiatric Association [APA], 2013), to better understand and assess
these conditions. The DSM-5 (2013) dedicates
one chapter to the 13 different personality disorders, which are broken down into four areas.
Cluster A includes paranoid personality disorder,
schizoid personality disorder, and schizotypal personality disorder (described in this chapter but also
listed as part of the schizophrenia spectrum and the
other psychotic disorders); cluster B is antisocial
personality disorder (described in this chapter but
listed in the chapter on the disruptive, impulsecontrol, and conduct disorders), borderline personality disorder, narcissistic personality disorder,
and histrionic personality disorder; and cluster C is
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DIAGNOST IC AND TREATMENT APPLICAT ION S
avoidant personality disorder, dependent personality disorder, and obsessive compulsive personality disorder. In addition, three other types of
personality disorders are listed as personality
change due to another medical condition, other
specified personality disorder, and unspecified
personality disorder.
It is beyond the purpose of this chapter to
explore in depth all of the diagnoses in the
personality disorders and the treatment options
specific to each. Rather, this chapter introduces
the primary disorders as listed in DSM-5. The
application section of this chapter provides a case
example of an individual suffering from borderline personality disorder. The extent, importance, and early predictors of problem behaviors
and symptoms are explored. The various aspects
of the disorder are presented with a case application that highlights diagnostic assessment,
treatment planning, and evidence-based treatment strategy. In addition, the latest practice
methods and newest research and findings are
here to further the understanding of these oftendevastating illnesses.
The DSM-5 provides an alternative model in
the area for further study that is designed to
better understand the traits that characterize
the personality disorders. In conceptualizing personality disorders, it focuses on personality functioning and personality traits and is included as an
emerging measure for current consideration or
future use. The foci of this chapter are to discuss
the description of personality disorders listed in
the DSM-5 (2013) and provide an overview of
the alternative model to be used for further study
in Section III.
TOWARD A BASIC UNDERSTANDING
OF THE PERSONALITY DISORDERS
The personality of each individual mediates
environmental, cognitive, emotional, spiritual,
physical, and interpersonal events. When disturbed, it can negatively affect the individual’s
way of understanding the self and virtually all
interactions in the world in which he or she lives.
The notion of personality disorders dates back to
the ancient Egyptians; allusion to the disorders is
contained in the Ebers Papyrus (Okasha &
Okasha, 2000). The ancient Greeks described
their god Achilles as antisocial (Walling, 2002);
accounts of Alcibiades, a Greek general, describe
him as having had the traits of antisocial personality disorder with narcissistic features (Evans,
2006). In addition, whether the condition runs
in families is not certain; however, individuals
suffering from a personality disorder may also
experience a genetic predisposition to developing a disorder similar to that diagnosed previously
for a first-degree relative. Research on family
members and how best to treat individuals
within the family system is gaining interest
(Hoffman, Buteau, & Fruzzetti, 2007).
The DSM-5 (2013) has some minor revisions of the DSM-IV-TR (APA, 2000) categories
of personality disorders. However, the DSM-5
also presents an alternative model from which to
construe personality disorders, which suggests
that an understanding of the disorders is shifting.
The APA Board of Trustees decided to include
both models to establish continuity between
current clinical practice and further study of
the alternative approach.
UNDERSTANDING INDIVIDUALS
SUFFERING FROM A
PERSONALITY DISORDER
Individuals who suffer from a personality disorder often report significant distress or impairment in social functioning (APA, 2013). The
personality disorders are placed in three clusters.
Each cluster has behavioral symptoms that can
impair social functioning, and behaviors can take
Personality Disorders
many forms, from odd-eccentric to dramaticemotional to anxious-fearful. Furthermore,
these unusual symptoms can affect interactions
with family members, functioning at school or
work, and other areas of an individual’s life
situation.
Cluster A personality disorders may appear
odd and eccentric. Individuals with schizoid
and schizotypal characteristics avoid social contact and find it difficult to place themselves
in situations where they need to interact with
others. Often they may seem odd and threatening to individuals who do not know them.
Individuals who suffer from paranoid and schizotypal personality disorders often present as suspicious and guarded, and when communication
is compromised, others may avoid them because
of their suspicious and threatening presentation.
In the cluster B grouping, individuals present
as dramatic-emotional. Antisocial individuals
may violate others’ rights and might also have
the potential to inflict physical harm on others or
lie and steal and otherwise con people. Those
with borderline personality traits may appear at
first to be close and admiring and then, once a
relationship is formed, become angry and critical.
Their intense anger may result in arguments and
physical fights. This erratic and intense behavior
makes it difficult for them to develop lasting
associations with others. The histrionic and narcissistic personality disorders share the theme of
dramatic attention-seeking behavior that gets in
the way of developing friendships or romantic
relationships. They often do not understand why
others avoid them.
Cluster C individuals have characteristics
that focus around anxiety and fear and thereby
often exhibit anxious and fearful behaviors.
Avoidant individuals shun social interaction
because they see themselves as inadequate and
fear negative responses from others. Dependent
individuals experience fear of separation and
cling to others, wanting others to make decisions
469
for them. They can appear burdensome to others
even in superficial social settings. Those with
obsessive-compulsive disorder focus on control
of their environment, and their perfectionism
can be offensive to others.
Social interaction on all levels can often lead
to emotional and sometimes physical injury to
those with a personality disorder. Individuals
suffering from a personality disorder often feel
isolated and negatively judged because of their
problematic social interactions; they may also be
difficult to work with because they lack insight
into their own conduct as well as subsequent
willingness to engage in treatment to address
problematic behaviors.
History of the Personality Disorder
and the DSM
Over the past 50 years, the number and types of
personality disorders listed in the DSM have
changed with each new edition. The DSM-I
(APA, 1952) had 17 categories of personality
“disturbance,” as well as “transient situational
personality disorders,” four of which were
labeled as “adjustment reactions.” (See Quick
Reference 13.1.)
The DSM-II (APA, 1965) is similar to the
listing of the disorders in DSM-I (1952). Its
several modifications include deletion of
inadequate personality pattern disturbance, emotionally unstable personality pattern disturbance,
and dyssocial reaction under the sociopathic
personality disturbance, and it removes the special symptoms reactions from the listing. The
term personality disorder appears to have replaced
personality pattern disturbances, personality trait
disturbance, and sociopathic personality disturbance. The DSM-II (1965) retained the sexual
deviations listing and added a description of
speci fic conditions in this section.
The DSM-III (1980) and DSM-III-R (1987)
removed the sexual deviations and substance-
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DIAGNOST IC AND TREATMENT APPLICAT ION S
QUICK REFERENCE 13.1
PERSONALITY DISORDERS AS LISTED IN EACH EDITION OF THE DSM
DSM-I (1952)
Personality
Pattern
Disturbance (PPD)
■ Inadequate PPD
■ Schizoid PPD
■ Cyclothymic PPD
■ Paranoid PPD
Personality Trait
Disturbance (PTD)
■ Emotionally
unstable PTD
■ Passiveaggressive PTD
■ Compulsive PTD
■ PTD, Other
Sociopathic
Personality
Disturbance
■ Antisocial
reaction
■ Dyssocial
reaction
■ Sexual deviation:
Specify term
■ Addiction
Alcoholism
Drug addiction
Special
Symptoms/
Reactions
■ Learning
disturbance
■ Speech
disturbance
■ Enuresis
■ Somnambulism
■ Other
DSM-II (1965)
Personality
Disorders (PD)
Paranoid PD
Cyclothymic PD
Schizoid PD
Explosive PD
Obsessive
compulsive PD
■ Hysterical PD
■ Asthenic PD
■ Antisocial PD
■ Passiveaggressive PD
■ Inadequate PD
■ Other PD NOS
■ Unspecified PD
Sexual
Deviations
■ Homosexuality
■ Fetishism
■ Pedophilia
■ Transvestitism
■ Exhibitionism
■ Voyeurism
■ Sadism
■ Masochism
■ Other sexual
deviation
■ Unspecified
sexual deviation
Alcoholism
Drug Dependence
■
DSM-III (1980)
DSM-III-R (1987)
DSM-IV (1994)
DSM-IV-TR (2000)
Cluster A
■ 301.00 Paranoid
■ 301.20 Schizoid
■ 301.22
Schizotypal
Cluster B
■ 301.70
Antisocial
■ 301.83
Borderline
■ 301.50 Histrionic
■ 301.81
Narcissistic
Cluster C
■ 301.82 Avoidant
■ 301.60
Dependent
■ 301.40
Obsessive
compulsive
■ 301.84 Passive
aggressive
■ 301.90
Personality
disorder NOS
Note:
301.89 Atypical,
mixed or other
personality
disorder was
listed in the DSMIII and changed
in the DSM-III-R
to 301.90
Personality
Disorder NOS
Cluster A
(odd-eccentric)
301.0 Paranoid
PD
301.20 Schizoid
PD
301.22
Schizotypal PD
Cluster B
(dramaticemotional)
301.7 Antisocial
301.83 Borderline
301.50 Histrionic
301.81 Narcissistic
Cluster C
(anxious-fearful)
301.82 Avoidant
301.6 Dependent
301.4 Obsessivecompulsive
301.9 Personality
disorder NOS
Note:
301.84 Passive
Aggressive
Personality
Disorder (listed in
the DSM-III-R)
was removed
from the
Personality
Disorders in the
DSM-IV and
placed in the
section titled
Criteria Sets and
Axes Provided for
Further Study.
*DSM-5 lists ICD-9-CM codes in this table; DSM-5 also lists ICD-10-CM codes.
*DSM-5 (2013)
General
Personality
Disorder
Cluster A
(odd-eccentric)
301.0 Paranoid
PD
301.20 Schizoid
PD
301.22
Schizotypal PD
Cluster B
(dramaticemotional)
301.7 Antisocial
301.83
Borderline
301.50 Histrionic
301.81
Narcissistic
Cluster C
(anxious-fearful)
301.82 Avoidant
301.6 Dependent
301.4 Obsessivecompulsive
Note: NOS was
changed to
three diagnostic
categories.
310.1 Personality
change due to
another medical
condition
301.89 Other
specified
personality
disorder and
unspecified PD
301.9
Unspecified
Personality
Disorder
Personality Disorders
related disorders (alcoholism and drug dependence) sections from the listings under personality
disorders. In the DSM-III-R (1987), the three
clusters of disorders were introduced. Cluster A
was disorders with odd or eccentric behaviors.
Cluster B included disorders that had dramatic,
emotional, or erratic behaviors. Cluster C
included those disorders characterized by anxiousness and fear.
In the DSM-IV-TR (2000), the personality
disorders were grouped into three clusters similar
to what was previously described in the DSMIII-R (1987). The DSM III-R cluster C disorder
labeled passive-aggressive personality disorder
was removed from the list of personality disorders and does not appear in the DSM-IV-TR
(2000). Because the symptoms can still be problematic, it has been added to the potential list of
defense mechanisms outlined in that version.
In the DSM-5 (2013), the NOS category
was deleted and changed to include three diagnostic labels: personality change due to another
medical condition, other specified personality
disorder, and unspecified personality disorder.
In addition, an alternate model for personality
disorders was presented in Section III. The APA
Board of Trustees included the alternate model
for further study (Kreuger & Markon, 2014).
WHAT IS A PERSONALITY DISORDER?
The development and usage of current criteria for
a personality disorder in the DSM provide a
definition with a clear listing of criteria, thereby
making an accurate diagnosis of a specific personality disorder. The general personality disorder
criteria involve a long-term pattern of inner
experience and behavior that differs strikingly
from the expectations of the individual’s culture.
The pattern is demonstrated by two of the following areas outlined in criterion A: (1) cognitive
functioning such as ways of observing and
471
understanding self, others, and events: (2) affective
response that includes the range, intensity, mood
fluctuation, and proper emotional reaction; (3)
social functioning, and (4) impulse control.
Criterion B includes an ongoing pattern that
is rigid across a range of personal and social
circumstances. Criterion C states that the ongoing
pattern results in clinically significant distress or
damage in social, occupational, or other signi ficant areasof functioning.Criterion D requires that
the onset began in adolescence or early adulthood
and is a long-term, stable pattern of behavior.
Criterion E states that the long-term pattern is not
better accounted for as a distinct element or
consequence of another mental disorder. Criterion F requires that the long-term pattern not be
the result of physiological effects of a substance of
abuse or prescription medication or another medical condition, such as traumatic brain injury.
When assessing for symptoms relevant to the
diagnosis, the practitioner needs to first review
for the presence of minimal levels of the criteria
for a personality disorder. Once the symptoms
are identified, the predominance of certain
symptoms that form clusters of behavior is noted.
To facilitate this process, a brief discussion of the
personality disorders organized under clusters A,
B, and C is presented with the diagnostic criteria
outlined by the DSM-5 (2013) for the disorder.
In addition, for each personality disorder, a brief
case example clearly identi fies how the behavior
meets the criteria. Because the behaviors exhibited are often less severe, although enduring, a
brief case scenario clearly outlines the occurrence
of the problematic behaviors. After the criteria
for the personality disorder are described, each
case scenario highlights how these behaviors
relate to the diagnostic assessment.
CLUSTER A PERSONALITY DISORDERS
The cluster A personality disorders include paranoid personality disorder, schizoid personality
472
DIAGNOST IC AND TREATMENT APPLICAT ION S
disorder, and schizotypal personality disorder.
Each of these personality disorders shares the
common theme of odd or eccentric behavior.
When diagnosed in this cluster, individuals have
trouble relating to others. Others might comment openly or privately that the person with a
cluster A personality disorder acts strangely, and
people often are uncomfortable around them.
Often they appear to others as odd and eccentric,
which causes them to be loners, or others avoid
them as they say they make them feel
uncomfortable.
Paranoid Personality Disorder (PPD)
[301.0 (F60.0)]
Paranoid personality disorder (PPD) is characterized by a pattern of distrust and suspiciousness of others, whose motives and intentions
are perceived as malicious. These perceptions
begin in early adulthood and are present in a
number of situations. Those with PPD assume
the ill intent of others and believe that others
might exploit, harm, or deceive them. At
times, they may believe others have seriously
injured them when there is no evidence that an
injury has taken place (APA, 2013). These
individuals and the suspicious nature of their
interactions can be so frustrating for others that
often they are avoided. It is most often diagnosed in males.
According to the DSM-5, there are two
primary criteria for the disorder (A-B). Of the
seven characteristics of the disorder that constitute criterion A, the individual must have at least
four. Generally, individuals suffering from paranoid personality disorder exhibit a pervasive
attitude of distrust, and when they interact,
they consider others’ motivations vindictive or
malevolent. This pattern is often so pronounced
that the individual avoids others at times because
of suspicion of their motives, often questioning
their true loyality, trustworthiness, and intent.
These patterns of behavior are usually noted as
beginning by early adulthood and present in a
variety of contexts.
To place the diagnosis, criterion A requires
four of the seven characteristic symptoms are
required: (A-1) The individual suspects and
distrusts others without sufficient basis and
believes others are exploiting him or her. He
or she may also believe others are trying to
cause harm and are deceiving in regard to true
intensions. (A-2) The client is preoccupied
with unjustified doubts about the loyalty or
trustworthiness of friends or associates. (A-3)
Often individuals with paranoid personality
disorder remain reluctant to confide in others.
They do not share because of an unwarranted
fear that the information will be maliciously
used against them. (A-4) In general conversations, others’ remarks are believed to have
hidden meanings, even when it is clear no
harm was intended. (A-5) Relationships with
them are often strained because the client bears
a grudge and remains unforgiving, even if the
injury or insult was unintended. (A-6) The
individual is often on the defensive, feels he
or she is under attack, and responds with a
counterattack that may appear out of proportion to the event. (A-7) Intimate relationships
are strained as the individual is convinced that a
partner is having an affair and questions fidelity
without cause. In criterion B, other mental
disorders that could be causing the characteristic symptoms should be assessed, such as schizophrenia, a bipolar disorder or depressive
disorder with psychotic features, or another
psychotic disorder, and it is not attributable
to the physiological effects of a general medical
condition (APA, 2013). If the criteria are met
prior to the onset of schizophrenia, the term
premorbid should be added and documented as
paranoid personality disorder (premorbid). The
following case example shows the characteristics of the disorder.
Personality Disorders
473
CASE EXAMPLE – CASE OF LEON
Leon has gotten up late this morning and suspects that someone who was meaning him harm
interfered with his alarm clock so that he would be late for work (Criterion A1). He thinks it is Morgan at
work, who he believes wants to make him look bad before his boss so that he will be fired (A6). When
he arrives an hour late at work, he is greeted by the receptionist, Mary, who says, “Good morning,
Leon” (A4). She was trying to be friendly, but Leon thinks she is trying to get him in trouble with the
boss by making a scene so the boss will know he is late. Morgan, who believes she is a good friend of
Leon, greets him. He ignores Morgan and goes to his workstation. He is thinking of how disloyal
Morgan has been (A2). Leon notices his boss, Jacob, and Morgan were whispering about something.
He believes they are discussing his tardiness this morning and plotting to write him up (A1 and A2). He
cannot contain himself any longer and confronts his boss about his conversation with Morgan. The
boss tells him they were planning a surprise for a coworker who was celebrating her 50th birthday.
Leon does not believe his boss. This incident adds to his grudge against Morgan, whom he cannot
forgive for meddling with his alarm clock (A5).
In reviewing this case, Leon meets five of the diagnostic criteria (A1, A2, A4, A5, and A6) for a
diagnosis of PPD. People with PPD commonly blame others for their own failures. Cultural considerations in diagnosing this disorder may have to do with immigrant groups who do not understand the
dominant culture, may experience language barriers, or may not understand rules and regulations of
the new country. Several ethnic groups may also display behaviors that might be incorrectly misinterpreted as paranoia (APA, 2013). Persons with PPD can be very difficult to treat in psychotherapy
because of their chronic suspiciousness and perception of attacks on their character (Dobbert, 2007).
Schizoid Personality Disorder (SPD)
[301.20 (F60.1)]
Schizoid personality disorder (SPD) is characterized by detachment from social contact and a
limited range of emotional expression in settings
that require interpersonal exchange. Individuals
with SPD do not seek or want to develop
intimate relationships and do not seek romantic
sexual relationships with others. They do not
desire to be part of a social group and prefer to be
alone. They prefer to work with mechanical or
abstract tasks and find little pleasure in hobbies or
the activities of life. When others socialize, these
individuals prefer to be alone. They do not
connect well with others and avoid social contact
whenever possible.
According to the DSM-5, seven characteristics of the disorder in criterion A, require that
an individual must have a minimum of four.
People diagnosed with this disorder are characterized by disconnection from social relationships
and constrained emotional expression in social
settings. They shun human interaction and are
loners who prefer solitude and activities that do
not include associating with others. Often those
diagnosed with this disorder do not have close
friends, except possibly a close relative (DSM-5).
To fit the diagnostic picture, criterion A
requires four of the seven characteristic symptoms: (A-1) The client does not seek close
relationships, including association with members of the family of origin. (A-2) The client
prefers solitary activities to the exclusion of time
spent with others. (A-3) The client lacks interest
in experiencing sexual activity with another
person. (A-4) The client has few, if any, activities
that bring him or her pleasure. (A-5) The client
does not develop close friendships to confide in,
other than close relatives. (A-6) The client does
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DIAGNOST IC AND TREATMENT APPLICAT ION S
CASE EXAMPLE – CASE OF SAL
Sal has just gotten off work as a night watchman at a warehouse, where he is the only employee
during the graveyard shift. Sal meets his brother for breakfast and tells him that he chose this job
because it allows him to spend a good amount of time alone (Criterion A2). He has never dated and
has lived alone in a one-bedroom apartment for 28 years. He is not interested in a sexual relationship,
even though his brother has attempted to set him up with dates over the years (A3). He goes from
home to work and, on rare occasion, to his brother’s home for dinner. He does not desire any
acquaintances or friends; he just does not like being around other people (A1). He simply prefers to be
alone. He has told his brother on several occasions that he does not like people. Since he entered
school, he has never sought to have friends, and he contacts his brother only when he needs
something and cannot figure out how to meet his need on his own (A5). Three weeks ago, he was
honored for 15 years’ service to his company. His boss showered him with praise for keeping the
company free of break-ins and stated he was one of the finest employees any employer would want to
have as part of the team. After the ceremony, Sal told his boss that he did not know what the ruckus
was about and that he did not desire or deserve the recognition (A6). Sal made it clear to his boss he
was just doing his job and nothing more and would prefer not to be subjected to another ceremony of
this type again in the future.
Sal meets five of the diagnostic criteria (A1, A2, A3, A5, and A6) for a diagnosis of SPD. Persons
with SPD do not see themselves as having a problem and are happy with being left alone. Some
individuals who come from a variety of cultural backgrounds may display defensive behaviors,
avoid social contact, and be misinterpreted as schizoid. For example, a person moving from a
rural environment to New York City may react with shock at the different, stressfully charged
milieu of the city. An individual may appear to be cold, hostile, and distant, preferring to stay to
himself or herself (APA, 2013). When the patterned behavior is related to the disorder, it would not
occur to them that they might benefit from psychotherapy. If a person with SPD were to see a
therapist, it would be due to a referral from a health professional or relative. Psychotherapy is
generally contraindicated for people with SPD because of their intense resistance to change their
way of life.
not respond to praise or criticism from others.
(A-7) The client presents with cold affect, indifference, and flattened affect. In criterion B, other
mental disorders that could be causing the characteristic symptoms should be assessed, such as
schizophrenia, a bipolar disorder or depressive
disorder with psychotic features, or another psychotic disorder or autism spectrum disorder, and
it is not attributable to the physiological effects of
a general medical condition (APA, 2013). If the
criteria are met prior to the onset of schizophrenia, the term premorbid should be added and
documented as schizoid personality disorder
(premorbid). The case example of Sal shows the
characteristics of the disorder.
Schizotypal Personality Disorder (STPD)
[301.22 (F21)]
Schizotypal personality disorder (STPD) is characterized by significant discomfort with social interaction and close personal relationships and a lack of
interest in developing enduring friendships. Additionally, the person with schizotypal personality
disorder has cognitive misrepresentations and
eccentric behavior. These experiences begin in
Personality Disorders
early adulthood and are present in a number of
situations. This personality disorder, although not
equivalent to schizophrenia, is sometimes referred
to as the most similar to schizophrenia. One reason
is the experience of ideas of reference versus delusions. Those diagnosed with STPD often experience ideas of reference that result from attaching
meaning to casual events specific to the individual.
The person focuses on the paranormal or entertains
superstitions that are not within the norms of his or
her cultural milieu. This is similar to schizophrenia, where individuals have a more pronounced
form of delusional thinking called delusions of
reference. In the personality disorder, the ideas of
reference are not as pronounced and usually are
related to a specific idea or item as opposed to a
general theme that pervades every aspect of a
person’s life. In assessing for this disorder, the
cultural context, including beliefs and practices,
need to be considered. Many religious rituals,
beliefs, and practices may appear to meet criteria
for STPD. For instance, shamanism, speaking and
singing in tongues, magical beliefs, voodoo ritual,
seeing and talking with dead relatives, and the evil
eye related to mental health and physical illness are
experiences that are common in many cultures.
With regard to etiology of the disorder, when
compared with the general population, there
appears to be a familial predisposition for development of STPD when first-degree biological
relatives are diagnosed with schizophrenia. The
child may observe the behaviors of a relative with
schizophrenia and copy the behaviors (APA,
2013; Dobbert, 2007).
According to the DSM-5, of the nine characteristics for Criterion A, an individual must
have a minimum of five. Individuals diagnosed
with this disorder are characterized by strong
anxiety and limited ability to develop close
relationships. They also experience cognitive
misinterpretation of reality and peculiar behavior. Often those diagnosed with this disorder
demonstrate ideas of reference, which should
475
be distinguished from delusions of reference.
In addition, they may be preoccupied with
the paranormal or superstitious beliefs that are
not commonly held by others of their cultural
background. To fit the diagnostic picture, five of
the nine characteristic symptoms are required:
(A-1) The individual reports ideas of reference,
not including delusions of reference. (A-2) The
client is preoccupied with odd thinking or magical beliefs that affect behavior and do not fit
within the individual’s cultural context. (A-3)
The client experiences physical illusions or odd
perceptions. (A-4) The client’s peculiar speech
and thought process may include metaphorical
thinking and expression. (A-5) The individual is
suspicious of others or may experience paranoid
thoughts. (A-6) There is unsuitable or constrained emotional impact on the individual’s
reality perception. (A-7) The client presents
with eccentric behavior or as strange. (A-8)
The client does not develop intimate friendships
with others to confide in, other than close relatives. (A-9) The client experiences high levels of
social anxiety that is not reduced by familiarity
and is related to mistrustful fears instead of
negative beliefs about self. In criterion B, other
mental disorders that could be causing the symptoms should be assessed, such as schizophrenia, a
bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder or
autism spectrum disorder (APA, 2013). If the
criteria are met prior to the onset of schizophrenia, the term premorbid should be added and
documented as schizotypal personality disorder
(premorbid). The case example of Marge shows
the characteristics of the disorder.
CLUSTER B PERSONALITY DISORDERS
The cluster B personality disorders are antisocial,
borderline, histrionic, and narcissistic personality
disorders. The majority of people who suffer
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DIAGNOST IC AND TREATMENT APPLICAT ION S
CASE EXAMPLE – CASE OF MARGE
Marge has lived alone during her adult life. She wears clothes that would have been popular in
the 1920s, and her makeup causes her to stand out when she is in public (Criterion A7). She is
currently suspicious of her neighbor, who she thinks is watching her (A5). The neighbor has left his
apartment the same time Marge has for the past 2 weeks, and she thinks he is plotting to take
advantage of her (A1). Marge has no friends and says she fears people, even those she has known
casually for a long time (A8). She thinks acquaintances may one day snap and take advantage of
her (A9). She has three large dogs in her backyard that she says are there for protection and to
keep people away from her. Marge has been known to hold odd beliefs as reported by her
acquaintances (A2). She believes she is clairvoyant and makes predictions about the future that
are not accurate, according to her coworkers. She recently went to a priest to discuss her psychic
gifts but was vague and circumstantial when the priest pressed her for a clear explanation of how
her psychic abilities work (A2). She was unsatisfied with her consult with the parish priest. She
states openly that she does not date and does not want to have any children as she is not sure she
could love a child.
Marge meets six of the diagnostic criteria (A1, A2, A4, A5, A7, and A9) for a diagnosis of
STPD. Marge is uncomfortable with interpersonal relationships, entertains perceptual distortions,
and appears eccentric to those around her. Treatment options for Marge depend on what she
is willing to tolerate. Psychotherapy, especially if resistive, is not always considered the
treatment of choice and can be contraindicated for individuals who are diagnosed with
STPD (Dobbert, 2007).
from a personality disorder fall in the cluster B
group (Caligar, 2006). Each of these personality
disorders shares the common theme of dramatic
and emotional behavior. Often individuals have
intense relationships with family and friends that
quickly become strained. This frustrates those in
their support system, and it is not uncommon for
family and friends to say that they simply cannot
take the intensity and drama that typically surround relationships with a person with this type
of personality disorder. Caregivers in particular
may find these behavioral traits extremely frustrating (Scheirs & Bok, 2007).
Antisocial Personality Disorder (APD)
[301.7 (60.2)]
Antisocial personality disorder (APD) is characterized by a history of disregarding others and
violating others’ rights, beginning in childhood
or early adolescence and continuing into
adulthood (APA, 2013). Key elements of APD
include deceit, manipulation of others, and failure to adhere to social norms. To be given a
diagnosis of APD, a person has to have a history
of conduct disorder symptoms prior to age 15
(APA, 2000). Somatic marker and social cognition models explain APD. Both models include
the cortical (prefrontal cortex) and limbic
(amygdalae) structures of the brain as integral
to the underlying process in the development of
APD (Sinclair & Gansler, 2006). Environmental
factors may also contribute to the development
of APD. Growing up in a home where parents
demonstrate antisocial behavior, including
domestic violence, separation, divorce, and living in foster care, can deprive children of an
emotional bond that may contribute to APD
(Black, 2006). Confusing discipline regimens,
child abuse, and inadequate supervision have
been associated with development of APD
(Black, 2006). There is a potential for association
Personality Disorders
with others who are also aggressive, and they
may become gang members (Black, 2006).
There may also be intense relationship problems
and domestic violence related to and complicated by substance abuse, extreme jealousy, and
violent responses (Costa & Babcock, 2008). The
key to understanding the individual who suffers
from APD (the old term is psychopath) is watching
for evidence of behavioral deviations from the
norm (Federman, Holmes, & Jacob, 2009). The
diagnosis of APD is more common in males than
in females.
According to the DSM-5, of the seven
characteristics of the disorder for criterion A,
an individual must have a minimum of three.
Individuals diagnosed with this disorder are characterized by a pattern of violating the rights of
others that begins in childhood or adolescence
and persists into adulthood. These individuals are
477
often diagnosed with conduct disorder. Principal
features of the diagnosis are deceit and manipulation of others. Those diagnosed with antisocial
personality disorder must be at least 18 years old
and have a history of some of the symptoms of
conduct disorder prior to age 15.
To fit the diagnostic picture, three of the
seven characteristic symptoms are required to
meet criterion A: (A-1) The client repeatedly
has difficulties with the law and engages in risky
behaviors without regard for the legal consequences; (A-2) The client has little regard to the
feelings or rights of others and often puts his/
her wishes first, conning the individual into
doing what the client wants regardless of the
benefit to the other individual; (A-3) The client
is impulsive and often acts before any thought is
given to the consequences that result; (A-4)
The client wants his or her own way and thinks
CASE EXAMPLE – CASE OF DAVID
David is 14 years old and has had lifelong problems conforming to societal rules and has had
repeated incidents involving the legal system (criterion A1). As an adolescent, he regularly stole from
parents and stores (A1). When confronted about stealing, he lied and blamed someone else (A2). He
cut the family dog with a knife when he was 14 years old; shortly thereafter, he was diagnosed with
conduct disorder, which is usually a precursor to the diagnosis of antisocial personality disorder.
David has little control over his impulses; for instance, when he wants something, if he does not have
the money, he just steals it (A3). When caught, he said he just focused on what he wanted and not on
the consequences of his stealing and breaking the law. Because of his low impulse control, he had a
history of starting fights in school until he was finally expelled (A4). When he stole a car, he raced the
vehicle over 100 mph, placing himself and others in danger (A5). When confronted with his law
violations, he never showed remorse for the harm he brought to others (A7). He simply dismissed his
wrongdoings as someone else ’s fault.
David meets six of the diagnostic criteria (A1, A2, A3, A4, A5, and A7) for antisocial personality
disorder. Persons diagnosed with APD do not learn from experience. This coincides with the social
cognition and somatic marker models that try to explain the development of APD. It appears to be
related to urban settings and low socioeconomic status. Practitioners should be careful not to
diagnose APD if a person lives in a hostile environment and antisocial behavior is seen as a
protective survival tactic. Often persons with APD are arrested for the same crime many times. Due to
their lack of insight, individuals with APD may respond best to specific goal-directed treatments with
clear goals and objectives that are linked directly to behavioral consequences.
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DIAGNOST IC AND TREATMENT APPLICAT ION S
little of hurting others resulting in fights or
assaultive behavior to secure what he or she
wants from others; (A-5) The client has a
wanton disregard for the safety or security of
others; (A-6) The client is consistently selfrewarding and often does maintain financial
or occupations responsibilities; (A-7) The client
presents with a clear lack of remorse and often
rationalizes his or her behavior as necessary to
obtain what is needed. Consequences for such
intrusive behavior are often seen as an
inconvenience rather than a problematic consequence. In criterion B, the individual must be
18 years old. Criterion C requires that onset of
conduct disorder be prior to the age of 15.
Criterion D requires that the occurrence of
antisocial behavior in not entirely during incidence of schizophrenia or bipolar disorder
(APA, 2013).
Borderline Personality Disorder (BPD)
[301.83(F60.3)]
Borderline personality disorder (BPD) is characterized as “an instability of interpersonal relationships, self-image, and affects, and marked by
impulsivity that begins by early adulthood and
is present in a variety of contexts” (APA, 2013,
p. 663). It is diagnosed more frequently in
females (75%) than in males. It begins in early
adulthood and manifests with symptoms of
instability in interpersonal relationships, problems with self-image, unstable affect, and notable
impulsivity (APA, 2013, p. 666). It is present in
the many person-in-environment circumstances
in which a person participates. Circumstances in
which BPD symptoms are exacerbated include
emotional instability, existential dilemmas,
uncertainty, anxiety-provoking choices, conflicts about sexual orientation, and competing
social pressures to decide on careers (APA, 2013,
pp. 665–666). Difficulties are often noted in
setting and establishing boundaries. Crisis
situations may be generated to avoid boundaries,
and these types of behavior can be very frustrating to family and friends.
According to the DSM-5, the criteria for this
personality disorder differs from the others in that
the criteria are not divided into similar lettered
steps. This disorder simply lists the criterion in
numerical order. When using the assessment
scheme outlined individuals must have nine
characteristics of the disorder, clearly experiencing a minimum of five. Individuals diagnosed
with this disorder are characterized by a persistent pattern of unstable social relationships, selfimage, emotion, and impulsive behavior, the
onset of which is during early adulthood. The
disorder exists in a number of contexts. Often
those diagnosed with this disorder fear abandonment and make every effort to avoid such a
situation. In addition, they have intense and
unstable social relationships.
To fit the diagnostic picture, five of the nine
characteristic symptoms are required: (1)
extreme efforts to avoid abandonment that is
either real or envisioned; (2) history of unstable
and intense interpersonal relationships that alternate between idealization and devaluation of the
other person; (3) persistent unstable identity
disturbance that manifests with one’s self-image
or sense of the self; (4) two speci fic situations
need to be identified where self-damaging situations and impulsive behaviors can result, such as
reckless driving, excessive spending, substance
abuse, binge eating, and unsafe sexual activity;
(5) continual self-injury, gestures and threats, or
suicidal behavior; (6) emotional instability resulting from a noticeable reactive mood response to
life circumstances; (7) persistent feelings of emptiness; (8) difficulty in controlling anger or experiencing unacceptable intense rage; and (9)
extreme dissociative symptoms or temporary,
stress-related paranoid thoughts with possible
separation (through disassociation) from the
event (APA, 2013).
Personality Disorders
479
CASE STUDY – CASE OF SARAH
Sarah was chronically unemployed because of her difficulty in controlling her anger (criterion 8) and
her development of intense and unstable relationships at work (2). She has been seeing a psychotherapist for 10 years. In therapy, she is working on her feelings of emptiness (7), abandonment issues
(1), and unstable pattern of relationships, both romantic and nonromantic (2). While in therapy, she
has attempted suicide four times (5) and states her partner is to blame for her insecurity. She
deliberately planned to be unavailable and not respond to requests by her therapist. She refused to
answer the phone when her therapist tried to contact her to check on her well-being. She cut her wrist
(self-mutilating behavior), and when she saw the psychotherapist at her next appointment, she said
she felt such intense emotional pain she wanted to feel it physically on her body as well (5). She had
numerous surface cuts to her arm from previous attempts at suicide. To hide these marks, she would
often wear a long-sleeve shirt. When she met with her therapist, however, she often folded up her
sleeves to expose the scarring on her arms. She often demonstrates her unstable relationship patterns
with her therapist. At times, she reports that she idealizes the therapist and, on other days, devalues
her contributions (2). She has been addicted to prescription medication for several years. She doctorshops so she will always have a sufficient supply of medications, and she smokes marijuana (4).
Sarah meets six of the diagnostic criteria (1, 2, 4, 5,7, and 8) for BPD, which is five times more
common among first-degree relatives diagnosed with the disorder than in the general population.
The research about the genetic association of families and BPD is mixed in its results. Dobbert
(2007) reports that there appears to be an inverse relationship between the neurochemical
serotonin and impulsivity. Additional research suggests that it is possible that exposure to abuse
as a child suppresses the level of serotonin, and life situations such as this can play an important
role in developing BPD (Dobbert, 2007). Symptoms are reported to decline with advancing
age, appropriate medication, and psychotherapy. Although BPD is chronic in nature, most people
with BPD successfully emerge from psychotherapy and experience a remission of symptoms
(Dobbert, 2007).
Histrionic Personality Disorder (HPD)
[301.50 (F60.4)]
Histrionic personality disorder (HPD) is characterized by “excessive expression of conditions
and attention-seeking behavior. This pattern
begins by early adulthood and is present in a
variety of contexts” (APA, 2013, p. 667). Often
persons diagnosed with HPD have a dramatic
flair in their self-presentation to others. They are
happy being the center of attention and become
uneasy and feel unappreciated when they are not
the focus of their environment. While they
command the position of life of the party,
they are often inappropriately attired in sexually
provocative dress and behave in a seductive
manner. Although they may present in a dramatic manner, they are often vague about details
and extremely impressionistic. Persons with
HPD are exceedingly trusting of authority figures and can be highly suggestible.
According to the DSM-5, of the eight characteristics of the disorder, an individual must
have a minimum of five. Similar to several other
personality disorders listed in this section, this
disorder also does not use the traditional alphabetical coding. Individuals diagnosed with this
disorder are characterized by extreme emotional
responses to life events, with a signi ficant focus
on attention-seeking behavior. When not the
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DIAGNOST IC AND TREATMENT APPLICAT ION S
center of attention in social settings, these individuals are awkward and perceive that others do
not appreciate them. Because their affectivity is
dramatic and engaging, they can charm new
associates by their passion, sincerity, and playfulness. In addition, they are often inappropriately
sexually solicitous and aggressive.
To fit the diagnostic picture, five of the eight
characteristic symptoms are required: (1) experiences discomfort when not the center of attention;
(2) when relating to others, often engages in sexually solicitous or offensive behavior; (3) emotional
expression is rapidly shifting and shallow; (4) draws
attention to self by regularly adjusting physical
appearance; (5) presents with excessively impressionistic style of speech that is lacking in specificity;
(6) excessive emotional expression characterized by
dramatic performance; (7) highly suggestible and
effortlessly influenced by others or life situation; and
(8) believes relationships are more intimate than
they are (APA, 2013). The case of Celeste shows
examples of the characteristics of the disorder.
Narcissistic Personality Disorder (NPD)
[301.81 (F60.81)]
Narcissistic personality disorder (NPD) is characterized by a grandiose sense of self-importance,
need to be affirmed, and lack of empathy that
emerges in early adulthood and is present in a
number of situations (APA, 2013, p. 670). Individuals with NPD are boastful and pretentious
and exaggerate their accomplishments to impress
others. They present with a “grandiose sense of
self-importance . . . and overestimate their abilities and inflate their accomplishments” (APA,
2013, p. 670). A common feature of a person
with NPD is emotional coldness and absence of
reciprocal interests with others.
According to the DSM-5, of the nine characteristics of the disorder, an individual must
have a minimum of five. Individuals diagnosed
with this disorder are characterized by lack of
empathy, excessive pattern of pretentiousness,
and need for admiration. Often they overrate
CASE STUDY – CASE OF CELESTE
Celeste presents herself to her vocational rehabilitation counselor, having been referred by her
psychiatrist. She is 42 years old, weighs 350 pounds, and is about 5 feet, 10 inches tall. She is dressed in
a provocative outfit: short shorts and a blouse that accentuates her large breasts (criterion 4). She
privately states she seeks a job in an environment where she can be the focus of attention (1). She
reports that her life is very chaotic and there is a great deal of drama in her relationships and within
her life situation (6). While there is a lot of volume and excitement in her conversation, it lacks content.
Her flamboyant hyperverbal style lacks details and is quite impressionistic (5). She talks quickly, and
her emotions rapidly fluctuate back and forth and appear to be shallow and incongruent (3). As the
counselor conducts the assessment, Celeste seems overly familiar, blinking her eyes and touching the
counselor on the shoulder in response to a question he asks her (2). When told this behavior is not
appropriate, she shrugs her shoulders and smiles. When it happens again and she is confronted
directly with this inappropriate behavior, she denies she has violated boundaries. She states that she
now believes there is a special connection and that her relationship with her counselor is growing
closer. She does not respond easily when boundaries are set and continues to be more intimate than
is appropriate, given the professional relationship (8). Celeste meets seven of the diagnostic criteria
(1, 2, 3, 4, 5, 6, and 8) for a diagnosis of HPD. In evaluating a person for the diagnosis of HPD, whether
the disorder is causing clinically significant impairment is important. Some studies suggest that HPD
is of similar prevalence for males and females.
Personality Disorders
their capabilities, overstate their successes, and
appear pretentious and self-important. These
individuals require disproportionate admiration
and are preoccupied with how positively others
regard them. To fit the diagnostic picture, five of
the nine characteristic symptoms are required: (1)
exhibits a pompous sense of worth, for instance,
expecting to be viewed as exceptional without
commensurate accomplishments; (2) preoccupied
with notions of great success, power, genius,
physical attractiveness, and love; (3) believes
481
that one should associate with prominent people
(or institutions), because of being special and
exceptional; (4) insists on disproportionate admiration; (5) exhibits a feeling of entitlement (e.g.,
overinflated expectations of positive treatment or
reflexive compliance with personal expectations);
(6) exploits others to accomplish own ends; (7)
lacks ability to empathize with others; (8) exhibits
envy of others and believes others are envious of
him or her; and (9) demonstrates arrogant, conceited behaviors or viewpoints (APA, 2013).
CASE STUDY – CASE OF GARY
Gary reports to family and friends that he has joined Mensa because he believes he is of high status
and prefers to be around geniuses (criterion 1). He does not tell anyone how he actually became a
member of Mensa. His friend is sworn to keep confidence and not reveal that to get into Mensa, Gary
had his friend take the qualifying test to join the organization. In all settings, he talks about his
brilliance and ability to innovate. He also discusses his fantasies with family members about
becoming wealthy and powerful (2). He travels in a crowd that pays him attention for his faux
successes and alleged brilliance (3). The thing he enjoys most is the attention and admiration of others
who believe his story (4). He has a strong sense of entitlement and believes he deserves fame, fortune,
and others’ compliance in following his wishes (5). When he does not get his way, he becomes
belligerent and demands to get his way (9). At work, he uses people to advance in the ranks (6). He has
caused two of his supervisors over the past 4 years to be fired, and he assumed their positions. He
coldly talks about them and shares his disgust of them as human beings. On a recent occasion at the
market, he met one of his former supervisors. He had actually supported the supervisor’s termination
of employment. The previous supervisor told Gary that he had been unemployed for 3 years since he
was terminated from the job where Gary still works. The man said he was in a desperate financial
situation and asked if Gary could be of any help getting him back in the agency from which he was
terminated. Gary shook his head no and demonstrated no empathy for his situation (7). He coldly
dismissed the former supervisor and passed him by, stating openly to him that this was not his
problem.
Gary meets eight of the diagnostic criteria (1, 2, 3, 4, 5, 6, 7, and 9) for a diagnosis of NPD. Note
that adolescents display narcissistic traits; however, that does not mean that they will become
adults diagnosed with NPD. People with NPD may have particular difficulty adjusting to the aging
process in that age limits both physical and occupational functioning (APA, 2013, p. 671). There is
no consensus about the etiology of NPD. The prevalence of NPD is higher in persons who have
first-degree biological relatives diagnosed with NPD (Dobbert, 2007). Therapy can be successful
with those diagnosed with NPD who are seriously committed to changing their behavior. Dobbert
(2007) asserts that “a consistently applied system of rewards and punishments is more effective”
(p. 103).
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DIAGNOST IC AND TREATMENT APPLICAT ION S
CLUSTER C PERSONALITY DISORDERS
The cluster C personality disorders are avoidant,
dependent, and obsessive-compulsive personality disorders. Each of these personality disorders
shares the common theme of anxious and fearful
behavior. For all three in this section alphabetical
designations are not used for the criteria and only
numerical coding is provided.
Avoidant Personality Disorder (AVPD)
[301.82 (F60.6)]
Avoidant personality disorder (AVPD) is characterized by “social inhibition, feelings of
inadequacy, and hypersensitivity to negative
evaluation that begins by early adulthood and
is present in a variety of contexts” (APA, 2013,
p. 673). Individuals with AVPD avoid contact
with others out of fear they may be criticized,
rejected, or meet with disapproval. They avoid
people as much as possible because if they engage
in interaction, the fear of being embarrassed or
rejected is too great to confront (CRS-Behavioral Health Advisor, 2009). They do not
attempt to make new acquaintances unless
they can be sure they will meet with approval
and be liked without criticism. They are
observed to be shy and inhibited and to stay
in the background, seemingly invisible, since
they fear being degraded or rejected. Adults
with AVPD report less involvement in extracurricular activities and, when compared with
other mental disorders, such as major depressive
disorder, are often considered less popular
(Rettew, 2006). Because they have a limited
support network due to isolation, they have
few resources to work through a crisis.
According to the DSM-5, of the seven
characteristics of the disorder, an individual
must have a minimum of four. Individuals diagnosed with this disorder are characterized by a
history of social inhibition, feeling inadequate,
and displaying hypersensitive responses to others’
assessment that is perceived as negative. Because
these individuals are fearful of disapproval, criticism, and rejection, they avoid work activity that
includes interpersonal relating. Often they exaggerate the likelihood of danger in normal daily
experience; their protective lifestyle is associated
with their need for security and assurance. To fit
the diagnostic picture, four of the seven characteristic symptoms are required: (1) exhibit fear of
disapproval, criticism, and rejection so they avoid
work activities; (2) must be assured that they will
be liked to get involved with other people;
(3) fear shame and derision from others and
this fear of rejection can limit their involvement
in intimate relationships; (4) demonstrate anxiety
about being criticized or scorned in social interactions; (5) feels inadequate around others and
avoids new interpersonal situations such as making new friends; (6) perceive self as incompetent,
personally unattractive, or of lower status than
others; and (7) fear embarrassment and hesitate to
take personal chances or participate in new
activities (APA, 2013). The case of Linda shows
examples of the characteristics of the disorder.
Dependent Personality Disorder (DPD)
[301.6 (F60.7)]
Dependent personality disorder (DPD) is characterized by “a pervasive excessive need to be taken
care of that leads to submissive and clinging
behavior and fears of separation” (APA, 2013,
p. 675). This set of behaviors starts in early adulthood and is experienced in a number of settings.
The person with DPD experiences great difficulty
in making basic decisions, such as what to wear or
what to eat, and needs strong direction and
reassurance from others. Individuals with DPD
require parents or spouses to make all of the
decisions for them. They have great difficulty
in getting angry with those they depend on out
of fear they may estrange them. When a close
Personality Disorders
483
CASE STUDY – CASE OF LINDA
Linda is a 30-year-old British American woman who has worked in a New York garment factory for 12
years. She likes her work setting, and upon arriving at work, she immediately goes to her workstation
without engaging in conversation (criterion 1). She stays to herself at break time, even when others
invite her to join a conversation (5). Several of her coworkers are part of groups that socialize after
work hours. She has been invited to join a card club, a sewing circle, and a service club that helps
elderly persons. She says she did not join any of those groups because she was not sure the members
would like her if they really got to know her (2). She also was concerned that with more than three
people in a group, several members of the group would make fun of her (4). A coworker tried to set her
up for a date with Sam, a popular employee who was handsome and kind. Linda said she could not
meet Sam for a date because she was afraid she would say something that might cause him to
ridicule her (3). She recently started seeing a psychotherapist because she would like to feel more
confident and make some real friends. She reports to the therapist that she sees herself as
unappealing, feels inferior to others (6), and fears she will be embarrassed if she tries to begin
new activities, such as joining the service club that serves elderly persons (7). She is hopeful that she
can make some positive changes with the help of her therapist.
Linda meets seven of the diagnostic criteria (1, 2, 3, 4, 5, 6, and 7) for a diagnosis of AVPD.
People with AVPD may be disposed to the disorder if they have grown up in a home with overly
anxious parents who may have been diagnosed with social phobia or AVPD. However, genetic
predisposition and the impact of environmental factors have not been clearly associated with the
development of AVPD (Tillfors, Furmak, Ekselius, & Fredrikson, 2001). Cultural practices may
consider avoidant behaviors appropriate; conversely, avoidant behavior could be the result of
acculturation following immigration to the United States. For instance, language barriers may
contribute to isolation and fear of criticism when a person attempts to communicate, which may
add difficulty to social situations.
relationship ends, they frantically seek another
relationship to replace the previous one.
According to the DSM-5, of the eight characteristics of the disorder, an individual must have
a minimum of four. Individuals diagnosed with
this disorder are characterized by an extreme and
enduring need to be cared for that may lead to
submissive and clinging conduct due to separation
anxiety. Individuals with this diagnosis have difficulty in making the simplest everyday decisions
without others’ input. They experience strong
fears of abandonment and see themselves as completely dependent on the counsel and help of
others they perceive as important in their lives.
To fit the diagnostic picture, five of the eight
characteristic symptoms are required: (1) difficulty in decision making, requiring excessive
levels of advice and reassurance from others;
(2) requires others to take responsibility for
most important areas of life; (3) fears loss of
support or approval and experiences strain
when expressing disagreement with others
(note that this does not include accurate fears
of revenge); (4) experiences strain when starting
projects or working alone (due to limited selfconfidence in decision-making or capabilities
rather than lack of motivation or energy); (5)
will go to extreme behaviors to receive nurturance and reinforcement from others and volunteer to perform unpleasant tasks to receive such
attention; (6) due to extreme fear of not being
able to care for self, experiences feelings of
discomfort or helplessness when alone; (7)
when a close relationship ends, immediately
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