What is Antisocial Personality Disorder?

Introduction

Antisocial personality disorder (ASPD or infrequently APD) is a personality disorder characterised by a long-term pattern of disregard for, or violation of, the rights of others. A weak or non-existent conscience is often apparent, as well as a history of legal problems or impulsive and aggressive behaviour.

Antisocial personality disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), while the equivalent concept of dissocial personality disorder (DPD) is defined in the International Statistical Classification of Diseases and Related Health Problems (ICD); the primary theoretical distinction between the two is that antisocial personality disorder focuses on observable behaviours, while dissocial personality disorder focuses on affective deficits. Otherwise, both manuals provide similar criteria for diagnosing the disorder. Both have also stated that their diagnoses have been referred to, or include what is referred to, as psychopathy or sociopathy. However, some researchers have drawn distinctions between the concepts of antisocial personality disorder and psychopathy, with many researchers arguing that psychopathy is a disorder that overlaps with but is distinguishable from ASPD.

Brief History

The first version of the DSM in 1952 listed sociopathic personality disturbance. This category was for individuals who were considered “…ill primarily in terms of society and of conformity with the prevailing milieu, and not only in terms of personal discomfort and relations with other individuals”. There were four subtypes, referred to as “reactions”: antisocial, dyssocial, sexual, and addiction. The antisocial reaction was said to include people who were “always in trouble” and not learning from it, maintaining “no loyalties”, frequently callous and lacking responsibility, with an ability to “rationalise” their behaviour. The category was described as more specific and limited than the existing concepts of “constitutional psychopathic state” or “psychopathic personality” which had had a very broad meaning; the narrower definition was in line with criteria advanced by Hervey M. Cleckley from 1941, while the term sociopathic had been advanced by George Partridge in 1928 when studying the early environmental influence on psychopaths. Partridge discovered the correlation between antisocial psychopathic disorder and parental rejection experienced in early childhood.

The DSM-II in 1968 rearranged the categories and “antisocial personality” was now listed as one of ten personality disorders but still described similarly, to be applied to individuals who are: “basically unsocialised”, in repeated conflicts with society, incapable of significant loyalty, selfish, irresponsible, unable to feel guilt or learn from prior experiences, and who tend to blame others and rationalise. The manual preface contains “special instructions” including “Antisocial personality should always be specified as mild, moderate, or severe.” The DSM-II warned that a history of legal or social offenses was not by itself enough to justify the diagnosis, and that a “group delinquent reaction” of childhood or adolescence or “social maladjustment without manifest psychiatric disorder” should be ruled out first. The dyssocial personality type was relegated in the DSM-II to “dyssocial behaviour” for individuals who are predatory and follow more or less criminal pursuits, such as racketeers, dishonest gamblers, prostitutes, and dope peddlers. (DSM-I classified this condition as sociopathic personality disorder, dyssocial type). It would later resurface as the name of a diagnosis in the ICD manual produced by the WHO, later spelled dissocial personality disorder and considered approximately equivalent to the ASPD diagnosis.

The DSM-III in 1980 included the full term antisocial personality disorder and, as with other disorders, there was now a full checklist of symptoms focused on observable behaviours to enhance consistency in diagnosis between different psychiatrists (‘inter-rater reliability’). The ASPD symptom list was based on the Research Diagnostic Criteria developed from the so-called Feighner Criteria from 1972, and in turn largely credited to influential research by sociologist Lee Robins published in 1966 as “Deviant Children Grown Up”. However, Robins has previously clarified that while the new criteria of prior childhood conduct problems came from her work, she and co-researcher psychiatrist Patricia O’Neal got the diagnostic criteria they used from Lee’s husband the psychiatrist Eli Robins, one of the authors of the Feighner criteria who had been using them as part of diagnostic interviews.

The DSM-IV maintained the trend for behavioural antisocial symptoms while noting “This pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder” and re-including in the ‘Associated Features’ text summary some of the underlying personality traits from the older diagnoses. The DSM-5 has the same diagnosis of antisocial personality disorder. The Pocket Guide to the DSM-5 Diagnostic Exam suggests that a person with ASPD may present “with psychopathic features” if he or she exhibits “a lack of anxiety or fear and a bold, efficacious interpersonal style”.

Epidemiology

As seen in two North American studies and two European studies, ASPD is more commonly seen in men than in women, with men three to five times more likely to be diagnosed with ASPD than women. The prevalence of ASPD is even higher in selected populations, like prisons, where there is a preponderance of violent offenders. It has been found that the prevalence of ASPD among prisoners is just under 50%. Similarly, the prevalence of ASPD is higher among patients in alcohol or other drug (AOD) use treatment programmes than in the general population, suggesting a link between ASPD and AOD use and dependence. As part of the Epidemiological Catchment Area (ECA) study, men with ASPD were found to be three to five times more likely to excessively use alcohol and illicit substances than those men without ASPD. While ASPD occurs more often in men than women, there was found to be increased severity of this substance use in women with ASPD. In a study conducted with both men and women with ASPD, women were more likely to misuse substances compared to their male counterparts.

Individuals with ASPD are at an elevated risk for suicide. Some studies suggest this increase in suicidality is in part due to the association between suicide and symptoms or trends within ASPD, such as criminality and substance use. Offspring of ASPD victims are also at risk. Some research suggests that negative or traumatic experiences in childhood, perhaps as a result of the choices a parent with ASPD might make, can be a predictor of delinquency later on in the child’s life. Additionally, with variability between situations, children of a parent with ASPD may suffer consequences of delinquency if they’re raised in an environment in which crime and violence is common. Suicide is a leading cause of death among youth who display antisocial behaviour, especially when mixed with delinquency. Incarceration, which could come as a consequence of actions from a victim of ASPD, is a predictor for suicide ideation in youth.

Signs and Symptoms

Antisocial personality disorder is defined by a pervasive and persistent disregard for morals, social norms, and the rights and feelings of others. Individuals with this personality disorder will typically have no compunction in exploiting others in harmful ways for their own gain or pleasure and frequently manipulate and deceive other people. While some do so through a façade of superficial charm, others do so through intimidation and violence. They may display arrogance, think lowly and negatively of others, and lack remorse for their harmful actions and have a callous attitude to those they have harmed. Irresponsibility is a core characteristic of this disorder; most have significant difficulties in maintaining stable employment as well as fulfilling their social and financial obligations, and people with this disorder often lead exploitative, unlawful, or parasitic lifestyles.

Those with antisocial personality disorder are often impulsive and reckless, failing to consider or disregarding the consequences of their actions. They may repeatedly disregard and jeopardise their own safety and the safety of others, which can place both themselves and other people in danger. They are often aggressive and hostile, with poorly regulated tempers, and can lash out violently with provocation or frustration. Individuals are prone to substance use disorders and addiction, and the non-medical use of various psychoactive substances is common in this population. These behaviours lead such individuals into frequent conflict with the law, and many people with ASPD have extensive histories of antisocial behaviour and criminal infractions stemming back to adolescence or childhood.

Serious problems with interpersonal relationships are often seen in those with the disorder. People with antisocial personality disorder usually form poor attachments and emotional bonds, and interpersonal relationships often revolve around the exploitation and abuse of others. They may have difficulties in sustaining and maintaining relationships, and some have difficulty entering them.

Conduct Disorder

While antisocial personality disorder is a mental disorder diagnosed in adulthood, it has its precedent in childhood. The DSM-5’s criteria for ASPD require that the individual have conduct problems evident by the age of 15. Persistent antisocial behaviour, as well as a lack of regard for others in childhood and adolescence, is known as conduct disorder and is the precursor of ASPD. About 25-40% of youths with conduct disorder will be diagnosed with ASPD in adulthood.

Conduct disorder (CD) is a disorder diagnosed in childhood that parallels the characteristics found in ASPD and is characterised by a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate norms are violated. Children with the disorder often display impulsive and aggressive behaviour, may be callous and deceitful, and may repeatedly engage in petty crime such as stealing or vandalism or get into fights with other children and adults. This behaviour is typically persistent and may be difficult to deter with threat or punishment. Attention deficit hyperactivity disorder (ADHD) is common in this population, and children with the disorder may also engage in substance use. CD is differentiated from oppositional defiant disorder (ODD) in that children with ODD do not commit aggressive or antisocial acts against other people, animals, and property, though many children diagnosed with ODD are subsequently re-diagnosed with CD.

Two developmental courses for CD have been identified based on the age at which the symptoms become present. The first is known as the “childhood-onset type” and occurs when conduct disorder symptoms are present before the age of 10 years. This course is often linked to a more persistent life course and more pervasive behaviours, and children in this group express greater levels of ADHD symptoms, neuropsychological deficits, more academic problems, increased family dysfunction, and higher likelihood of aggression and violence. The second is known as the “adolescent-onset type” and occurs when conduct disorder develops after the age of 10 years. Compared to the childhood-onset type, less impairment in various cognitive and emotional functions are present, and the adolescent-onset variety may remit by adulthood. In addition to this differentiation, the DSM-5 provides a specifier for a callous and unemotional interpersonal style, which reflects characteristics seen in psychopathy and are believed to be a childhood precursor to this disorder. Compared to the adolescent-onset subtype, the childhood-onset subtype, especially if callous and unemotional traits are present, tends to have a worse treatment outcome.

Comorbidity

ASPD commonly coexists with the following conditions:

  • Anxiety disorders.
  • Depressive disorder.
  • Impulse control disorders.
  • Substance-related disorders.
  • Somatization disorder.
  • Attention deficit hyperactivity disorder.
  • Bipolar disorder.
  • Borderline personality disorder.
  • Histrionic personality disorder.
  • Narcissistic personality disorder.
  • Sadistic personality disorder.

When combined with alcoholism, people may show frontal function deficits on neuropsychological tests greater than those associated with each condition. Alcohol Use Disorder is likely caused by lack of impulse and behavioural control exhibited by Antisocial Personality Disorder patients. The rates of ASPD tends to be around 40-50% in male alcohol and opiate addicts. However, it is important to remember this is not a causal relationship, but rather a plausible consequence of cognitive deficits as a result of ASPD.

Causes

Personality disorders are seen to be caused by a combination and interaction of genetic and environmental influences. Genetically, it is the intrinsic temperamental tendencies as determined by their genetically influenced physiology, and environmentally, it is the social and cultural experiences of a person in childhood and adolescence encompassing their family dynamics, peer influences, and social values. People with an antisocial or alcoholic parent are considered to be at higher risk. Fire-setting and cruelty to animals during childhood are also linked to the development of antisocial personality. The condition is more common in males than in females, and among people who are in prison.

Genetic

Research into genetic associations in antisocial personality disorder suggests that ASPD has some or even a strong genetic basis. Prevalence of ASPD is higher in people related to someone afflicted by the disorder. Twin studies, which are designed to discern between genetic and environmental effects, have reported significant genetic influences on antisocial behaviour and conduct disorder.

In the specific genes that may be involved, one gene that has seen particular interest in its correlation with antisocial behaviour is the gene that encodes for Monoamine oxidase A (MAO-A), an enzyme that breaks down monoamine neurotransmitters such as serotonin and norephinephrine. Various studies examining the genes’ relationship to behaviour have suggested that variants of the gene that results in less MAO-A being produced, such as the 2R and 3R alleles of the promoter region, have associations with aggressive behaviour in men. The association is also influenced by negative experience in early life, with children possessing a low-activity variant (MAOA-L) who experience such maltreatment being more likely to develop antisocial behaviour than those with the high-activity variant (MAOA-H). Even when environmental interactions (e.g. emotional abuse) are controlled for, a small association between MAOA-L and aggressive and antisocial behaviour remains.

The gene that encodes for the serotonin transporter (SCL6A4), a gene that is heavily researched for its associations with other mental disorders, is another gene of interest in antisocial behaviour and personality traits. Genetic associations studies have suggested that the short “S” allele is associated with impulsive antisocial behaviour and ASPD in the inmate population. However, research into psychopathy find that the long “L” allele is associated with the Factor 1 traits of psychopathy, which describes its core affective (e.g. lack of empathy, fearlessness) and interpersonal (e.g. grandiosity, manipulativeness) personality disturbances. This is suggestive of two different forms, one associated more with impulsive behaviour and emotional dysregulation, and the other with predatory aggression and affective disturbance, of the disorder.

Various other gene candidates for ASPD have been identified by a genome-wide association study published in 2016. Several of these gene candidates are shared with attention-deficit hyperactivity disorder, with which ASPD is comorbid. Furthermore, the study found that those who carry 4 mutations on chromosome 6 are 1.5 times more likely to develop antisocial personality disorder than those who do not.

Physiological

Hormones and Neurotransmitters

Traumatic events can lead to a disruption of the standard development of the central nervous system, which can generate a release of hormones that can change normal patterns of development. Aggressiveness and impulsivity are among the possible symptoms of ASPD. Testosterone is a hormone that plays an important role in aggressiveness in the brain. For instance, criminals who have committed violent crimes tend to have higher levels of testosterone than the average person. The effect of testosterone is counteracted by cortisol which facilitates the cognitive control of impulsive tendencies.

One of the neurotransmitters that has been discussed in individuals with ASPD is serotonin, also known as 5HT.[41] A meta-analysis of 20 studies found significantly lower 5-HIAA levels (indicating lower serotonin levels), especially in those who are younger than 30 years of age.

While it has been shown that lower levels of serotonin may be associated with ASPD, there has also been evidence that decreased serotonin function is highly correlated with impulsiveness and aggression across a number of different experimental paradigms. Impulsivity is not only linked with irregularities in 5HT metabolism, but may be the most essential psychopathological aspect linked with such dysfunction. Correspondingly, the DSM classifies “impulsivity or failure to plan ahead” and “irritability and aggressiveness” as two of seven sub-criteria in category A of the diagnostic criteria of ASPD.

Some studies have found a relationship between monoamine oxidase A and antisocial behaviour, including conduct disorder and symptoms of adult ASPD, in maltreated children.

Neurological

Antisocial behaviour may be related to head trauma. Antisocial behaviour is associated with decreased grey matter in the right lentiform nucleus, left insula, and frontopolar cortex. Increased volumes have been observed in the right fusiform gyrus, inferior parietal cortex, right cingulate gyrus, and post central cortex.

Intellectual and cognitive ability is consistently found to be impaired or reduced in the ASPD population. Contrary to stereotypes in popular culture of the “psychopathic genius”, antisocial personality disorder is associated with both reduced overall intelligence and specific reductions in individual aspects of cognitive ability. These deficits also occur in general-population samples of people with antisocial traits and in children with the precursors to antisocial personality disorder.

People that exhibit antisocial behaviour demonstrate decreased activity in the prefrontal cortex. The association is more apparent in functional neuroimaging as opposed to structural neuroimaging. The prefrontal cortex is involved in many executive functions, including behaviour inhibitions, planning ahead, determining consequences of action, and differentiating between right and wrong. However, some investigators have questioned whether the reduced volume in prefrontal regions is associated with antisocial personality disorder, or whether they result from co-morbid disorders, such as substance use disorder or childhood maltreatment. Moreover, it remains an open question whether the relationship is causal, i.e. whether the anatomical abnormality causes the psychological and behavioural abnormality, or vice versa.

Cavum septi pellucidi (CSP) is a marker for limbic neural maldevelopment, and its presence has been loosely associated with certain mental disorders, such as schizophrenia and post-traumatic stress disorder. One study found that those with CSP had significantly higher levels of antisocial personality, psychopathy, arrests and convictions compared with controls.

Environmental

Family Environment

Some studies suggest that the social and home environment has contributed to the development of antisocial behaviour. The parents of these children have been shown to display antisocial behaviour, which could be adopted by their children. A lack of parental stimulation and affection during early development leads to sensitization of the child’s stress response systems, which is thought to lead to underdevelopment of the child’s brain that deals with emotion, empathy and ability to connect to other humans on an emotional level. According to Dr. Bruce Perry in his book The Boy Who Was Raised as a Dog, “the [infant’s developing] brain needs patterned, repetitive stimuli to develop properly. Spastic, unpredictable relief from fear, loneliness, discomfort, and hunger keeps a baby’s stress system on high alert. An environment of intermittent care punctuated by total abandonment may be the worst of all worlds for a child.”

Cultural Influences

The sociocultural perspective of clinical psychology views disorders as influenced by cultural aspects; since cultural norms differ significantly, mental disorders such as ASPD are viewed differently. Robert D. Hare has suggested that the rise in ASPD that has been reported in the United States may be linked to changes in cultural mores, the latter serving to validate the behavioural tendencies of many individuals with ASPD. While the rise reported may be in part merely a byproduct of the widening use (and abuse) of diagnostic techniques, given Eric Berne’s division between individuals with active and latent ASPD – the latter keeping themselves in check by attachment to an external source of control like the law, traditional standards, or religion – it has been suggested that the erosion of collective standards may indeed serve to release the individual with latent ASPD from their previously prosocial behaviour.

There is also a continuous debate as to the extent to which the legal system should be involved in the identification and admittance of patients with preliminary symptoms of ASPD. Controversial clinical psychiatrist Pierre-Édouard Carbonneau suggested that the problem with legal forced admittance is the rate of failure when diagnosing ASPD. He states that the possibility of diagnosing and coercing a patient into prescribing medication to someone without ASPD, but is diagnosed with it could be potentially disastrous, but the possibility of not diagnosing it and seeing a patient go untreated because of a lack of sufficient evidence of cultural or environmental influences is something a psychiatrist must ignore, and in his words, “play it safe”.

ICD-10

The World Health Organisation’s (WHO’s) International Statistical Classification of Diseases and Related Health Problems, tenth edition (ICD-10), has a diagnosis called dissocial personality disorder (F60.2):

It is characterised by at least 3 of the following:

  • Callous unconcern for the feelings of others;
  • Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations;
  • Incapacity to maintain enduring relationships, though having no difficulty in establishing them;
  • Very low tolerance to frustration and a low threshold for discharge of aggression, including violence;
  • Incapacity to experience guilt or to profit from experience, particularly punishment; and/or
  • Marked readiness to blame others or to offer plausible rationalisations for the behaviour that has brought the person into conflict with society.

The ICD states that this diagnosis includes “amoral, antisocial, asocial, psychopathic, and sociopathic personality”. Although the disorder is not synonymous with conduct disorder, presence of conduct disorder during childhood or adolescence may further support the diagnosis of dissocial personality disorder. There may also be persistent irritability as an associated feature.

It is a requirement of the ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Psychopathy

Psychopathy is commonly defined as a personality disorder characterised partly by antisocial behaviour, a diminished capacity for empathy and remorse, and poor behavioural controls. Psychopathic traits are assessed using various measurement tools, including Canadian researcher Robert D. Hare’s Psychopathy Checklist, Revised (PCL-R). “Psychopathy” is not the official title of any diagnosis in the DSM or ICD; nor is it an official title used by other major psychiatric organisations. The DSM and ICD, however, state that their antisocial diagnoses are at times referred to (or include what is referred to) as psychopathy or sociopathy.

American psychiatrist Hervey Cleckley’s work on psychopathy formed the basis of the diagnostic criteria for ASPD, and the DSM states ASPD is often referred to as psychopathy. However, critics argue ASPD is not synonymous with psychopathy as the diagnostic criteria are not the same, since criteria relating to personality traits are emphasized relatively less in the former. These differences exist in part because it was believed such traits were difficult to measure reliably and it was “easier to agree on the behaviours that typify a disorder than on the reasons why they occur”.

Although the diagnosis of ASPD covers two to three times as many prisoners than the diagnosis of psychopathy, Robert Hare believes the PCL-R is better able to predict future criminality, violence, and recidivism than a diagnosis of ASPD. He suggests there are differences between PCL-R-diagnosed psychopaths and non-psychopaths on “processing and use of linguistic and emotional information”, while such differences are potentially smaller between those diagnosed with ASPD and without. Additionally, Hare argued confusion regarding how to diagnose ASPD, confusion regarding the difference between ASPD and psychopathy, as well as the differing future prognoses regarding recidivism and treatability, may have serious consequences in settings such as court cases where psychopathy is often seen as aggravating the crime.

Nonetheless, psychopathy has been proposed as a specifier under an alternative model for ASPD. In the DSM-5, under “Alternative DSM-5 Model for Personality Disorders”, ASPD with psychopathic features is described as characterised by “a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviours (e.g. fraudulence).” Low levels of withdrawal and high levels of attention-seeking combined with low anxiety are associated with “social potency” and “stress immunity” in psychopathy. Under the specifier, affective and interpersonal characteristics are comparatively emphasized over behavioural components.

Treatment

ASPD is considered to be among the most difficult personality disorders to treat. Rendering an effective treatment for ASPD is further complicated due to the inability to look at comparative studies between psychopathy and ASPD due to differing diagnostic criteria, differences in defining and measuring outcomes and a focus on treating incarcerated patients rather than those in the community. Because of their very low or absent capacity for remorse, individuals with ASPD often lack sufficient motivation and fail to see the costs associated with antisocial acts. They may only simulate remorse rather than truly commit to change: they can be seductively charming and dishonest, and may manipulate staff and fellow patients during treatment. Studies have shown that outpatient therapy is not likely to be successful, but the extent to which persons with ASPD are entirely unresponsive to treatment may have been exaggerated.

Most treatment done is for those in the criminal justice system to whom the treatment regimes are given as part of their imprisonment. Those with ASPD may stay in treatment only as required by an external source, such as parole conditions. Residential programmes that provide a carefully controlled environment of structure and supervision along with peer confrontation have been recommended. There has been some research on the treatment of ASPD that indicated positive results for therapeutic interventions. Psychotherapy also known as talk therapy is found to help treat patients with ASPD. Schema therapy is also being investigated as a treatment for ASPD. A review by Charles M. Borduin features the strong influence of Multisystemic therapy (MST) that could potentially improve this imperative issue. However, this treatment requires complete cooperation and participation of all family members. Some studies have found that the presence of ASPD does not significantly interfere with treatment for other disorders, such as substance use, although others have reported contradictory findings.

Therapists working with individuals with ASPD may have considerable negative feelings toward patients with extensive histories of aggressive, exploitative, and abusive behaviours. Rather than attempt to develop a sense of conscience in these individuals, which is extremely difficult considering the nature of the disorder, therapeutic techniques are focused on rational and utilitarian arguments against repeating past mistakes. These approaches would focus on the tangible, material value of prosocial behaviour and abstaining from antisocial behaviour. However, the impulsive and aggressive nature of those with this disorder may limit the effectiveness of even this form of therapy.

The use of medications in treating antisocial personality disorder is still poorly explored, and no medications have been approved by the FDA to specifically treat ASPD. A 2020 Cochrane review of studies that explored the use of pharmaceuticals in ASPD patients, of which 8 studies met the selection criteria for review, concluded that the current body of evidence was inconclusive for recommendations concerning the use of pharmaceuticals in treating the various issues of ASPD. Nonetheless, psychiatric medications such as antipsychotics, antidepressants, and mood stabilizers can be used to control symptoms such as aggression and impulsivity, as well as treat disorders that may co-occur with ASPD for which medications are indicated.

Prognosis

According to Professor Emily Simonoff of the Institute of Psychiatry, Psychology and Neuroscience there are many variables that are consistently connected to ASPD, such as: childhood hyperactivity and conduct disorder, criminality in adulthood, lower IQ scores and reading problems. The strongest relationship between these variables and ASPD are childhood hyperactivity and conduct disorder. Additionally, children who grow up with a predisposition of ASPD and interact with other delinquent children are likely to later be diagnosed with ASPD. Like many disorders, genetics play a role in this disorder but the environment holds an undeniable role in its development.

Boys are twice as likely to meet all of the diagnostic criteria for ASPD than girls (40% versus 25%) and they will often start showing symptoms of the disorder much earlier in life. Children that do not show symptoms of the disease through age 15 will not develop ASPD later in life. If adults exhibit milder symptoms of ASPD, it is likely that they never met the criteria for the disorder in their childhood and were consequently never diagnosed. Overall, symptoms of ASPD tend to peak in late-teens and early twenties, but can often reduce or improve through age 40.

ASPD is ultimately a lifelong disorder that has chronic consequences, though some of these can be moderated over time. There may be a high variability of the long-term outlook of antisocial personality disorder. The treatment of this disorder can be successful, but it entails unique difficulties. It is unlikely to see rapid change especially when the condition is severe. In fact, past studies revealed that remission rates were small, with up to only 31% rates of improvement instead of remittance. As a result of the characteristics of ASPD (e.g. displaying charm in effort of personal gain, manipulation), patients seeking treatment (mandated or otherwise) may appear to be “cured” in order to get out of treatment. According to definitions found in the DSM-5, people with ASPD can be deceitful and intimidating in their relationships. When they are caught doing something wrong, they often appear to be unaffected and unemotional about the consequences. Over time, continual behaviour that lacks empathy and concern may lead to someone with ASPD taking advantage of the kindness of others, including his or her therapist.

Without proper treatment, individuals suffering with ASPD could lead a life that brings about harm to themselves or others. This can be detrimental to their families and careers. ASPD victims suffer from lack of interpersonal skills (e.g. lack of remorse, lack of empathy, lack of emotional-processing skills). As a result of the inability to create and maintain healthy relationships due to the lack of interpersonal skills, individuals with ASPD may find themselves in predicaments such as divorce, unemployment, homelessness and even premature death by suicide. They also see higher rates of committed crime, reaching peaks in their late teens and often committing higher-severity crimes in their younger ages of diagnoses. Comorbidity of other mental illnesses such as Depression or substance use disorder is prevalent among ASPD victims. People with ASPD are also more likely to commit homicides and other crimes. Those who are imprisoned longer often see higher rates of improvement with symptoms of ASPD than others who have been imprisoned for a shorter amount of time.

According to one study, aggressive tendencies show in about 72% of all male patients diagnosed with ASPD. About 29% of the men studied with ASPD also showed a prevalence of pre-meditated aggression. Based on the evidence in the study, the researchers concluded that aggression in patients with ASPD is mostly impulsive, though there are some long-term evidences of pre-meditated aggressions. It often occurs that those with higher psychopathic traits will exhibit the pre-meditated aggressions to those around them. Over the course of a patient’s life with ASPD, he or she can exhibit this aggressive behaviour and harm those close to him or her.

Additionally, many people (especially adults) who have been diagnosed with ASPD become burdens to their close relatives, peers, and caretakers. Harvard Medical School recommends that time and resources be spent treating victims who have been affected by someone with ASPD, because the patient with ASPD may not respond to the administered therapies. In fact, a patient with ASPD may only accept treatment when ordered by a court, which will make their course of treatment difficult and severe. Because of the challenges in treatment, the patient’s family and close friends must take an active role in decisions about therapies that are offered to the patient. Ultimately, there must be a group effort to aid the long-term effects of the disorder.

What is Dependent Personality Disorder?

Introduction

Dependent personality disorder (DPD) is a personality disorder that is characterised by a pervasive psychological dependence on other people.

This personality disorder is a long-term condition in which people depend on others to meet their emotional and physical needs, with only a minority achieving normal levels of independence. Dependent personality disorder is a Cluster C personality disorder, characterised by excessive fear and anxiety. It begins by early adulthood, and it is present in a variety of contexts and is associated with inadequate functioning. Symptoms can include anything from extreme passivity, devastation or helplessness when relationships end, avoidance of responsibilities and severe submission.

Brief History

The conceptualisation of dependency, within classical psychoanalytic theory, is directly related to Freud’s oral psychosexual stage of development. Frustration or over-gratification was said to result in an oral fixation and in an oral type of character, characterised by feeling dependent on others for nurturance and by behaviours representative of the oral stage. Later psychoanalytic theories shifted the focus from a drive-based approach of dependency to the recognition of the importance of early relationships and establishing separation from these early caregivers, in which the exchanges between the caregiver and the child become internalised, and the nature of these interactions becomes part of the concepts of the self and of others.

Signs and Symptoms

People who have dependent personality disorder are overdependent on other people when it comes to making decisions. They cannot make a decision on their own as they need constant approval from other people. Consequently, individuals diagnosed with DPD tend to place needs and opinions of others above their own as they do not have the confidence to trust their decisions. This kind of behaviour can explain why people with DPD tend to show passive and clingy behaviour. These individuals display a fear of separation and cannot stand being alone. When alone, they experience feelings of isolation and loneliness due to their overwhelming dependence on other people. Generally people with DPD are also pessimistic: they expect the worst out of situations or believe that the worst will happen. They tend to be more introverted and are more sensitive to criticism and fear rejection.

Risk Factors

People with a history of neglect and an abusive upbringing are more susceptible to develop DPD, specifically those involved in long-term abusive relationships. Those with overprotective or authoritarian parents are also more at risk to develop DPD. Having a family history of anxiety disorder can play a role in the development of DPD as a 2004 twin study found a 0.81 heritability for personality disorders collectively.

Causes

The exact cause of dependent personality disorder is unknown. A study in 2012 estimated that between 55% and 72% of the risk of the condition is inherited from one’s parents. The difference between a “dependent personality” and a “dependent personality disorder” is somewhat subjective, which makes diagnosis sensitive to cultural influences such as gender role expectations.

Dependent traits in children tended to increase with parenting behaviours and attitudes characterized by overprotectiveness and authoritarianism. Thus the likelihood of developing dependent personality disorder increased, since these parenting traits can limit them from developing a sense of autonomy, rather teaching them that others are powerful and competent.

Traumatic or adverse experiences early in an individual’s life, such as neglect and abuse or serious illness, can increase the likelihood of developing personality disorders, including dependent personality disorder, later on in life. This is especially prevalent for those individuals who also experience high interpersonal stress and poor social support.

There is a higher frequency of the disorder seen in women than men, hence expectations relating to gender role may contribute to some extent.

Diagnosis

Clinicians and clinical researchers conceptualise dependent personality disorder in terms of four related components:

  • Cognitive: a perception of oneself as powerless and ineffectual, coupled with the belief that other people are comparatively powerful and potent.
  • Motivational: a desire to obtain and maintain relationships with protectors and caregivers.
  • Behavioural: a pattern of relationship-facilitating behaviour designed to strengthen interpersonal ties and minimise the possibility of abandonment and rejection.
  • Emotional: fear of abandonment, fear of rejection, and anxiety regarding evaluation by figures of authority.

American Psychiatric Association and DSM

The Diagnostic and Statistical Manual of Mental Disorders (DSM) contains a dependent personality disorder diagnosis. It refers to a pervasive and excessive need to be taken care of which leads to submissive and clinging behaviour and fears of separation. This begins by early adulthood and can be present in a variety of contexts.

In the DSM Fifth Edition (DSM-5), there is one criterion by which there are eight features of dependent personality disorder. The disorder is indicated by at least five of the following factors:

  1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
  2. Needs others to assume responsibility for most major areas of their life.
  3. Has difficulty expressing disagreement with others because of fear of loss of support or approval.
  4. Has difficulty initiating projects or doing things on their own (because of a lack of self confidence in judgement or abilities rather than a lack of motivation or energy).
  5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
  6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for themselves.
  7. Urgently seeks another relationship as a source of care and support when a close relationship ends.
  8. Is unrealistically preoccupied with fears of being left to take care of themselves.

The diagnosis of personality disorders in the fourth edition the DSM, including dependent personality disorder, was found to be problematic due to reasons such as excessive diagnostic comorbidity, inadequate coverage, arbitrary boundaries with normal psychological functioning, and heterogeneity among individuals within the same categorial diagnosis.

World Health Organisation

The World Health Organisation’s (WHO) ICD-10 lists dependent personality disorder as F60.7 Dependent personality disorder:

  • It is characterised by at least 4 of the following:
    1. Encouraging or allowing others to make most of one’s important life decisions;
    2. Subordination of one’s own needs to those of others on whom one is dependent, and undue compliance with their wishes;
    3. Unwillingness to make even reasonable demands on the people one depends on;
    4. Feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself;
    5. Preoccupation with fears of being abandoned by a person with whom one has a close relationship, and of being left to care for oneself;
    6. Limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others.
  • Associated features may include perceiving oneself as helpless, incompetent, and lacking stamina.
  • Includes:
    • Asthenic, inadequate, passive, and self-defeating personality (disorder).

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

SWAP-200

The SWAP-200 is a diagnostic tool that was proposed with the goal of overcoming limitations, such as limited external validity for the diagnostic criteria for dependent personality disorder, to the DSM. It serves as a possible alternative nosological system that emerged from the efforts to create an empirically based approach to personality disorders – while also preserving the complexity of clinical reality. Dependent personality disorder is considered a clinical prototype in the context of the SWAP-200. Rather than discrete symptoms, it provides composite description characteristic criteria – such as personality tendencies.

Based on the Q-Sort method and prototype matching, the SWAP-200 is a personality assessment procedure relying on an external observer’s judgment. It provides:

  • A personality diagnosis expressed as the matching with ten prototypical descriptions of DSM-IV personality disorders.
  • A personality diagnosis based on the matching of the patient with 11 Q-factors of personality derived empirically.
  • A dimensional profile of healthy and adaptive functioning.

The traits that define dependent personality disorder according to SWAP-200 are:

  1. They tend to become attached quickly and/or intensely, developing feelings and expectations that are not warranted by the history or context of the relationship.
  2. Since they tend to be ingratiating and submissive, people with DPD tend to be in relationships in which they are emotionally or physically abused.
  3. They tend to feel ashamed, inadequate, and depressed.
  4. They also feel powerless and tend to be suggestible.
  5. They are often anxious and tend to feel guilty.
  6. These people have difficulty acknowledging and expressing anger and struggle to get their own needs and goals met.
  7. Unable to soothe or comfort themselves when distressed, they require involvement of another person to help regulate their emotions.

Psychodynamic Diagnostic Manual

The Psychodynamic Diagnostic Manual (PDM) approaches dependent personality disorder in a descriptive, rather than prescriptive sense and has received empirical support. The Psychodynamic Diagnostic Manual includes two different types of dependent personality disorder:

  • Passive-aggressive.
  • Counter-dependent.

The PDM-2 adopts and applies a prototypic approach, using empirical measures like the SWAP-200. It was influenced by a developmental and empirically grounded perspective, as proposed by Sidney Blatt. This model is of particular interest when focusing on dependent personality disorder, claiming that psychopathology comes from distortions of two main coordinates of psychological development:

  • The anaclitic/introjective dimension.
  • The relatedness/self-definition dimension.

The anaclitic personality organization in individuals exhibits difficulties in interpersonal relatedness, exhibiting the following behaviours:

  • Preoccupation with relationships.
  • Fear of abandonment and of rejection.
  • Seeking closeness and intimacy.
  • Difficulty managing interpersonal boundaries.
  • Tend to have an anxious-preoccupied attachment style.

Introjective personality style is associated with problems in self-definition.

Differential Diagnosis

There are similarities between individuals with dependent personality disorder and individuals with borderline personality disorder, in that they both have a fear of abandonment. Those with dependent personality disorder do not exhibit impulsive behaviour, unstable affect, and poor self-image experienced by those with borderline personality disorder, differentiating the two disorders.

The following conditions commonly coexist (comorbid) with dependent personality disorder:

Treatment

People who have DPD are generally treated with psychotherapy. The main goal of this therapy is to make the individual more independent and help them form healthy relationships with the people around them. This is done by improving their self-esteem and confidence.

Medication can be used to treat patients who suffer from depression or anxiety because of their DPD, but this does not treat the core problems caused by DPD. Individuals who take these prescription drugs are susceptible to addiction and substance abuse and therefore may require monitoring.

Epidemiology

Based on a recent survey of 43,093 Americans, 0.49% of adults meet diagnostic criteria for DPD (National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; Grant et al., 2004). Traits related to DPD, like most personality disorders emerge in childhood or early adulthood. Findings from the NESArC study found that 18 to 29 year olds have a greater chance of developing DPD. DPD is more common among women compared to men as 0.6% of women have DPD compared to 0.4% of men.

A 2004 twin study suggests a heritability of 0.81 for developing dependent personality disorder. Because of this, there is significant evidence that this disorder runs in families.

Children and adolescents with a history of anxiety disorders and physical illnesses are more susceptible to acquiring this disorder.

What is Histrionic Personality Disorder?

Introduction

Histrionic personality disorder (HPD) is defined by the American Psychiatric Association as a personality disorder characterised by a pattern of excessive attention-seeking behaviours, usually beginning in early childhood, including inappropriate seduction and an excessive desire for approval.

Individuals diagnosed with the disorder are said to be lively, dramatic, vivacious, enthusiastic, and flirtatious. Women are diagnosed with HPD roughly 4 times as often as men. It affects 2-3% of the general population and 10-15% in inpatient and outpatient mental health institutions.

HPD lies in the dramatic cluster of personality disorders. People with HPD have a high desire for attention, make loud and inappropriate appearances, exaggerate their behaviours and emotions, and crave stimulation. They may exhibit sexually provocative behaviour, express strong emotions with an impressionistic style, and can be easily influenced by others. Associated features include egocentrism, self-indulgence, continuous longing for appreciation, and persistent manipulative behaviour to achieve their own needs.

Signs and Symptoms

People with HPD are usually high-functioning, both socially and professionally. They usually have good social skills, despite tending to use them to manipulate others into making them the centre of attention. HPD may also affect a person’s social and romantic relationships, as well as their ability to cope with losses or failures. They may seek treatment for clinical depression when romantic (or other close personal) relationships end.

Individuals with HPD often fail to see their own personal situation realistically, instead dramatising and exaggerating their difficulties. They may go through frequent job changes, as they become easily bored and may prefer withdrawing from frustration (instead of facing it). Because they tend to crave novelty and excitement, they may place themselves in risky situations. All of these factors may lead to greater risk of developing clinical depression.

Additional characteristics may include:

  • Exhibitionist behaviour.
  • Constant seeking of reassurance or approval.
  • Excessive sensitivity to criticism or disapproval.
  • Pride of own personality and unwillingness to change, viewing any change as a threat.
  • Inappropriately seductive appearance or behaviour of a sexual nature.
  • Using factitious somatic symptoms (of physical illness) or psychological disorders to garner attention.
  • Craving attention.
  • Low tolerance for frustration or delayed gratification.
  • Rapidly shifting emotional states that may appear superficial or exaggerated to others.
  • Tendency to believe that relationships are more intimate than they actually are.
  • Making rash decisions.
  • Blaming personal failures or disappointments on others.
  • Being easily influenced by others, especially those who treat them approvingly.
  • Being overly dramatic and emotional.
  • Influenced by the suggestions of others.

Some people with histrionic traits or personality disorder change their seduction technique into a more maternal or paternal style as they age.

Mnemonic

A mnemonic that can be used to remember the characteristics of histrionic personality disorder is shortened as “PRAISE ME”:

  • Provocative (or seductive) behaviour.
  • Relationships are considered more intimate than they actually are.
  • Attention-seeking.
  • Influenced easily by others or circumstances.
  • Speech (style) wants to impress; lacks detail.
  • Emotional lability; shallowness.
  • Make-up; physical appearance is used to draw attention to self.
  • Exaggerated emotions; theatrical.

Causes

Little research has been done to find evidence of what causes histrionic personality disorder. Although direct causes are inconclusive, various theories and studies suggest multiple possible causes, of a neurochemical, genetic, psychoanalytic, or environmental nature. Traits such as extravagance, vanity, and seductiveness of hysteria have similar qualities to women diagnosed with HPD. HPD symptoms typically do not fully develop until the age of 15, while the onset of treatment only occurs, on average, at approximately 40 years of age.

Neurochemical/Physiological

Studies have shown that there is a strong correlation between the function of neurotransmitters and the Cluster B personality disorders such as HPD. Individuals diagnosed with HPD have highly responsive noradrenergic systems which is responsible for the synthesis, storage, and release of the neurotransmitter, norepinephrine. High levels of norepinephrine leads to anxiety-proneness, dependency, and high sociability.

Genetic

Twin studies have aided in breaking down the genetic vs. environment debate. A twin study conducted by the Department of Psychology at Oslo University attempted to establish a correlation between genetic and Cluster B personality disorders. With a test sample of 221 twins, 92 monozygotic and 129 dizygotic, researchers interviewed the subjects using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and concluded that there was a correlation of 0.67 that histrionic personality disorder is hereditary.

Psychoanalytic Theory

Though criticised as being unsupported by scientific evidence, psychoanalytic theories incriminate authoritarian or distant attitudes by one (mainly the mother) or both parents, along with conditional love based on expectations the child can never fully meet. Using psychoanalysis, Freud believed that lustfulness was a projection of the patient’s lack of ability to love unconditionally and develop cognitively to maturity, and that such patients were overall emotionally shallow. He believed the reason for being unable to love could have resulted from a traumatic experience, such as the death of a close relative during childhood or divorce of one’s parents, which gave the wrong impression of committed relationships. Exposure to one or multiple traumatic occurrences of a close friend or family member’s leaving (via abandonment or mortality) would make the person unable to form true and affectionate attachments towards other people.

HPD and Antisocial Personality Disorder

Another theory suggests a possible relationship between histrionic personality disorder and antisocial personality disorder. Research has found 2/3 of patients diagnosed with histrionic personality disorder also meet criteria similar to those of the antisocial personality disorder, which suggests both disorders based towards sex-type expressions may have the same underlying cause. Women are hypersexualised in the media consistently, ingraining thoughts that the only way women are to get attention is by exploiting themselves, and when seductiveness is not enough, theatrics are the next step in achieving attention. Men can just as well be flirtatious towards multiple women yet feel no empathy or sense of compassion towards them. They may also become the centre of attention by exhibiting the “Don Juan” macho figure as a role-play.

Some family history studies have found that histrionic personality disorder, as well as borderline and antisocial personality disorders, tend to run in families, but it is unclear if this is due to genetic or environmental factors. Both examples suggest that predisposition could be a factor as to why certain people are diagnosed with histrionic personality disorder, however little is known about whether or not the disorder is influenced by any biological compound or is genetically inheritable. Little research has been conducted to determine the biological sources, if any, of this disorder.

Diagnosis

The person’s appearance, behaviour and history, along with a psychological evaluation, are usually sufficient to establish a diagnosis. There is no test to confirm this diagnosis. Because the criteria are subjective, some people may be wrongly diagnosed.

DSM 5

The current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) defines histrionic personality disorder (in Cluster B) as:

A pervasive pattern of excessive emotionality and attention-seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  • Is uncomfortable in situations in which he or she is not the centre of attention.
  • Interaction with others is often characterised by inappropriate sexually seductive or provocative behaviour.
  • Displays rapidly shifting and shallow expression of emotions.
  • Consistently uses physical appearance to draw attention to self.
  • Has a style of speech that is excessively impressionistic and lacking in detail.
  • Shows self-dramatisation, theatricality, and exaggerated expression of emotion.
  • Is suggestible, i.e. easily influenced by others or circumstances.
  • Considers relationships to be more intimate than they actually are.

The DSM 5 requires that a diagnosis for any specific personality disorder also satisfies a set of general personality disorder criteria.

ICD-10

The World Health Organization’s ICD-10 lists histrionic personality disorder as:

A personality disorder characterised by:

  • Shallow and labile affectivity.
  • Self-dramatisation.
  • Theatricality.
  • Exaggerated expression of emotions.
  • Suggestibility.
  • Egocentricity.
  • Self-indulgence.
  • Lack of consideration for others.
  • Easily hurt feelings.
  • Continuous seeking for appreciation, excitement and attention.

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Comorbidity

Most histrionics also have other mental disorders. Comorbid conditions include: antisocial, dependent, borderline, and narcissistic personality disorders, as well as depression, anxiety disorders, panic disorder, somatoform disorders, anorexia nervosa, substance use disorder and attachment disorders, including reactive attachment disorder.

Millon’s Subtypes

Theodore Millon identified six subtypes of histrionic personality disorder. Any individual histrionic may exhibit none or one of the following (as outlined in the table below).

SubtypeDescriptionPersonality Traits
Appeasing histrionicIncluding dependent and compulsive features.Seeks to placate, mend, patch up, smooth over troubles; knack for settling differences, moderating tempers by yielding, compromising, conceding; sacrifices self for commendation; fruitlessly placates the unplacatable.
Vivacious histrionicThe seductiveness of the histrionic mixed with the energy typical of hypomania.
Some narcissistic features can also be present.
Vigorous, charming, bubbly, brisk, spirited, flippant, impulsive; seeks momentary cheerfulness and playful adventures; animated, energetic, ebullient.
Tempestuous histrionicIncluding negativistic features.Impulsive, out of control; moody complaints, sulking; precipitous emotion, stormy, impassioned, easily wrought-up, periodically inflamed, turbulent.
Disingenuous histrionicIncluding antisocial features.Underhanded, double-dealing, scheming, contriving, plotting, crafty, false-hearted; egocentric, insincere, deceitful, calculating, guileful.
Theatrical histrionicVariant of “pure” pattern.Affected, mannered, put-on; postures are striking, eyecatching, graphic; markets self-appearance; is synthesized, stagy; simulates desirable/dramatic poses.
Infantile histrionicIncluding borderline features.Labile, high-strung, volatile emotions; childlike hysteria and nascent pouting; demanding, overwrought; fastens and clutches to another; is excessively attached, hangs on, stays fused to and clinging.

Treatment

Treatment is often prompted by depression associated with dissolved romantic relationships. Medication does little to affect the personality disorder, but may be helpful with symptoms such as depression. The only successful method studied and proven to succeed is to fully break contact with their lovers in order to gain a sense of stability and independence once again. Treatment for HPD itself involves psychotherapy, including cognitive therapy.

Interviews and Self-Report Methods

In general clinical practice with assessment of personality disorders, one form of interview is the most popular; an unstructured interview. The actual preferred method is a semi-structured interview but there is reluctance to use this type of interview because they can seem impractical or superficial. The reason that a semi-structured interview is preferred over an unstructured interview is that semi-structured interviews tend to be more objective, systematic, replicable, and comprehensive. Unstructured interviews, despite their popularity, tend to have problems with unreliability and are susceptible to errors leading to false assumptions of the client.

One of the single most successful methods for assessing personality disorders by researchers of normal personality functioning is the self-report inventory following up with a semi-structured interview. There are some disadvantages with the self-report inventory method that with histrionic personality disorder there is a distortion in character, self-presentation, and self-image. This cannot be assessed simply by asking most clients if they match the criteria for the disorder. Most projective testing depend less on the ability or willingness of the person to provide an accurate description of the self, but there is currently limited empirical evidence on projective testing to assess histrionic personality disorder.

Functional Analytic Psychotherapy

Another way to treat histrionic personality disorder after identification is through functional analytic psychotherapy. The job of a Functional Analytic Psychotherapist is to identify the interpersonal problems with the patient as they happen in session or out of session. Initial goals of functional analytic psychotherapy are set by the therapist and include behaviours that fit the client’s needs for improvement. Functional analytic psychotherapy differs from the traditional psychotherapy due to the fact that the therapist directly addresses the patterns of behaviour as they occur in-session.

The in-session behaviours of the patient or client are considered to be examples of their patterns of poor interpersonal communication and to adjust their neurotic defences. To do this, the therapist must act on the client’s behaviour as it happens in real time and give feedback on how the client’s behaviour is affecting their relationship during therapy. The therapist also helps the client with histrionic personality disorder by denoting behaviours that happen outside of treatment; these behaviours are termed “Outside Problems” and “Outside Improvements”. This allows the therapist to assist in problems and improvements outside of session and to verbally support the client and condition optimal patterns of behaviour. This then can reflect on how they are advancing in-session and outside of session by generalising their behaviours over time for changes or improvement.

Coding Client and Therapist Behaviours

This is called coding client and therapist behaviour. In these sessions there is a certain set of dialogue or script that can be forced by the therapist for the client to give insight on their behaviours and reasoning. Here is an example a hypothetical conversation. T = therapist C = Client. This coded dialogue can be transcribed as:

  • ECRB – Evoking clinically relevant behaviour:
    • T: Tell me how you feel coming in here today (CRB2).
    • C: Well, to be honest, I was nervous. Sometimes I feel worried about how things will go, but I am really glad I am here.
  • CRB1 – In-session problems:
    • C: Whatever, you always say that. (becomes quiet). I don’t know what I am doing talking so much.
  • CRB2 – In-session improvements.
  • TCRB1 – Clinically relevant response to client problems.
    • T: Now you seem to be withdrawing from me. That makes it hard for me to give you what you might need from me right now. What do you think you want from me as we are talking right now?”.
  • TCRB2 – Responses to client improvement:
    • T: That’s great. I am glad you’re here, too. I look forward to talking to you.

Functional Ideographic Assessment Template

Another example of treatment besides coding is functional ideographic assessment template. The functional ideographic assessment template, also known as FIAT, was used as a way to generalize the clinical processes of functional analytic psychotherapy. The template was made by a combined effort of therapists and can be used to represent the behaviours that are a focus for this treatment. Using the FIAT therapists can create a common language to get stable and accurate communication results through functional analytic psychotherapy at the ease of the client; as well as the therapist.

Epidemiology

The survey data from the National epidemiological survey from 2001-2002 suggests a prevalence of HPD of 1.84%. Major character traits may be inherited, while other traits may be due to a combination of genetics and environment, including childhood experiences. This personality is seen more often in women than in men. Approximately 65% of HPD diagnoses are women while 35% are men. In Marcie Kaplan’s A Women’s View of DSM-III, she argues that women are overdiagnosed due to potential biases and expresses that even healthy women are often automatically diagnosed with HPD.

Many symptoms representing HPD in the DSM are exaggerations of traditional feminine behaviours. In a peer and self-review study, it showed that femininity was correlated with histrionic, dependent and narcissistic personality disorders. Although two thirds of HPD diagnoses are female, there have been a few exceptions. Whether or not the rate will be significantly higher than the rate of women within a particular clinical setting depends upon many factors that are mostly independent of the differential sex prevalence for HPD. Those with HPD are more likely to look for multiple people for attention, which leads to marital problems due to jealousy and lack of trust from the other party. This makes them more likely to become divorced or separated once married. With few studies done to find direct causations between HPD and culture, cultural and social aspects play a role in inhibiting and exhibiting HPD behaviours.

Brief History

Histrionic personality disorder stems from Etruscan histrio which means “an actor”. Hysteria can be described as an exaggerated or uncontrollable emotion that people, especially in groups, experience. Beliefs about hysteria have varied throughout time. It wasn’t until Sigmund Freud who studied histrionic personality disorder in a psychological manner. “The roots of histrionic personality can be traced to cases of hysterical neurosis described by Freud.” He developed the psychoanalytic theory in the late 19th century and the results from his development led to split concepts of hysteria. One concept labelled as hysterical neurosis (also known as conversion disorder) and the other concept labelled as hysterical character (currently known as histrionic personality disorder). These two concepts must not be confused with each other, as they are two separate and different ideas.

Histrionic personality disorder is also known as hysterical personality. Hysterical personality has evolved in the past 400 years and it first appeared in the DSM II (Diagnostic and Statistical Manual of Mental Disorders, 2nd edition) under the name hysterical personality disorder. The name we know today as histrionic personality disorder is due to the name change in DSM III, third edition. Renaming hysterical personality to histrionic personality disorder is believed to be because of possible negative connotations to the roots of hysteria, such as intense sexual expressions, demon possessions, etc.

Histrionic personality disorder has gone through many changes. From hysteria, to hysterical character, to hysterical personality disorder, to what it is listed as in the most current DSM, DSM-5.[clarification needed] “Hysteria is one of the oldest documented medical disorders.” Hysteria dates back to both ancient Greek and Egyptian writings. Most of the writings related hysteria and women together, similar to today where the epidemiology of histrionic personality disorder is generally more prevalent in women and also frequently diagnosed in women.

Ancient Times

  • Ancient Egypt:
    • First description of the mental disorder, hysteria, dates back to 1900 BC in Ancient Egypt. Biological issues, such as the uterus movement in the female body, were seen as the cause of hysteria.
    • Traditional symptoms and descriptions of hysteria can be found in the Ebers Papyrus, the oldest medical document.
  • Ancient Greece:
    • Similar to ancient Egyptians, the ancient Greeks saw hysteria being related to the uterus.
    • Hippocrates (5th century BC) is the first to use the term hysteria.
    • Hippocrates believed hysteria was a disease that lies in the movement of uterus (from the Greek ὑστέρα hystera “uterus”).
    • Hippocrates’s theory was that since a woman’s body is cold and wet compared to a man’s body which is warm and dry, the uterus is prone to illness, especially if deprived from sex.
    • He saw sex as the cleansing of the body so that being overemotional was due to sex deprivation.
  • According to History Channel’s Ancients Behaving Badly, Cleopatra and Nero had histrionic personality disorder.

Middle Ages

  • The Trotula:
    • A group of three texts from the 12th century, discusses women’s diseases and disorders as understood during this time period, including hysteria.
    • Trota of Salerno, a female medical practitioner from 12th-century Italy, is an authoritative figure behind one of the texts of the Trotula.
    • Authoritative in that it is her treatments and theories that are presented in the text.
    • Some people believe Trota’s teachings resonated with those of Hippocrates.

Renaissance

  • The uterus was still the explanation of hysteria, the concept of women being inferior to men was still present, and hysteria was still the symbol for femininity.

Modern Age

  • Thomas Willis (17th century) introduces a new concept of hysteria.
    • Thomas Willis believed that the causes of hysteria was not linked to the uterus of the female, but to the brain and nervous system.
  • Hysteria was consequence of social conflicts during the Salem witch trials.
  • Witchcraft and sorcery was later considered absurd during the Age of Enlightenment in the late 17th century and 18th century.
    • Hysteria starts to form in a more scientific way, especially neurologically.
    • New ideas formed during this time and one of them was that if hysteria is connected to the brain, men could possess it too, not just women.
  • Franz Mesmer (18th century) treated patients suffering from hysteria with his method called mesmerism, or animal magnetism.
  • Jean-Martin Charcot (19th century) studied effects of hypnosis in hysteria.
    • Charcot states that hysteria is a neurological disorder and that it is actually very common in men.

Contemporary Age

  • Sigmund Freud’s work with Josef Breuer, Studies on Hysteria, contributes to a psychoanalytic theory of hysteria.
  • Freud believed that hysteria was caused by a lack of libidinal evolution.

Social Implications

The prevalence of histrionic personality disorder in women is apparent and urges a re-evaluation of cultural notions of normal emotional behaviour. The diagnostic approach classifies histrionic personality disorder behaviour as “excessive”, considering it in reference to a social understanding of normal emotionality.

What is Neurosis?

Introduction

Neurosis is a class of functional mental disorders involving chronic distress, but neither delusions nor hallucinations. The term is no longer used by the professional psychiatric community in the United States, having been eliminated from the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980 with the publication of DSM III. However, it is still used in the ICD-10 Chapter V F40-48.

Neurosis should not be mistaken for psychosis, which refers to a loss of touch with reality. Nor should it be mistaken for neuroticism, a fundamental personality trait proposed in the Big Five personality traits theory.

Etymology

The term is derived from the Greek word neuron (νεῦρον, ‘nerve’) and the suffix -osis (-ωσις, ‘diseased’ or ‘abnormal condition’).

The term neurosis was coined by Scottish doctor William Cullen in 1769 to refer to “disorders of sense and motion” caused by a “general affection of the nervous system.” Cullen used the term to describe various nervous disorders and symptoms that could not be explained physiologically. Physical features, however, were almost inevitably present, and physical diagnostic tests, such as exaggerated knee-jerks, loss of the gag reflex and dermatographia, were used into the 20th century. The meaning of the term was redefined by Carl Jung and Sigmund Freud over the early and middle 20th century, and has continued to be used in psychology and philosophy.

The DSM eliminated the neurosis category in 1980, because of a decision by its editors to provide descriptions of behaviour rather than descriptions of hidden psychological mechanisms. This change has been controversial. Likewise, according to the American Heritage Medical Dictionary, neurosis is “no longer used in psychiatric diagnosis.”

Symptoms and Causes

Neurosis may be defined simply as a “poor ability to adapt to one’s environment, an inability to change one’s life patterns, and the inability to develop a richer, more complex, more satisfying personality.” There are many different neuroses, including:

According to C. George Boeree, professor emeritus at Shippensburg University, the symptoms of neurosis may involve:

… anxiety, sadness or depression, anger, irritability, mental confusion, low sense of self-worth, etc., behavioral symptoms such as phobic avoidance, vigilance, impulsive and compulsive acts, lethargy, etc., cognitive problems such as unpleasant or disturbing thoughts, repetition of thoughts and obsession, habitual fantasizing, negativity and cynicism, etc. Interpersonally, neurosis involves dependency, aggressiveness, perfectionism, schizoid isolation, socio-culturally inappropriate behaviors, etc.

Jungian Theory

Carl Jung found his approach particularly effective for patients who are well adjusted by social standards but are troubled by existential questions. Jung claims to have “frequently seen people become neurotic when they content themselves with inadequate or wrong answers to the questions of life”. Accordingly, the majority of his patients “consisted not of believers but of those who had lost their faith”. Contemporary man, according to Jung,

…is blind to the fact that, with all his rationality and efficiency, he is possessed by ‘powers’ that are beyond his control. His gods and demons have not disappeared at all; they have merely got new names. They keep him on the run with restlessness, vague apprehensions, psychological complications, an insatiable need for pills, alcohol, tobacco, food — and, above all, a large array of neuroses.

Jung found that the unconscious finds expression primarily through an individual’s inferior psychological function, whether it is thinking, feeling, sensation, or intuition. The characteristic effects of a neurosis on the dominant and inferior functions are discussed in his Psychological Types. Jung also found collective neuroses in politics: “Our world is, so to speak, dissociated like a neurotic.”

Psychoanalytic Theory

According to psychoanalytic theory, neuroses may be rooted in ego defence mechanisms, though the two concepts are not synonymous. Defence mechanisms are a normal way of developing and maintaining a consistent sense of self (i.e. an ego). However, only those thoughts and behaviours that produce difficulties in one’s life should be called neuroses.

A neurotic person experiences emotional distress and unconscious conflict, which are manifested in various physical or mental illnesses; the definitive symptom being anxiety. Neurotic tendencies are common and may manifest themselves as acute or chronic anxiety, depression, an obsessive compulsive disorder, a phobia, or a personality disorder.

Horney’s Theory

In her final book, Neurosis and Human Growth, Karen Horney lays out a complete theory of the origin and dynamics of neurosis. In her theory, neurosis is a distorted way of looking at the world and at oneself, which is determined by compulsive needs rather than by a genuine interest in the world as it is. Horney proposes that neurosis is transmitted to a child from his or her early environment and that there are many ways in which this can occur:

When summarized, they all boil down to the fact that the people in the environment are too wrapped up in their own neuroses to be able to love the child, or even to conceive of him as the particular individual he is; their attitudes toward him are determined by their own neurotic needs and responses.

The child’s initial reality is then distorted by his or her parents’ needs and pretences. Growing up with neurotic caretakers, the child quickly becomes insecure and develops basic anxiety. To deal with this anxiety, the child’s imagination creates an idealised self-image:

Each person builds up his personal idealized image from the materials of his own special experiences, his earlier fantasies, his particular needs, and also his given faculties. If it were not for the personal character of the image, he would not attain a feeling of identity and unity. He idealizes, to begin with, his particular “solution” of his basic conflict: compliance becomes goodness, love, saintliness; aggressiveness becomes strength, leadership, heroism, omnipotence; aloofness becomes wisdom, self-sufficiency, independence. What—according to his particular solution—appear as shortcomings or flaws are always dimmed out or retouched.

Once he identifies himself with his idealised image, a number of effects follow. He will make claims on others and on life based on the prestige he feels entitled to because of his idealised self-image. He will impose a rigorous set of standards upon himself in order to try to measure up to that image. He will cultivate pride, and with that will come the vulnerabilities associated with pride that lacks any foundation. Finally, he will despise himself for all his limitations. Vicious circles will operate to strengthen all of these effects.

Eventually, as he grows to adulthood, a particular “solution” to all the inner conflicts and vulnerabilities will solidify. He will be either:

  • Expansive, displaying symptoms of narcissism, perfectionism, or vindictiveness;
  • Self-effacing and compulsively compliant, displaying symptoms of neediness or codependence; or
  • Resigned, displaying schizoid tendencies.

In Horney’s view, mild anxiety disorders and full-blown personality disorders all fall under her basic scheme of neurosis as variations in the degree of severity and in the individual dynamics. The opposite of neurosis is a condition Horney calls self-realisation, a state of being in which the person responds to the world with the full depth of his or her spontaneous feelings, rather than with anxiety-driven compulsion. Thus the person grows to actualize his or her inborn potentialities. Horney compares this process to an acorn that grows and becomes a tree: the acorn has had the potential for a tree inside it all along.

What is Paranoid Personality Disorder?

Introduction

Paranoid personality disorder (PPD) is a mental illness characterised by paranoid delusions, and a pervasive, long-standing suspiciousness and generalised mistrust of others.

People with this personality disorder may be hypersensitive, easily insulted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions that may validate their fears or biases. They are eager observers. They think they are in danger and look for signs and threats of that danger, potentially not appreciating other interpretations or evidence.

They tend to be guarded and suspicious and have quite constricted emotional lives. Their reduced capacity for meaningful emotional involvement and the general pattern of isolated withdrawal often lend a quality of schizoid isolation to their life experience. People with PPD may have a tendency to bear grudges, suspiciousness, tendency to interpret others’ actions as hostile, persistent tendency to self-reference, or a tenacious sense of personal right. Patients with this disorder can also have significant comorbidity with other personality disorders (such as schizotypal, schizoid, narcissistic, avoidant and borderline).

Epidemiology

PPD occurs in about 0.5-2.5% of the general population. It is seen in 2-10% of psychiatric outpatients. It is more common in males.

Brief History

Paranoid personality disorder is listed in DSM-V and was included in all previous versions of the DSM. One of the earliest descriptions of the paranoid personality comes from the French psychiatrist Valentin Magnan who described a “fragile personality” that showed idiosyncratic thinking, hypochondriasis, undue sensitivity, referential thinking and suspiciousness.

Closely related to this description is Emil Kraepelin’s description from 1905 of a pseudo-querulous personality who is “always on the alert to find grievance, but without delusions”, vain, self-absorbed, sensitive, irritable, litigious, obstinate, and living at strife with the world. In 1921, he renamed the condition paranoid personality and described these people as distrustful, feeling unjustly treated and feeling subjected to hostility, interference and oppression. He also observed a contradiction in these personalities: on the one hand, they stubbornly hold on to their unusual ideas, on the other hand, they often accept every piece of gossip as the truth. Kraepelin also noted that paranoid personalities were often present in people who later developed paranoid psychosis. Subsequent writers also considered traits like suspiciousness and hostility to predispose people to developing delusional illnesses, particularly “late paraphrenias” of old age.

Following Kraepelin, Eugen Bleuler described “contentious psychopathy” or “paranoid constitution” as displaying the characteristic triad of suspiciousness, grandiosity and feelings of persecution. He also emphasized that these people’s false assumptions do not attain the form of real delusion.

Ernst Kretschmer emphasized the sensitive inner core of the paranoia-prone personality: they feel shy and inadequate but at the same time they have an attitude of entitlement. They attribute their failures to the machinations of others but secretly to their own inadequacy. They experience constant tension between feelings of self-importance and experiencing the environment as unappreciative and humiliating.

Karl Jaspers, a German phenomenologist, described “self-insecure” personalities who resemble the paranoid personality. According to Jaspers, such people experience inner humiliation, brought about by outside experiences and their interpretations of them. They have an urge to get external confirmation to their self-deprecation and that makes them see insults in the behaviour of other people. They suffer from every slight because they seek the real reason for them in themselves. This kind of insecurity leads to overcompensation: compulsive formality, strict social observances and exaggerated displays of assurance.

In 1950, Kurt Schneider described the “fanatic psychopaths” and divided them into two categories: the combative type that is very insistent about his false notions and actively quarrelsome, and the eccentric type that is passive, secretive, vulnerable to esoteric sects but nonetheless suspicious about others.

The descriptions of Leonhard and Sheperd from the sixties describe paranoid people as overvaluing their abilities and attributing their failure to the ill-will of others; they also mention that their interpersonal relations are disturbed and they are in constant conflict with others.

In 1975, Polatin described the paranoid personality as rigid, suspicious, watchful, self-centred and selfish, inwardly hypersensitive but emotionally undemonstrative. However, when there is a difference of opinion, the underlying mistrust, authoritarianism and rage burst through.

In the 1980s, paranoid personality disorder received little attention, and when it did receive it, the focus was on its potential relationship to paranoid schizophrenia. The most significant contribution of this decade comes from Theodore Millon who divided the features of paranoid personality disorder to four categories:

  1. Behavioural characteristics of vigilance, abrasive irritability and counterattack.
  2. Complaints indicating oversensitivity, social isolation and mistrust.
  3. The dynamics of denying personal insecurities, attributing these to others and self-inflation through grandiose fantasies.
  4. Coping style of detesting dependence and hostile distancing of oneself from others.

Causes

A genetic contribution to paranoid traits and a possible genetic link between this personality disorder and schizophrenia exist. A large long-term Norwegian twin study found paranoid personality disorder to be modestly heritable and to share a portion of its genetic and environmental risk factors with the other cluster A personality disorders, schizoid and schizotypal.

Psychosocial theories implicate projection of negative internal feelings and parental modelling. Cognitive theorists believe the disorder to be a result of an underlying belief that other people are unfriendly in combination with a lack of self-awareness.

Diagnosis

ICD-10

The World Health Organisation’s ICD-10 lists paranoid personality disorder under (F60.0). It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria. It is also pointed out that for different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and other obligations.

PPD is characterised by at least three of the following symptoms:

  1. Excessive sensitivity to setbacks and rebuffs;
  2. Tendency to bear grudges persistently (i.e. refusal to forgive insults and injuries or slights);
  3. Suspiciousness and a pervasive tendency to distort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous;
  4. A combative and tenacious sense of self-righteousness out of keeping with the actual situation;
  5. Recurrent suspicions, without justification, regarding sexual fidelity of spouse or sexual partner;
  6. Tendency to experience excessive self-aggrandising, manifest in a persistent self-referential attitude;
  7. Preoccupation with unsubstantiated “conspiratorial” explanations of events both immediate to the patient and in the world at large.

Includes: expansive paranoid, fanatic, querulant and sensitive paranoid personality disorder.

Excludes: delusional disorder and schizophrenia.

DSM-5

The American Psychiatric Association’s DSM-5 has similar criteria for paranoid personality disorder. They require in general the presence of lasting distrust and suspicion of others, interpreting their motives as malevolent, from an early adult age, occurring in a range of situations. Four of seven specific issues must be present, which include different types of suspicions or doubt (such as of being exploited, or that remarks have a subtle threatening meaning), in some cases regarding others in general or specifically friends or partners, and in some cases referring to a response of holding grudges or reacting angrily.

PPD is characterised by a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts. To qualify for a diagnosis, the patient must meet at least four out of the following criteria:

  1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them.
  2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
  3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against them.
  4. Reads hidden demeaning or threatening meanings into benign remarks or events.
  5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
  6. Perceives attacks on their character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
  7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

The DSM-5 lists paranoid personality disorder essentially unchanged from the DSM-IV-TR version and lists associated features that describe it in a more quotidian way. These features include suspiciousness, intimacy avoidance, hostility and unusual beliefs/experiences.

Other

Various researchers and clinicians may propose varieties and subsets or dimensions of personality related to the official diagnoses. Psychologist Theodore Millon has proposed five subtypes of paranoid personality (table below).

SubtypeFeatures
Obdurate paranoid (including compulsive features)Self-assertive, unyielding, stubborn, steely, implacable, unrelenting, dyspeptic, peevish, and cranky stance; legalistic and self-righteous; discharges previously restrained hostility; renounces self-other conflict.
Fanatic paranoid (including narcissistic features)Grandiose delusions are irrational and flimsy; pretentious, expensive supercilious contempt and arrogance toward others; lost pride re-established with extravagant claims and fantasies.
Querulous paranoid (including negativistic features)Contentious, cavilling, fractious, argumentative, fault-finding, unaccommodating, resentful, choleric, jealous, peevish, sullen, endless wrangles, whiny, waspish, snappish.
Insular paranoid (including avoidant features)Reclusive, self-sequestered, hermitical; self-protectively secluded from omnipresent threats and destructive forces; hypervigilant and defensive against imagined dangers.
Malignant paranoid (including sadistic features)Belligerent, cantankerous, intimidating, vengeful, callous, and tyrannical; hostility vented primarily in fantasy; projects own venomous outlook onto others; persecutory delusions.

Differential Diagnosis

Paranoid personality disorder can involve, in response to stress, very brief psychotic episodes (lasting minutes to hours). The paranoid may also be at greater than average risk of experiencing major depressive disorder, agoraphobia, social anxiety disorder, obsessive-compulsive disorder or alcohol and substance-related disorders. Criteria for other personality disorder diagnoses are commonly also met, such as:

Treatment

Because of reduced levels of trust, there can be challenges in treating PPD. However, psychotherapy, antidepressants, antipsychotics and anti-anxiety medications can play a role when a person is receptive to intervention.

What is the Negativistic Personality Disorder?

Introduction

Negativistic personality disorder is characterised by procrastination, covert obstructionism, inefficiency and stubbornness.

The current version of the Diagnostic and Statistical Manual of Mental Disorders no longer uses this phrase or label, and it is not one of the ten listed specific personality disorders. The previous edition, the revision IV (DSM-IV) describes passive-aggressive personality disorder as a proposed disorder involving a “pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance” in a variety of contexts.

Passive-aggressive behaviour is the obligatory symptom of the passive-aggressive personality disorder. Persons with passive-aggressive personality disorder are characterised by procrastination, covert obstructionism, inefficiency and stubbornness.

Brief History

In the first version of the Diagnostic and Statistical Manual of Mental Disorders, DSM-I, in 1952, the Passive-aggressive was defined in a narrow way, grouped together with the passive-dependent.

The DSM-III-R stated in 1987 that Passive-aggressive disorder is typified by, among other things, “fail[ing] to do the laundry or to stock the kitchen with food because of procrastination and dawdling.”

Causes

Passive-aggressive disorder may stem from a specific childhood stimulus (e.g. alcohol/drug addicted parents, bullying, abuse) in an environment where it was not safe to express frustration or anger. Families in which the honest expression of feelings is forbidden tend to teach children to repress and deny their feelings and to use other channels to express their frustration. For example, if physical and psychological punishment were to be dealt to children who express anger, they would be inclined to be passive aggressive.

Children who sugarcoat hostility may have difficulties being assertive, never developing better coping strategies or skills for self-expression. They can become adults who, beneath a “seductive veneer,” harbour “vindictive intent,” in the words of Timothy F. Murphy and Loriann Oberlin. Alternatively individuals may simply have difficulty being as directly aggressive or assertive as others. Martin Kantor suggests three areas that contribute to passive-aggressive anger in individuals: conflicts about dependency, control, and competition, and that a person may be termed passive-aggressive if they behave so to few people on most occasions.

Murphy and Oberlin also see passive aggression as part of a larger umbrella of hidden anger stemming from ten traits of the angry child or adult. These traits include making one’s own misery, the inability to analyse problems, blaming others, turning bad feelings into angry ones, attacking people, lacking empathy, using anger to gain power, confusing anger with self-esteem, and indulging in negative self-talk. Lastly, the authors point out that those who hide their anger can be nice when they wish to be.

Diagnosis

Diagnostic and Statistical Manual

With the publication of the DSM-5, this label has been largely disregarded. The equivalent DSM-5 diagnostic label would be “Other specified personality and unspecified personality disorder,” as the individual may meet general criteria for a personality disorder, but does not meet the trait-based diagnostic criteria for any specific personality disorder (p.645).

Passive-aggressive [personality disorder] was listed as an Axis II personality disorder in the DSM-III-R, but was moved in the DSM-IV to Appendix B (“Criteria Sets and Axes Provided for Further Study”) because of controversy and the need for further research on how to also categorise the behaviours in a future edition. According to DSM-IV, people with passive-aggressive personality disorder are “often overtly ambivalent, wavering indecisively from one course of action to its opposite. They may follow an erratic path that causes endless wrangles with others and disappointment for themselves.” Characteristic of these persons is an “intense conflict between dependence on others and the desire for self-assertion.” Although exhibiting superficial bravado, their self-confidence is often very poor, and others react to them with hostility and negativity. This diagnosis is not made if the behaviour is exhibited during a major depressive episode or can be attributed to dysthymic disorder.

ICD-10

The 10th revision of the International Classification of Diseases (ICD-10) of the World Health Organisation (WHO) includes passive-aggressive personality disorder in the “other specific personality disorders” rubric (description: “a personality disorder that fits none of the specific rubrics: F60.0-F60.7”). ICD-10 code for “other specific personality disorders” is F60.8. For this psychiatric diagnosis a condition must meet the general criteria for personality disorder listed under F60 in the clinical descriptions and diagnostic guidelines.

The general criteria for personality disorder includes markedly disharmonious behaviour and attitudes (involving such areas of functioning as affectivity – ability to experience affects: emotions or feelings, involving ways of perceiving and thinking, impulse control, arousal, style of relating to others), the abnormal behaviour pattern (enduring, of long standing), personal distress and the abnormal behaviour pattern must be clearly maladaptive and pervasive. Personality disorder must appear during childhood or adolescence and continue into adulthood.

Specific diagnostic criteria of the passive-aggressive personality disorder in the “Diagnostic criteria for research” by WHO is not presented.

Millon’s Subtypes

The psychologist Theodore Millon has proposed four subtypes of ‘negativist’ (‘Passive-aggressive’). Any individual negativist may exhibit none or one of the following:

SubtypeDescriptionPersonality Traits
Vacillating negativistIncluding borderline featuresEmotions fluctuate in bewildering, perplexing, and enigmatic ways; difficult to fathom or comprehend own capricious and mystifying moods; wavers, in flux, and irresolute both subjectively and intrapsychically.
Discontented negativistIncluding depressive featuresGrumbling, petty, testy, cranky, embittered, complaining, fretful, vexed, and moody; gripes behind pretence; avoids confrontation; uses legitimate but trivial complaints.
Circuitous negativistIncluding antisocial and dependent featuresOpposition displayed in a roundabout, labyrinthine, and ambiguous manner, e.g. procrastination, dawdling, forgetfulness, inefficiency, neglect, stubbornness, indirect and devious in venting resentment and resistant behaviours.
Abrasive negativistIncluding sadistic featuresContentious, intransigent, fractious, and quarrelsome; irritable, caustic, debasing, corrosive, and acrimonious, contradicts and derogates; few qualms and little conscience or remorse (no longer a valid diagnosis in DSM).

Treatment

Psychiatrist Kantor suggests a treatment approach using psychodynamic, supportive, cognitive, behavioural and interpersonal therapeutic methods. These methods apply to both the passive-aggressive person and their target victim.

What is Avoidant Personality Disorder?

Introduction

Avoidant personality disorder (AvPD) is a Cluster C personality disorder in which the main coping mechanism of those affected is avoidance of feared stimuli.

Those affected display a pattern of severe social anxiety, social inhibition, feelings of inadequacy and inferiority, extreme sensitivity to negative evaluation and rejection, and avoidance of social interaction despite a strong desire for intimacy.

People with AvPD often consider themselves to be socially inept or personally unappealing and avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked. They often avoid becoming involved with others unless they are certain they will be liked.

Childhood emotional neglect (in particular, the rejection of a child by one or both parents) and peer group rejection are associated with an increased risk for its development; however, it is possible for AvPD to occur without any notable history of abuse or neglect.

Brief History

The avoidant personality has been described in several sources as far back as the early 1900s, although it was not so named for some time. Swiss psychiatrist Eugen Bleuler described patients who exhibited signs of avoidant personality disorder in his 1911 work Dementia Praecox: Or the Group of Schizophrenias. Avoidant and schizoid patterns were frequently confused or referred to synonymously until Kretschmer (1921), in providing the first relatively complete description, developed a distinction.

Signs and Symptoms

Avoidant individuals are preoccupied with their own shortcomings and form relationships with others only if they believe they will not be rejected. They often view themselves with contempt, while showing a decreased ability to identify traits within themselves that are generally considered as positive within their societies. Loss and social rejection are so painful that these individuals will choose to be alone rather than risk trying to connect with others.

Some with this disorder fantasize about idealized, accepting and affectionate relationships because of their desire to belong. They often feel themselves unworthy of the relationships they desire, and shame themselves from ever attempting to begin them. If they do manage to form relationships, it is also common for them to pre-emptively abandon them out of fear of the relationship failing.

Individuals with the disorder tend to describe themselves as uneasy, anxious, lonely, unwanted and isolated from others. They often choose jobs of isolation in which they do not have to interact with others regularly. Avoidant individuals also avoid performing activities in public spaces for fear of embarrassing themselves in front of others.

Symptoms include:

  • Extreme shyness or anxiety in social situations, though the person feels a strong desire for close relationships;
  • Heightened attachment-related anxiety, which may include a fear of abandonment; and
  • Substance abuse and/or dependence.

Comorbidity

AvPD is reported to be especially prevalent in people with anxiety disorders, although estimates of comorbidity vary widely due to differences in (among others) diagnostic instruments. Research suggests that approximately 10-50% of people who have panic disorder with agoraphobia have avoidant personality disorder, as well as about 20-40% of people who have social anxiety disorder. In addition to this, AvPD is more prevalent in people who have comorbid social anxiety disorder and generalised anxiety disorder (GAD) than in those who have only one of the aforementioned conditions.

Some studies report prevalence rates of up to 45% among people with GAD and up to 56% of those with obsessive-compulsive disorder. Posttraumatic stress disorder is also commonly comorbid with AvPD.

Avoidants are prone to self-loathing and, in certain cases, self-harm. In particular, avoidants who have comorbid PTSD have the highest rates of engagement in self-harming behaviour, outweighing even those with borderline personality disorder (with or without PTSD). Substance use disorders are also common in individuals with AvPD – particularly in regard to alcohol, benzodiazepines and heroin – and may significantly affect a patient’s prognosis.

Earlier theorists proposed a personality disorder with a combination of features from borderline personality disorder and avoidant personality disorder, called “avoidant-borderline mixed personality” (AvPD/BPD).

Causes

Causes of AvPD are not clearly defined, but appear to be influenced by a combination of social, genetic and psychological factors. The disorder may be related to temperamental factors that are inherited.

Specifically, various anxiety disorders in childhood and adolescence have been associated with a temperament characterised by behavioural inhibition, including features of being shy, fearful and withdrawn in new situations. These inherited characteristics may give an individual a genetic predisposition towards AvPD.

Childhood emotional neglect and peer group rejection are both associated with an increased risk for the development of AvPD. Some researchers believe a combination of high-sensory-processing sensitivity coupled with adverse childhood experiences may heighten the risk of an individual developing AvPD.

Subtypes

Millon

Psychologist Theodore Millon notes that because most patients present a mixed picture of symptoms, their personality disorder tends to be a blend of a major personality disorder type with one or

more secondary personality disorder types. He identified four adult subtypes of AvPD as outlined below.

SubtypePersonality Traits/Features
Phobic Avoidant (including dependent features)General apprehensiveness displaced with avoidable tangible precipitant; qualms and disquietude symbolised by a repugnant and specific dreadful object or circumstances.
Conflicted Avoidant (including negativistic features)Internal discord and dissension; fears dependence; unsettled; unreconciled within self; hesitating, confused, tormented, paroxysmic, embittered; and unresolvable angst.
Hypersensitive Avoidant (including paranoid features)Intensely wary and suspicious; alternatively panicky, terrified, edgy, and timorous, then thin-skinned, high-strung, petulant, and prickly.
Self-Deserting Avoidant (including depressive features)Blocks or fragments self-awareness; discards painful images and memories; casts away untenable thoughts and impulses; ultimately jettisons self (suicidal).

Others

In 1993, Lynn E. Alden and Martha J. Capreol proposed two other subtypes of avoidant personality disorder, as outlined below.

SubtypePersonality Traits/Features
Cold-AvoidantCharacterised by an inability to experience and express positive emotion towards others.
Exploitable-AvoidantCharacterised by an inability to express anger towards others or to resist coercion from others. May be at risk for abuse by others.

Diagnosis

ICD

The World Health Organisation’s ICD-10 lists avoidant personality disorder as anxious (avoidant) personality disorder (F60.6).

It is characterised by the presence of at least four of the following:

  1. Persistent and pervasive feelings of tension and apprehension.
  2. Belief that one is socially inept, personally unappealing, or inferior to others.
  3. Excessive preoccupation with being criticised or rejected in social situations.
  4. Unwillingness to become involved with people unless certain of being liked.
  5. Restrictions in lifestyle because of need to have physical security.
  6. Avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection.

Associated features may include hypersensitivity to rejection and criticism.

It is a requirement of ICD-10 that all personality disorder diagnoses also satisfy a set of general personality disorder criteria.

DSM

The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the APA also has an avoidant personality disorder diagnosis (301.82). It refers to a widespread pattern of inhibition around people, feeling inadequate and being very sensitive to negative evaluation. Symptoms begin by early adulthood and occur in a range of situations.

Four of the following seven specific symptoms should be present:

  1. Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.
  2. Is unwilling to get involved with people unless certain of being liked.
  3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
  4. Is preoccupied with being criticised or rejected in social situations.
  5. Is inhibited in new interpersonal situations because of feelings of inadequacy.
  6. Views self as socially inept, personally unappealing, or inferior to others.
  7. Is unusually reluctant to take personal risk or to engage in any new activities because they may prove embarrassing.

Differential Diagnosis

In contrast to social anxiety disorder, a diagnosis of AvPD also requires that the general criteria for a personality disorder are met.

According to the DSM-5, avoidant personality disorder must be differentiated from similar personality disorders such as dependent, paranoid, schizoid, and schizotypal. But these can also occur together; this is particularly likely for AvPD and dependent personality disorder. Thus, if criteria for more than one personality disorder are met, all can be diagnosed.

There is also an overlap between avoidant and schizoid personality traits and AvPD may have a relationship to the schizophrenia spectrum.

Epidemiology

Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions indicates a prevalence of 2.36% in the US general population. It appears to occur with equal frequency in males and females. In one study, it was seen in 14.7% of psychiatric outpatients.

Criticism

There is controversy as to whether avoidant personality disorder (AvPD) is distinct from generalised social anxiety disorder. Both have similar diagnostic criteria and may share a similar causation, subjective experience, course, treatment and identical underlying personality features, such as shyness.

It is contended by some that they are merely different conceptualisations of the same disorder, where avoidant personality disorder may represent the more severe form. In particular, those with AvPD experience not only more severe social phobia symptoms, but are also more depressed and more functionally impaired than patients with generalised social phobia alone. But they show no differences in social skills or performance on an impromptu speech. Another difference is that social phobia is the fear of social circumstances whereas AvPD is better described as an aversion to intimacy in relationships.

Treatment

Treatment of avoidant personality disorder can employ various techniques, such as social skills training, psychotherapy, cognitive therapy, and exposure treatment to gradually increase social contacts, group therapy for practicing social skills, and sometimes drug therapy.

A key issue in treatment is gaining and keeping the patient’s trust since people with an avoidant personality disorder will often start to avoid treatment sessions if they distrust the therapist or fear rejection. The primary purpose of both individual therapy and social skills group training is for individuals with an avoidant personality disorder to begin challenging their exaggerated negative beliefs about themselves.

Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort.

Prognosis

Being a personality disorder, which is usually chronic and has long-lasting mental conditions, an avoidant personality disorder is not expected to improve with time without treatment. Given that it is a poorly studied personality disorder and in light of prevalence rates, societal costs, and the current state of research, AvPD qualifies as a neglected disorder.

Can We Link Personality Pathology with Smoking & Traits?

Research Paper Title

Predicting smoking and nicotine dependence from the DSM-5 alternative model for personality pathology.

Background

Individuals with personality disorders (PDs) have higher morbidity and mortality than the general population, which may be due to maladaptive health behaviours such as smoking.

Previous studies have examined the links between categorical PD diagnoses/personality traits and smoking/nicotine dependence, but little is known about how the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition alternative model for personality disorders relates to smoking and nicotine dependence.

Methods

The current study examined this question in a sample of 500 participants using the Levels of Personality Functioning Scale to assess general personality pathology, the Personality Inventory for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition to measure specific traits, the Fagerström test for Nicotine Dependence to assess nicotine dependence, and questions about current and past smoking to assess smoking status (i.e. current, former, never).

Results

Multinomial logistic regression results demonstrated that general personality pathology (Criterion A) was not related to smoking status, and there were no reliable associations between traits (Criterion B) and smoking status. However, correlations showed that higher negative affectivity and disinhibition were related to higher levels of nicotine dependence within smokers.

Conclusions

Findings are discussed in regard to previous findings linking personality pathology to smoking/nicotine dependence as well as the general validity of this new personality disorder diagnostic system.

Reference

Halberstadt, A.L., Skrzynski, C.J., Wright, A.G.C. & Creswell, K.G. (2021) Predicting smoking and nicotine dependence from the DSM-5 alternative model for personality pathology. Personality Disorders. doi: 10.1037/per0000487. Online ahead of print.

Book: Working Effectively with ‘Personality Disorder’

Book Title:

Working Effectively with ‘Personality Disorder’: Contemporary and Critical Approaches to Clinical and Organisational Practice.

Author(s): Jo Ramsden (Author & Editor), Sharon Prince (Editor), and Julia Blazdell (Editor).

Year: 2020.

Edition: First (1st).

Publisher: Luminate.

Type(s): Paperback and Kindle.

Synopsis:

The history of personality disorder services is problematic to say the least. The very concept is under heavy fire, services are often expensive and ineffective, and many service users report feeling that they have been deceived, stigmatised or excluded. Yet while there are inevitably serious (and often destructive) relational challenges involved in the work, creative networks of learning do exist – professionals who are striving to provide progressive, compassionate services for and with this client group.

Working Effectively with Personality Disorder shares this knowledge, articulating an alternative way of working that acknowledges the contemporary debate around diagnosis, reveals flawed assumptions underlying current approaches, and argues for services that work more positively, more holistically and with a wider and more socially focused agenda.

TABLE OF CONTENTS

  • Foreword by John Livesley.
  • Introduction (Jo Ramsden, Sharon Prince and Julia Blazdell).
  • PART 1: CONTEMPORARY AND CRITICAL PERSPECTIVES ON PERSONALITY DISORDER.
    • Chapter 1: Life and Labels: Some Personal Thoughts about Personality Disorder (Sue Sibbald).
    • Chapter 2: Personality Disorder: Breakdown in the Relational Field (Nick Benefield & Rex Haigh).
    • Chapter 3: The Scale of the Problem (Sarah Skett & Kimberley Barlow).
    • Chapter 4: The Politics of Personality Disorder A Critical Realist Account (David Pilgrim).
    • Chapter 5: The Importance of Personal Meaning (Sharon Prince & Sue Ellis).
    • Chapter 6: The Organisation and Its Discontents: In Search of the Fallible and Good Enough Care Enterprise (Jina Barrett).
  • PART 2: GOVERNANCE PRINCIPLES SUPPORTING SERVICES TO ENACT CONTEMPORARY AND CRITICAL PERSPECTIVES.
    • Chapter 7: Access to Services – Moving beyond Specialist Provision while Applying the Learning (Jo Ramsden).
    • Chapter 8: Reimagining Interventions (Alan Hirons & Ruth Sutherland).
    • Chapter 9: Service User Involvement and Co-production in Personality Disorder Services An Invitation to Transcend Re Traumatising Power Politics (Melanie Ann Ball).
    • Chapter 10: Partnership Working (David Harvey & Bernie Tuohy).
    • Chapter 11: Outcomes (Mary McMurran).
    • Chapter 12: Contained and Containing Teams (Jo Ramsden).
    • Chapter 13: Co-Produced Practice Near Learning: Developing Critically Reflective Relational Systems (Neil Gordon).

Book: Personality Disorders and Mental Illnesses: The Truth About Psychopaths, Sociopaths, and Narcissists

Book Title:

Personality Disorders and Mental Illnesses: The Truth About Psychopaths, Sociopaths, and Narcissists.

Author(s): Clarence T. Rivers.

Year: 2014.

Edition: First (1st).

Publisher: Createspace Independent Publishing Platform.

Type(s): Paperback and Kindle.

Synopsis:

From the ~Unleash the Power of the Mind~ collection and the award winning writer, Clarence T. Rivers, comes a masterful explanation of the mind and the various personality disorders and mental illnesses.

Topics of Discussion

  • Personality Disorders and Mental Illnesses.
  • Psychopathy Defined.
  • Crime and Psychopaths.
  • Psychopaths vs. Sociopaths.
  • Sociopath Defined.
  • The Goal of a Sociopath.
  • The Weaknesses of a Sociopath.
  • Dealing with a Sociopath.
  • Narcissism Defined.
  • The Narcissist in You.
  • The Narcissists of Today.
  • How to Deal with a Narcissist.
  • and much more!