Table of Contents:

  1. Prototypic Descriptions
  2. Defining Characteristics
  3. Maladaptive Schemas
  4. Attachment Styles
  5. Case Conceptualisations

Personality Disorder Concepts

Prototypic Descriptions

Prototypic descriptions are brief descriptions that “capture the essence of how a particular disorder commonly presents”, i.e., a summary of the key features of the disorder. The following are the protoypic descriptions of the DSM-5-TR personality disorders, summarised from Sperry:

AsPD

Antisocials displayed symptoms of Conduct Disorder from early childhood, and their manipulative and irresponsible behaviour continued into adulthood. They lack empathy and use others for their own gain. Because they can’t tolerate boredom, they are reckless, impulsive thrill-seekers and disregard their safety and others’. AsPD is over-diagnosed in prisons and detention centres.

AvPD

Avoidants are frightened and anxious, which makes them socially awkward. They are hypersensitive to criticism and rejection, and the fear of being embarrassed and humiliated causes them to withdraw and avoid social interaction. They crave connection with others, and may have trusted people with whom they can relax and feel safe.

BPD

Borderlines are terrified of being abandoned, which leads to intense relationships that often end in disappointment when they split on their favourite person. They are prone to self-damaging behaviours, and self-harm and suicide attempts are common. They have a fragmented, confused sense of self. They are often impulsive and prone to anger.

DPD

Dependents feel inadequate and fragile and need others to rely on. They struggle with being alone and find it nearly impossible to make their own decisions. They are submissive and are more than willing to put others’ needs and views above their own. They will do whatever it takes to get others to care for them, to give them affection, and give direction to their lives.

HPD

Histrionics are dramatic, charming and intense people. Their emotions are both intense and shallow at the same time. Their interests and attitudes are easily influenced by what others think and value. They need attention and reassurance that they are loved from others, so they often overestimate the intimacy of relationships.

NPD

Narcissists have a grandiose sense of self-importance, specialness and uniqueness that leads them to feel entitled and privileged. They expect and need admiration and respect from others to fuel their self-esteem. They lack empathy, so they have difficulty recognising the needs, concerns, or feelings of others. Criticism, rejection and failure leads to massive feelings of shame which is often redirected into anger.

OCPD

Obsessive-compulsives are perfectionists and need to get every detail right. As such, they are anxious and want to be in control of situations, so to avoid mistakes. They find comfort in schedules, rules and details, but their devotion to perfection interferes with their relationships and life outside of work or school. They have a tendency to hoard and are unusually tight with money, just in case.

PPD

Paranoids believe that the world is dangerous and that others will try to harm, exploit and deceive them if they open up. They are always on guard to any sign of threat. They hold on to grudges, never forget a slight, nor pass up a chance for revenge.

StPD

Schizotypals are eccentric, disorganised people whose emotions and speech are strange and blunted. Their strange beliefs are associated with ideas of reference and magical thinking, but don’t extend to full-blown psychosis. It’s not uncommon for schizotypals to be misdiagnosed as being autistic.

SzPD

Schizoids are uncomfortable being around others and just want to be left alone. Connection with others is scary and difficult, so they tend to keep to themselves. They come across as awkward, distant, and overly formal, and may be described as “cold fish”.

Defining Characteristics

These are the defining characteristics of each PD, each of which are different depending on the PD in question.

Triggering event(s): The situations that trigger a maladaptive response that is reflected in the person’s behavioral, interpersonal, cognitive, and affective styles. Triggering events can be intrapersonal (e.g. failing an exam), or interpersonal (e.g. being criticised).

  • AsPD Social standards and rules.
  • AvPD: Close relationships; being social / in public.
  • BPD: The expectation of meeting goals; maintaining close relationships; real or imagined abandonment.
  • DPD: The expectation that they can rely on themselves; being alone.
  • HPD: Relationships, particularly with those they’re attracted to.
  • NPD: Self-evaluation, either by themselves or others.
  • OCPD: Unstructured situations; meeting other’s standards (in all aspects of life: work, family, etc).
  • PPD: Close relationships; personal questions.
  • StPD: Close relationships.
  • SzPD: Close relationships.

Behavioral style: The way in which the person reacts to a triggering event.

  • AsPD: Impulsive, irritable, aggressive; irresponsible and struggles to keep commitments; relies on themselves, uses cunning and force; risk-taking and thrill-seeking.
  • AvPD: Tense and self-conscious; controlled speech & behaviour; appear apprehensive and awkward; self-criticising and overly humble.
  • BPD: Self-damaging behaviours (self-harm, self-sabotage, suicidal ideation); aggression; achieve less than they could (e.g. in work or school); chronic insomnia & irregular circadian rhythms (”body clocks”); feel helpless & empty void.
  • DPD: Docile, passive, non-assertive, insecure, and submissive; doubts themselves & lacks self-confidence.
  • HPD: Charming, dramatic, expressive; demanding, self-indulgent, inconsiderate; attention-seeking, mood swings, impulsive, unpredictable, and superficial.
  • NPD: Self-centred, egotistical, self-assured; dominates conversations; seeks approval and attention; impatient, arrogant, hypersensitive.
  • OCPD: Perfectionists; workaholics; dependable, stubborn, possessive; indecisive, prone to procrastination.
  • PPD: Always tense and hypervigilant; defensive, argumentative, guarded.
  • StPD: Eccentric, bizarre; strange speech; struggles with work and school and often become drifters and wanderers; avoids long-term commitment and looses touch with society’s expectations; dissociative.
  • SzPD: Lethargic, inattentive, eccentric; slow and monotone speech; rarely spontaneous; indifferent.

Interpersonal style: The way they relate to others.

  • AsPD: Deceitful; irritable, antagonistic and aggressive; disregards their and other’s safety; distrustful; lacks empathy; competitive.
  • AvPD: Sensitive to rejection; want acceptance but are too scared; withdraw and avoid when afraid; test people to see if they’re safe to interact with.
  • BPD: “Paradoxical instability”; splitting (idealise & cling vs devalue & dismiss); sensitive to rejection; “abandonment depression” & separation anxiety; superficial yet quickly developed and intense relationships; “extraordinarily intolerant” of being alone.
  • DPD: People-pleasers, self-sacrificing, clingy & needs reassurance; over-compliant & over-reliant on others; want others to be in control of their lives; avoids arguments; puts themselves down so they can receive the support of others; urgently seeks a new relationship when one ends.
  • HPD: Needs attention; flirtatious, manipulative; lacks empathy; overestimates intimacy of relationships.
  • NPD: Exploitative; self-indulgent; charming, pleasant & endearing; lacks empathy; irresponsible; jealous; needs approval and admiration.
  • OCPD: Very aware of social hierarchy; deferential to superiors and haughty to subordinates; polite and loyal; insist that their way is the right way to do things, because they are anxious to ensure perfection; stubborn; devoted to work which interferes with relationships.
  • PPD: Distrustful, secretive, suspicious, tend to isolate themselves and avoid intimacy; hypersensitive to criticism; bears grudges and blames others; reluctant to open up for fear of vulnerability.
  • StPD: Loners; socially anxious, apprehensive, suspicious and paranoid, which doesn’t fade as they get to know people; tends to live on the margins of society and relationships; often choose jobs with minimal social interaction that are usually below their skill level; indifferent to social norms.
  • SzPD: Aloof, loners, reserved, solitary; socially awkward; tend to fade into the background; happy to remain alone.

Cognitive style: How the person perceives and thinks about a problem and its solution.

  • AsPD: Impulsive; realistic; very aware of social cues; prone to executive dysfunction.
  • AvPD: Hypervigilant; distracted and preoccupied with their fears of rejection.
  • BPD: Inflexible (splitting) & impulsive; difficulty learning from the past; external loss of control leads them to blame others to avoid feeling powerless; emotions fluctuate between hope and despair; unstable self-image and fragmented sense of self; unable to tolerate frustration; brief psychotic episodes; dissociation; intense rage; difficulty focusing & processing information.
  • DPD: Suggestible and persuadable; optimistic, sometimes to the point of naïveté; uncritical; minimises difficulties and are easily taken advantage of.
  • HPD: Impulsive, dramatic; vague; suggestible; relies on intuition; avoids reflection and introspection as so to avoid realising their dependency on others; needs approval from others; has separate real/inner/private & constructed/outer/public selves; tendency to mimic speech patterns.
  • NPD: Focuses on feelings rather than facts; compulsive lying (to themselves as well as others); inflexible, impatient, persistent; superiority; unrealistic goals of success, power, ideal love.
  • OCPD: Rule & detail oriented; difficulty with prioritising; inflexible, unimaginative; conflicted between assertiveness & defiance vs obedience & pleasing people.
  • PPD: Mistrustful; hypervigilant; focuses on feelings (of paranoia) rather than facts; brief psychotic episodes; their need to find evidence for their paranoid suspicions gives them a tendency for authoritarianism.
  • StPD: Scattered; obsessive and tends to ruminate; superstitious, bizarre fantasies; vague ideas of reference (thinking things are about them when they’re not, e.g. someone laughing is directed at them) and magical thinking (thinking they caused something to happen by thinking about it); dissociative.
  • SzPD: Distracted; difficulty organising their thoughts; vague and indecisive; difficulty with introspection and reflection.

Affective style: How the person expresses and experiences emotions.

  • AsPD: Superficially expresses emotions; avoids emotions that will make them vulnerable; rarely feels guilt, shame or remorse; unable to tolerate boredom, depression, & frustration and needs stimulation.
  • AvPD: Shy & apprehensive; feels empty, sad, lonely & tense; depersonalisation.
  • BPD: Mood swings; inappropriately intense anger; feelings of emptiness, boredom, a “void”; emotional dysregulation.
  • DPD: Insecure & anxious; lacks self-confidence & fears being alone; fears abandonment & rejection; often sad or somber.
  • HPD: Displays intense, extreme emotions but may only feel them shallowly; sensitive to rejection; mood swings; need reassurance that they are loved.
  • NPD: Presents as self-confident and nonchalant; when criticised or rejected (”narcissistic injury”) they experience extreme shame which is often redirected into anger (”narc rage”/shame redirect); splitting; lacks empathy and so has difficulty with commitments.
  • OCPD: Somber, difficulty expressing feelings; avoids emotions that will make them vulnerable; comes across as stiff and stilted.
  • PPD: Cold, aloof, humourless; difficulty expressing feelings; tendency for anger and jealousy.
  • StPD: Cold, humourless, aloof; difficult to engage with; suspicious and mistrustful; hypersensitive; may react inappropriately for the situation or not at all.
  • SzPD: Humourless, cold, aloof; indifferent; lacks empathy; emotionally and socially distant; difficulty responding to other people’s feelings.

Temperament: The response pattern that reflects the person’s energy level, emotions and intensity of emotions, and how quick they react.

  • AsPD: Irresponsible, aggressive and impulsive.
  • AvPD: Irritable.
  • BPD: Passive (dependent subtype); hyperreactive (histrionic subtype); irritable (passive-aggressive subtype).
  • DPD: Low energy; fearful, sad or withdrawn; melancholic.
  • HPD: Hyperresponsive; needs attention from others.
  • NPD: Active and responsive; has special talents and developed language early.
  • OCPD: Irritable, difficult, anxious.
  • PPD: Active and hyperresponsive (narcissistic subtype); irritable (obsessive-compulsive and passive-aggressive subtypes).
  • StPD: Passive (schizoid subtype); fearful (avoidant subtype).
  • SzPD: Passive, difficulty experiencing pleasure and motivation (anhedonia).

Parental injunction: The expectation (explicit or implied) from caregivers for how the child should be or act.

  • AsPD: “The end justifies the means.”
  • AvPD: “We don’t accept you, and probably nobody else will either.”
  • BPD: “If you grow up, bad things will happen to me [caregiver].”; overprotective, demanding or inconsistent parenting.
  • DPD: “You can’t do it by yourself.”
  • HPD: “I’ll give you attention when you do what I want.”
  • NPD: “Grow up and be wonderful, for me.”
  • OCPD: “You must do / be better to be worthwhile.”
  • PPD: “You’re different. Keep alert. Don’t make mistakes.”
  • StPD: “You’re a strange bird.”
  • SzPD: “Who are you, what do you want?”

Self view: The way they view and conceptualise themselves.

  • AsPD: Cunning & entitled.
  • AvPD: Inadequate & frightened of rejection.
  • BPD: Identity problems involving gender, career, loyalties, and values; self-esteem fluctuates with emotions.
  • DPD: Pleasant but inadequate, fragile.
  • HPD: Needs to be noticed.
  • NPD: Special, unique and entitled; relies on others for self-esteem.
  • OCPD: Responsible for anything that goes wrong, so they must be perfect.
  • PPD: They’re alone and disliked because they’re different and better than others.
  • StPD: Different than other people.
  • SzPD: Different from others; self-sufficient; indifferent to everything.

World view: The way they view the world, others, and life in general.

  • AsPD: Life is dangerous and rules get in the way of their needs. They won’t be controlled or degraded.
  • AvPD: Life is unfair; even though they want to be accepted, people will reject them, so they’ll be vigilant & demand reassurance; escapes using fantasies and daydreams.
  • BPD: Splits between people and the world as either all-good or all-bad, resulting in commitment issues.
  • DPD: Other people need to take care of them because they are unable to.
  • HPD: Life makes them nervous, so they need attention and reassurance that they’re loved.
  • NPD: Life is full of opportunities; they expect admiration and respect.
  • OCPD: Life is unpredictable and expects too much, so they manage this by being in control and being perfectionists.
  • PPD: Life is unfair, unpredictable, demanding, and dangerous; they need to be suspicious and on guard against others, who are to blame for failures.
  • StPD: Life is strange and unusual; others have special magic intentions, so they are curious but also cautious when interacting with the world.
  • SzPD: Life is difficult and dangerous; if they trust no one and keep their distance from others, they won’t get hurt.

Optimal diagnostic criterion: One key criterion for each personality disorder, based on its ability to summarise all criteria for that PD, accurate description of behaviour, and the predictive value (ability to predict if the person has the PD or not).

  • AsPD: Aggressive, impulsive, irresponsible behavior.
  • AvPD: Avoids activities that involve being social out of fear of criticism, disapproval, or rejection.
  • BPD: Frantic efforts to avoid real or imagined abandonment.
  • DPD: Needs other people to be responsible for most major parts of their lives.
  • HPD: Uncomfortable not being the centre of attention.
  • NPD: Grandiose sense of self-importance.
  • OCPD: Perfectionism that interferes with life.
  • PPD: Paranoia, without evidence, that others are trying to harm, exploit or deceive them.
  • StPD: Thinking, speech, behavior, or appearance that is odd, eccentric, or peculiar.
  • SzPD: Doesn’t want or enjoy close relationships.

Maladaptive Schemas

Schemas are broad, pervasive themes in people’s view of themselves and others that develop during childhood. They are self-defeating, dysfunctional patterns, that can interfere with life.

There are 18 schemas, grouped into 5 domains. Each domain represents an important component of a child’s core needs.

  1. Disconnection and Rejection
    1. Abandonment / Instability: Believing that others won’t or can’t provide reliable and stable support.
    2. Mistrust / Abuse: Believing that others will abuse, humiliate, cheat, lie, manipulate, or take advantage.
    3. Emotional Deprivation: Believing that others won’t provide emotional support.
    4. Defectiveness / Shame: Believing that they [the person with a PD] are defective, bad, unwanted, or inferior.
    5. Social Isolation / Alienation: Believing that they are alienated, different from others, or don’t belong.
  2. Impaired Autonomy and Performance
    1. Dependence / Incompetence: Believing that they can’t function fully without considerable help.
    2. Vulnerability to Harm or Illness: Fearing that disaster is just around the corner and that nothing can stop it.
    3. Enmeshment / Undeveloped Self: Believing that they must be extremely emotionally close with others at the expense of a fully developed, independent sense of self.
    4. Failure: Believing that they are doomed to fail.
  3. Impaired Limits
    1. Entitlement / Grandiosity: Believing that they are superior and above rules and norms.
    2. Insufficient Self-Control / Self-Discipline: Believing that they are unable to demonstrate self-control and tolerate frustration.
  4. Other-Directedness
    1. Subjugation: Believing that they must meet the needs of others in order to avoid retaliation or criticism.
    2. Self-Sacrifice: Believing that they must meet the needs of others at the expense of their own.
    3. Approval-Seeking / Recognition-Seeking: Believing that they must be constantly trying to belong and be accepted, at the expense of not developing a true sense of self.
  5. Hypervigilance and Inhibition
    1. Negativity / Pessimism: Overly focusing on the negative while dismissing the positive.
    2. Emotional inhibition: Avoiding spontaneity at all costs, including actions, feelings and communication, in order to avoid disapproval, shame, embarrassment and feelings of losing control.
    3. Unrelenting Standards / Over-criticising: Believing that constantly trying to meet unrealistically high standards is essential to be accepted and to avoid criticism.
    4. Punitiveness: Believing that mistakes should be harshly punished.

Some schemas are associated with certain PDs; for example punitiveness is associated with OCPD, and mistrust / abuse is associated with AsPD & PPD.

Attachment Styles

Attachment is the “emotional bond” between a child and their caregiver. It’s relevant to personality disorders since it influences the child’s “capacity to form mature intimate relationships in adulthood”. It “influences and organizes motivational, emotional, and memory processes that involve caregivers”. Attachment is associated with “emotional regulation, social relatedness” and the “development of self-reflection and narrative”, all things that are impacted by personality disorders.

Attachment styles are made up of two dimensions:

  1. the distinction between self and others
  2. “valence”: positive vs. negative evaluation

Most people will exhibit more than one attachment style.

The five styles are:

  1. Secure: positive view of self and others
  2. Preoccupied: negative view of self, positive view of others
  3. Dismissing: positive view of self, negative view of others
  4. Fearful: negative view of self and others
  5. Disorganized: fluctuating positive and negative views of self and others

Preoccupied style: DPD, OCPD & HPD

  • Negative view of self (“a sense of personal unworthiness”)
  • Positive view of others
  • Tend to be very “externally oriented in their self-definitions”, i.e. look to others to define them

Dismissing style: SzPD

  • Positive view of self (“a sense of self that is worthy and positive”)
  • Negative view of others, which “typically manifests as mistrust”
  • See themselves as “emotionally self-sufficient”
  • See others as emotionally unresponsive
  • Therefore they “dismiss the need for friendship and contact with others”

Fearful style: PPD

  • Negative view of self and others
  • Expectation that others are untrustworthy & will reject them
  • Don’t trust themselves or others
  • Believe themselves to be “special and different”
  • Hypervigilant against threats and “unexpected circumstances”

Preoccupied-fearful style: AvPD

  • Negative view of self
  • Fluctuates between negative and positive view of others
  • Want to be liked and accepted but fear rejection and abandonment, so they avoid and withdraw

Fearful-dismissing style: AsPD, NPD, StPD

  • Fluctuates between negative and positive view of self
  • Negative view of others
  • See themselves as “special and entitled”
  • Acknowledge their need for others, as well as others’ potential to hurt them
  • Use others to meet their needs but are fearful and dismissing of them

Disorganized style: BPD

Case Conceptualisations

Sperry describes different ways of conceptualising personality disorders, i.e. summarising why PDs form in people, and how they work.

A case conceptualisation is made up of four components: the diagnostic formulation, clinical formulation, cultural formulation, and treatment formulation.

  • The diagnostic formulation describes the person’s psychiatric diagnosis and the severity of the disorder, i.e. “What happened?”
  • The clinical formulation describes why certain patterns form in people, i.e. “Why did it happen?”
  • Cultural formulation addresses the person’s cultural background in relation to their mental health, i.e. “What role does culture play?”
  • Treatment formulation takes information from all the components and figures out what can be done to help the person, i.e. “What can be done, and how?”

The best treatment integrates all these components, instead of focusing on only one.

There are different approaches to clinical formulations, including psychodynamic, biosocial, cognitive-behavioural, interpersonal, and integrative models.

  • The psychodynamic model analyses defense mechanisms which PDs arise from. For example, OCPD defense mechanisms are rationalisation, intellectualisation, and focusing on logic and facts instead of feelings.
  • The biosocial model looks at biological reasons for PDs. For example, low serotonin levels are related to impulsivity and aggression.
  • The cognitive-behavioural model looks at the patterns of behaviour and thinking of people with PDs. These include their core beliefs, their conditional beliefs, and their instrumental beliefs. For example, the core belief of a person with AsPD is that they must look out for themselves.
  • The interpersonal model analyses PDs from the perspective that parenting methods and childhood trauma are the reasons for PDs. For example, the parents of someone with AvPD held social image to a very high standard.
  • The integrative model combines the different models, i.e. a biopsychosocial analysis.

Case conceptualisations & clinical formulations of specific PDs:

[links to be added as posts are made]