Dr Niko Tiliopoulos, BSc(Hons), MRes/Dip, PhD, MBPsS, CSci

University of Sydney, Australia

Email: niko.tiliopoulos@sydney.edu.au

From normality to abnormality I

The intensity of personality traits is seen as vulnerability to the aetiology,

development, and manifestation of PDs

PDs represent one extreme

end of the personality continuum

Under extreme stress, normal

personality traits may appear
or become psychopathological

From normality to abnormality II

Personality traits exist in both non-clinical and clinical samples

(e.g. anxiety, aggression, sensation-seeking, or impulsivity)

Neuroticism, extraversion, agreeableness, and insecure attachment

(anxiety dysregulation) styles have the most consistent associations
with PDs

Biology is the same for

disordered & normal personality
traits (30%-60%)

(Exactly) the same biological

systems are responsible for
normal traits and PDs

Cross-cultural similarity of
traits and PDs

Profiling with the NEO

From normality to abnormality III

Personality traits play a role in the persistence or long-term stability of PDs

Personality traits (can) predict symptom profile differences and help

explain heterogeneity in PD expression (e.g. see Cloningers typology)
Deviant temperament dimensions and psychopathology
Deviant temperament

Associated psychopathology

High

activation (novelty seeking)

High inhibition (harm avoidance)
Low activation & high inhibition
High maintenance (reward dependence) & high inhibition

Drug abuse; pathological gambling; antisocial PD

Anxiety disorders and PDs; alcohol abuse
Eating disorders; late-onset alcoholism
Abuse trauma; PTSD; psychotic PDs

Personality has a direct role in determining how people respond to

their PDs (e.g. willingness to seek help or follow treatment)

From normality to abnormality IV

(Theodore Millon)

Three main cognitive/behavioural dimensional

differences between PDs and normal personality
traits:

Rigidity & inflexibility in behaviour & thought

Increased

levels of habitual engagement

with self-defeating behaviour

Structural

instability and fragility of the self

From normality to abnormality V

Ecological/evolutionary dimensions of personality differentiation

Aim of existence (the Pain-Pleasure polarity)

Modes of adaptation (the Passive-Active polarity)

Life preservation (pain-avoidance)

Life enhancement (pleasure-seeking)

Ecological accommodation (passive orientation)

Ecological modification (active orientation)

Strategies of replication (the Self-Other polarity)

Reproductive nurturance (constructively loving others, k-strategy)

Reproductive propagation (individuating & actualising self, r-strategy)

Not a dichotomous classification

All (should) exist to a balanced degree in normal individuals

Personality disorders (PDs)

Definition (APA, 2000):

Enduring patterns of inner experience & behaviour that deviate

markedly from the expectations of the individuals culture, are
pervasive & inflexible

Deviance reflected in two or more of the following areas:

Cognition

Affect

Interpersonal functioning

Impulse control

Deviance features

Deviant cognition

Deviant affectivity

Range
Intensity
Appropriateness of emotions

Deviant interpersonal functioning

Perception
Interpretation
Formation of images & attitudes

Relating to others (Dyads-Triads-Groups)

Handling interpersonal situations

Lack of control

Impulses
Gratification of needs

Common features I

Extreme or significant deviations from the way an individual in a

given culture perceives, thinks, feels, & relates to others

Onset in adolescence or early adulthood

Relatively stable & of a long duration

Considerable personal (and clinical) distress & impairment in social,

occupational, interpersonal areas of functioning

Inflexible & pervasive across situations

Maladaptive or otherwise dysfunctional behaviour

Not limited to one specific triggering stimulus, stressor, or situation

Common features II

Not better accounted for by mental (clinical)

disorders of Axis I

Not a manifestation or consequence of Axis I

Not a result of:

Substance abuse
Medication
General medical condition
Injury (e.g. TBI)

Common features III

The evolutionary perspective

Ineffectiveness

Suboptimal functioning in:

Self-preservation
Ecological adaptation
Reproductivity

Inflexible strategies that lead to pervasive fitness reduction or failure

Uncooperativeness

Frictional features that frustrate social goals, resulting in fitness costs

Classification

DSM-IV-TR

Axis II
Codes 301.0 - 301.9
Ten specified PDs

ICD-10

Codes F60 - F69

Eight specified PDs

High degree of concordance

(average Cohens Kappa = .97)

Cluster A (odd / eccentric)

Symptoms similar to schizophrenia (atypical psychoses)

High levels of (elements of) Introversion & Psychoticism

Paranoid (301.0 / F60.0)

Schizoid (301.20 / F60.1)

Distrust & suspiciousness of others

Unforgiving, preoccupied with unjustified doubts
Optimal criterion: Suspect, without sufficient basis, that others are exploiting, harming, or deceiving them
Detachment from social relationships
Restricted range of emotional
expressions and anhedonia
Optimal criterion: Neither desires nor enjoys close relationships, including being part of a family

Schizotypal (301.22; not present in ICD,

subclass of schizophrenia)

Cognitive disturbances, odd thinking

Excessive social anxiety, inappropriate affect
Optimal criterion: Odd thinking and speech: Behaviour or appearance that is odd, eccentric, or peculiar

Cluster B (dramatic / emotional)

Highly variable behaviour, exaggerated emotional display

High levels of trait impulsivity & sensation-seeking

Antisocial (301.7 / F60.2 - Dissocial)

Borderline (301.83 / F60.31)

Interpersonal & emotional instability / impulsivity

Chronic feeling of emptiness, suicidal behaviour
Optimal criterion: (Unreasonable) Expectations of meeting personal goals, and/or maintaining close relations

Histrionic (301.50 / F60.4)

Disregard & violation of others rights

Failure to conform to social norms
Optimal criterion: Criminal, aggressive, impulsive, irresponsible behaviour
Psychopath vs. sociopath

Excessive emotionality (theatricality) & attention seeking

Suggestible, attention to physical appearance, inappropriate sexuality (nymphomania)
Optimal criterion: Uncomfortable in situations in which they are not the centre of attention

Narcissistic (301.81; not present in ICD)

Grandiosity (in fantasy or behaviour) & need for admiration

Preoccupied with success and power, interpersonally exploitive
Optimal criterion: Grandiose sense of self-importance

Items from PCL-R (Hare, 2003)

Superficial charm
Grandiose sense of self-worth
Proneness to boredom
Pathological lying
Manipulative
Lack of remorse or guilt
Shallow affect
Lack of empathy
Parasitic lifestyle
Poor behavioural control
Promiscuity
Impulsivity
Irresponsibility
Juvenile delinquency
Criminal versatility

Cluster C (anxious / fearful)

High interpersonal deficits

High levels of insecure attachment traits (anxiety deregulation)

Avoidant (301.82 / F60.6 Anxious)

Dependent (301.6 / F60.7)

Social inhibition & feelings of inadequacy

Preoccupied with fear of being criticised, shamed, or ridicule
Optimal criterion: Avoids occupational activities that involve
significant interpersonal contact, fearing criticism, disapproval, or rejection

Submissiveness & clinging behaviour

Unrealistic fear of being left alone, needs constant reassurance
Optimal criterion: Needs others to assume responsibility for most major areas of her or his life

Obsessive-Compulsive (301.4 / F60.5 - Anankastic)

Perfectionism & mental or interpersonal control

Preoccupied with details, rules, order; excessive devotion to work
Not the same as OCD!
Optimal criterion: Shows perfectionism that interferes with task completion

Prevalence of PDs (if only we knew!)

Figures vary from 0.5% to 13 % in the general population

In clinical samples 25% to 40%

Problem with epidemiological assessment

Gender differences in PDs

Antisocial PD is more
than five times as
common among men than
women!
Rising more rapidly
among women in recent
years
The opposite pattern is
observed with borderline
and histrionic PDs

Actually sexist biases!

Certain personality disorders may have sexist underpinnings
The DSM seems to more often label stereotypical feminine
behaviors as pathological than stereotypical masculine
behaviors
E.g. Histrionic PD
A caricature of the traditional male stereotype of the feminine
personality:
Flighty, emotional, shallow, seductive, attention-seeking

Aetiology

Attenuated forms of mental (symptom-based) disorders (latent taxa)

(Quantitative and/or qualitative) exaggerations of normal personality

variations

Psychobiology & genes

Monoamine oxidase (MAO A & B)

High levels of dopamine (Cluster A)
Low levels of serotonin (Cluster B)
Differential arousability of NS (e.g. low GSR in antisocial)
Brain abnormalities
Genetic disposition (especially for antisocial, schizotypal, & borderline)

(Non-shared) environment

Attachment, trauma (both psychological & physical), neglect, deprivation,

diseases, diet, etc.

Classification & diagnosis problems

The categorical (binary) approach (the clinical approach)

Largely not evidence-based (e.g. Cluster C is very poorly defined)

A heuristic device for descriptive purposes

Serious problems with diagnostic reliability (alpha as low as 0.1!)

Problems with construct validity (e.g. schizotypy schizophrenia phenotype)

Practically no agreement on the distinction between normal & abnormal behaviour

(false positives/negatives)

Confusion with personality terms that are not used in normal personality profiling
(e.g. schizoid vs. introvert; histrionic vs. extraversion)

Limits scientific enquiry (requires far larger N to achieve sufficient statistical power)

The (major) problem of comorbidity

The more severe the dysfunction the greater the number of PDs diagnosed

75-85% chance that one will be diagnosed with more than one PD

50-80% of BPD individuals have an Axis I diagnosis that accounts for all their symptoms
(primarily of the bipolar spectrum)

Classification & diagnosis problems

The quasi-dimensional approach (e.g. Claridge, 2006)
Determination of the existence of a PD (categorical pathogenesis)
Determination of the nature/severity of a PD (dimensional pathoplasticity)

Problems with treatment & intervention

People with personality disorders usually see their

personality expressions, even when maladaptive, as
normal (egosyntonic)

They are unlikely to perceive their own behaviour,

thoughts and feelings as the causes of their distress
(externalisation of locus of distress)

Unlikely they will voluntarily seek treatment

May cause problems during therapy

Treatment & intervention

No clear evidence of effective therapies for all PDs

Psychoactive drugs
(e.g. tranquillizers for avoidant PD)

Psychodynamic therapies
(e.g. OCPD: No need to be perfect
to gain approval)

Rational-Emotive therapy
(e.g. paranoid PD: Learn more adaptive ways of dealing with others)

Cognitive therapy

Help realise biased schemata

(e.g. histrionic PD: People are not there to serve and admire me)

Treatment tends to concentrate on Axis I

Onwards and upwards: The DSM-V, Axis II

Definition: Personality disorders represent the failure to develop a sense

of self (identity and direction) and the capacity for interpersonal
functioning (empathy and intimacy) that are adaptive in the context of
the individuals developmental stage or cultural norms and expectations

Can be a result of or related to Axis I disorders, substance abuse, general

medical or physiological conditions, or head injury

The impairments in personality functioning and the individuals personality

trait expression are relatively stable across time and consistent across
situations

PDs should not be diagnosed in children or adolescents

Six PD types
Antisocial/Psychopathic
Avoidant
Borderline
Narcissistic
Obsessive-Compulsive
Schizotypal

Onwards and upwards: The DSM-V, Axis II

Five higher order personality trait domains (personality

dimensions), comprising a total of 25 lower hierarchical
order trait facets (personality traits)

Impairment in personality functioning

on the Interpersonal continuum of Self-Other (Criterion A)

and in at least one personality domain and at least one specific trait facet
(Criterion B)

Negative Affectivity (Facets: Anxiousness, Depressivity, Insecurity, etc.)

Detachment (Facets: Withdrawal, Anhedonia, Intimacy avoidance, etc.)
Antagonism (Facets: Hostility, Deceitfulness, Grandiosity, etc.)
Disinhibition (Facets: Irresponsibility, Impulsivity, Risk-taking, etc.)
Psychoticism (Facets: Eccentricity, Cognitive-Perceptual dysregulation, etc.)

Ordinal scale assessment on five severity levels of personality

functioning: from No impairment to Extreme impairment

Links, journals, & inventories

Weblinks (for questionnaires and further information)

International Personality Item Pool (IPIP)

The Adult Attachment Lab, University of California

http://www.sjdm.org/dmidi/index.html

Main journals in personality

http://psychology.ucdavis.edu/labs/Shaver/index.htm

Decision Making Individual Differences Inventory, Columbia University

http://ipip.ori.org/

Journal of Personality
Journal of Research in Personality
European Journal of Personality
Personality & Individual Differences
Journal of Personality Disorders
Personality Disorders

Main psychometric personality questionnaires (some are copyrighted)

Lexical approach: NEO-PI, HEXACO, 16PF, 6PFQ, JPI
Psychobiological approach: EPQ, EPI, BIS/BAS, TCI, ZKPQ
Interpersonal approach: ECR-R, AB5C
Exclusive personality pathology: DAPP-BQ, SNAP, SWAP-200, MPQ

Further reading

Adshead, G., & Jacob, C. (Eds.) (2009). Personality disorders: Forensic focus. London: J.K. Pubs.
Canli, T. (Ed.) (2006). Biology of personality and individual differences. New York: Guilford.
Distel, M.A., et al. (2009). The Five-Factor Model of personality and Borderline Personality Disorder:
A genetic analysis of comorbidity. Biological Psychiatry, 66, 1131-1138.
Helzer, J.E. et al. (Eds.) (2008). Dimensional approaches in diagnostic classification. Arlington: APA.
Hersen, M., & Thomas, J.C. (Eds.) (2006). Comprehensive handbook of personality &
psychopathology. Int: Wiley.
Millon, T., Grossman, S., Meagher, S., Millon, C., & Ramnath, R. (2011). Personality disorders in
modern Life (3rd ed.). Int.: Wiley.
Piedmont, R.L., et al. (2009). Using the Five-Factor Model to Identify a New Personality Disorder
Domain: The Case for Experiential Permeability. Journal of Personality & Social Psychology, 96,
1245-1258.
Plomin, R. (2008). Behavioral genetics (5th ed.). London: Palgrave.
O Donohue, W., Fowler, K.A., & Lilienfeld, S.O. (Eds.) (2007). Personality disorders: Toward the
DSM-V. London: Sage.
Paulhus, D.L., & Williams, K.M. (2002). The dark triad of personality: Narcissism, Machiavellianism,
and Psychopathy. Journal of Research in Personality, 36, 556-563
Richter, J., & Brandstrom, S. (2009). Personality disorder diagnosis by means of the Temperament and
Character Inventory. Comprehensive Psychiatry, 50, 347-352.
Rushton, P.J., & Irwing, P. (2009). A general factor of personality in the Millon Clinical Multiaxial
Inventory-III, the Dimensional Assessment of Personality Pathology, and the Personality Assessment
Inventory. Journal of Research in Personality, 43, 1091-1095.
Strack, S. (Ed.) (2006). Differentiating normal & abnormal personality (2nd ed.). New York: Springer.
Taylor, M.A., & Vaidya, N.A. (2009). Descriptive psychopathology. Cambridge: CUP.
Widiger, T.A., Livesley, J.W., & Clark, A.L. (2009). An integrative dimensional classification of
personality disorders. Psychological Assessment, 21, 243-255.

Your personality is your soul

Be nice to it

After all, a PD
may simply be
a sane response to
an insane world!