Mark Vakkur, MD

    Lecture Learning Objectives

    Key Concepts and Terms:

    Personality Style = deeply ingrained, pervasive pattern of inner experience and interpersonal behavior that is relatively stable from adolescence through adulthood = "who we are."
    Personality Traits = characteristics of behaving, interacting, and reacting that define our personality style.  E.g. vulnerability to criticism, entitlement, and difficulty with empathy.
    Personality Disorder = collection of personality traits that is markedly deviant from the individual's culture and that leads to conflict or chaos in multiple life areas, such as regulation of mood and impulses, ability to self-soothe, be in an intimate relationship, hold a job, tolerate criticism or rejection, or defer gratification.

Personality Disorders:

 Cluster A (Avoidant):

    Paranoid: chronic pattern of suspicion and distrust of others WITHOUT JUSTIFICATION; interprets mistakes as malevolent; quick to anger; reluctant to confide in others because of fear information will be used to harm; doubts fidelity of significant other.  Must differentiate from schizophrenia and psychotic disorders; hint: paranoid personality disorder has no hallucinations or frank delusions.
     Schizoid:  SOCIAL WITHDRAWAL and paucity of interpersonal relationships because of NO  DESIRE for this contact (v. anxiety disorders or avoidant personality disorder, in which social contact is desired, but FEARED).   NOT psychotic or bizarre; make excellent night watchmen and librarians.  HAS NOTHING TO DO WITH SCHIZOPHRENIA.
    Schizotypal:  ODD and BIZARRE with strange beliefs (e.g. ideas of reference, paranoid ideation, overelaborate or stereotyped speech), lack of close friends because of strangeness or paranoia.  Maybe associated with schizophrenia.

 Cluster B (Boisterous):


     Antisocial:  pervasive pattern of disregard for rights of others, beginning before age 16; classical behaviors:  firestarting, animal torture, criminality (stealing, assaulting); LACK OF REMORSE (no conscience) is a critical feature; usually "smooth operators," pleasant and manipulative.  Rule out substance abuse, narcissistic p.d., major psychiatric disorder.  Estimated prevalence:  1-3% of men, 1% of women.
     Borderline:  remember RABID:  Relationships are stormy; Affect is unstable and they have trouble self-soothing; Boundaries (interpersonal) are poorly defined and maintained; severe Identity disturbance (a chronic inner emptiness is the core of their problem); and they engage in self-Destructive behaviors (suicidal gestures more than attempts, as well as SELF-MUTILATION (wrist-cutting, burning is classic)).
     Histrionic:  remember Scarlett O'Hara; craves attention, is inappropriately sexually seductive or provocative, has shallow and shifting emotions, uses physical appearance to draw attention to self, very impressionistic speech, theatrical and dramatic, considers relationships to be more intimate than they are.  Sometimes difficult to distinguish from borderline.
     Narcissistic:  critical features are LACK OF EMPATHY for the suffering of others, SENSE OF ENTITLEMENT to things they haven't earned, and extreme SENSITIVITY TO CRITICISM (as well as its flipside:  being overly dependent on external validation such as grades, money, public acclaim to feel whole).  Like the borderline, narcissists have profound inner emptiness.  Unlike the antisocial, narcissists usually have tremendous inner pain (the antisocial is usually cool, pleasant, and collected [unless caught!]).

 Cluster C (Clinging):

     Avoidant:  avoids any relationship unless acceptance is guaranteed; feels inadequate or inept especially socially;  fears public ridicule or criticism (but unlike the narcissist would react with self-reproach, not rage).    Usually shy, quiet, and self-deprecating.  Need to differentiate from anxiety disorders (which have a high response rate to antidepressant medications).
     Dependent:  fears being alone, will do anything to maintain a relationship that gives some support, even if unpleasant; cannot make everyday decisions without excessive advice from others; exaggerated fears of being unable to care for self.  Very similar to the borderline's fear of abandonment (without the other disruptive features).
     Obsessive-compulsive personality disorder:  rigid, obsessed with rules and regulations, often missing the "big picture", may spend more time planning than doing; often judgmental, unpleasant people.  Can become paranoid under pressure.  Unlike OBSESSIVE-COMPULSIVE DISORDER, obsessive-compulsive PERSONALITY disorder has NO frank obsessions or compulsions (e.g. handwashing) and the behavior is EGO SYNTONIC (does not appear ridiculous or disturbing to the patient, as it does in O.C.D.).



DSM-IV Criteria for Narcissistic Personality Disorder

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

(3) believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

(4) requires excessive admiration

(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

(8) is often envious of others or believes that others are envious of him or her

(9) shows arrogant, haughty behaviors or attitudes

- American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.


 Optional Reading:

 - Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), pp. 629 - 634:  gives a good overview and discussion of personality disorders in general; pp. 645-650:  good description of antisocial personality disorder; pp. 650-654:  borderline personality disorder; 658-661: narcissistic personality disorder (see below for sample criteria); 669-673:  obsessive compulsive personality disorder.

 - Personality Disorders and Culture: Clinical and Conceptual Interactions by Renato D. Alarcon, Edward F. Foulks, Mark Vakkur. June 1998, John Wiley & Sons, pp. 60-68:  "Personalities and Personality Disorders in World Politics"  explores Lenin, Hitler, and Stalin from a personality disorder perspective, highlighting the interplay between cultural and individual pathology.