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Predisposing Factors There is no clear cause of avoidant personality disorder

. Contributing factors are most likely a combination of biological, genetic, and psychosocial influences. Some infants who exhibit traits of hyperirritability, crankiness, tension, and withdrawal behaviors may possess a temperamental disposition toward an avoidant pattern later in life. Psychosocial influences may include childhood trauma or neglect leading to fears of abandonment or views of the world as a hostile and dangerous place.

Diagnostic Criteria for Histrionic Personality Disorder

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 center of attention Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior 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-dramatization, 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

3 Diagnostic Criteria for Schizotypal Personality Disorder

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: Ideas of reference (excluding delusions of reference) Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense;" in children and adolescents, bizarre fantasies or preoccupations) Unusual perceptual experiences, including bodily illusions Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped) Suspiciousness or paranoid ideation Inappropriate or constricted affect Behavior or appearance that is odd, eccentric, or peculiar Lack of close friends or confidants other than first-degree relatives Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.

Diagnostic Criteria for Avoidant Personality Disorder

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection Is unwilling to get involved with people unless certain of being liked Shows restraint within intimate relationships because of the fear of being shamed or ridiculed Is preoccupied with being criticized or rejected in social situations Is inhibited in new interpersonal situations because of feelings of inadequacy Views self as socially inept, personally unappealing, or inferior to others Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Borderline Personality Disorder Definition and Epidemiological Statistics

BPD is characterized by a pattern of intense and chaotic relationships, with affective instability and fluctuating attitudes toward other people. These individuals are impulsive, are directly and indirectly self-destructive, and lack a clear sense of identity. Prevalence of BPD is estimated at 1 to 2 percent of the population. It is generally estimated to be twice as common in women than in men (Sadock et al., 2015), and some have identified female-to-male ratios as high as 4 to 1 (Lubit, 2016).

are constantly on guard, hypervigilant, and ready for any real or imagined threat. They appear tense and irritable. They have developed a hard exterior and become immune or insensitive to the feelings of others. They avoid interactions with other people lest they be forced to relinquish some of their own power. They always feel that others plan to take advantage of them. They are extremely oversensitive and tend to misinterpret even minute cues within the environment, magnifying and distorting them into thoughts of trickery and deception. Because they trust no one, they are constantly "testing" the honesty of others. Their intimidating manner provokes exasperation and anger in almost everyone with whom they come in contact. Individuals with paranoid personality disorder maintain their self-esteem by attributing their shortcomings to others. They do not accept responsibility for their own behaviors and feelings and project this responsibility onto others. They are envious and hostile toward those who are highly successful and believe the only reason they are not as successful is because they have been treated unfairly. People who are paranoid are extremely vulnerable and constantly on the defensive. Any real or imagined threat can release hostility and anger fueled by animosities from the past. The desire for reprisal and vindication is so intense that a possible loss of control can result in aggression and violence. These outbursts are usually brief, and the paranoid person soon regains the external control, rationalizes the behavior, and reconstructs the defenses central to his or her personality pattern.

Clinical Picture Individuals with paranoid personality disorder

are aloof and isolated and behave in a bland and apathetic manner. Magical thinking, ideas of reference, illusions, and depersonalization are part of their everyday world. Examples include superstitiousness; belief in clairvoyance, telepathy, or "sixth sense"; as well as beliefs that "others can feel my feelings." The speech pattern is sometimes bizarre. People with this disorder often cannot orient their thoughts logically and become lost in personal irrelevancies and tangential asides that seem vague and digress from the topic at hand. This feature only further alienates them from others. Under stress, these individuals may decompensate and demonstrate psychotic symptoms, such as delusional thoughts, hallucinations, or bizarre behaviors, but these are usually of brief duration (Sadock et al., 2015). They often talk or gesture to themselves, as if "living in their own world." Their affect is bland or inappropriate, such as laughing at their own problems or at a situation that most people would consider sad.

Clinical Picture Individuals with schizotypal personality disorder

They typically have a long-standing history of engaging in primarily solitary activities or engaging more with animals than people. They prefer to work in isolation and are unsociable, with little need or desire for emotional ties. They are able to invest enormous affective energy in intellectual pursuits. In the presence of others, they appear shy, anxious, or uneasy. They are inappropriately serious about everything and have difficulty acting in a lighthearted manner. Their behavior and conversation exhibit little or no spontaneity. Typically, they are unable to experience pleasure, and their affect is commonly bland and constricted.

Clinical Picture People with schizoid personality disorder appear cold, aloof, and indifferent to others.

Dependent Personality Disorder Definition and Epidemiological Statistics

Dependent personality disorder is characterized by lack of self-confidence and extreme reliance on others to take responsibility for them, sometimes to the point of intense discomfort with being alone for even a brief period (Sadock et al., 2015). This mode of behavior is evident in the tendencies to allow others to make decisions, feel helpless when alone, act submissively, subordinate needs to others, tolerate mistreatment by others, demean oneself to gain acceptance, and fail to function adequately in situations that require assertive or dominant behavior.

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, as indicated by four (or more) of the following: Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her Reads hidden demeaning or threatening meanings into benign remarks or events Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights) Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.

Diagnostic Criteria for Paranoid Personality Disorder

A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: Neither desires nor enjoys close relationships, including being part of a family Almost always chooses solitary activities Has little, if any, interest in having sexual experiences with another person Takes pleasure in few, if any, activities Lacks close friends or confidants other than first-degree relatives Appears indifferent to the praise or criticism of others Shows emotional coldness, detachment, or flattened affectivity Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition.

Diagnostic Criteria for Schizoid Personality Disorder

histrionic personality disorder Predisposing Factors

Heredity may be a factor because the disorder is apparently more common among first-degree biological relatives of people with the disorder than in the general population. Some traits may be inherited, whereas others are related to a combination of genetic predisposition and childhood experiences. But at present, the cause or causes are unknown. From a psychosocial perspective, learning experiences may contribute to the development of . The child may have learned that positive reinforcement was contingent on the ability to perform parentally approved and admired behaviors. It is likely that the child rarely received either positive or negative feedback. Parental acceptance and approval came inconsistently and only when the behaviors met parental expectations

Histrionic Personality Disorder Definition and Epidemiological Statistics

Histrionic personality disorder is characterized by colorful, dramatic, and extroverted behavior in excitable, emotional people. They have difficulty maintaining long-lasting relationships, although they require constant affirmation of approval and acceptance from others. This often gives rise to seductive, flirtatious behavior in efforts to reassure themselves of their attractiveness and gain approval. Prevalence of the disorder is thought to be about 2 to 3 percent, and it is more common in women than in men.

Clinical Picture Avoidant Personality Disorder

Individuals with this disorder are awkward and uncomfortable in social situations. From a distance, others may perceive them as timid, withdrawn, or perhaps cold and strange. Those who have closer relationships with them, however, soon learn of their sensitivities, touchiness, evasiveness, and mistrustful qualities. Their speech is usually slow and constrained, with frequent hesitations, fragmentary thought sequences, and occasional confused and irrelevant digressions. They are often lonely and express feelings of being unwanted. They view others as critical, betraying, and humiliating. They desire to have close relationships but avoid connecting with others because of their fear of being rejected. Depression, anxiety, and anger at oneself for failing to develop social relations are commonly experienced.

disorder is unclear, introversion appears to be a highly inheritable characteristic. Further studies are required before definitive statements can be made. Psychosocially, the development of schizoid personality is probably influenced by early interactional patterns that the person found cold and unsatisfying. The childhoods of these individuals have often been characterized as bleak, cold, and lacking empathy and nurturing. A child brought up with this type of parenting may develop schizoid personality traits if that child possesses a temperamental disposition that is shy, anxious, and introverted.

Predisposing Factors Although the role of heredity in the etiology of schizoid personality

is more common among the first-degree biological relatives of people with schizophrenia than among the general population. It is now considered part of the genetic spectrum of schizophrenia (APA, 2013). Twin studies reveal a higher incidence in monozygotic twins than dizygotic twins (Sadock et al., 2015). Psychological and environmental factors may also interact with genetic vulnerability in the development of schizotypal personality traits. One recent study (Hur et al., 2016) found that individuals with schizotypal personality disorder demonstrated reduced activation of brain areas responsive to motion perception and executive control of perception. These findings may explain a biological basis for the peculiar ways that individuals with schizotypal personality disorder behave in social situations. Affective blandness, peculiar behaviors, and discomfort with interpersonal relationships may provoke other children to avoid relationships with them, or worse, engage in bullying, which reinforces their withdrawal from others. Having failed repeatedly to cope with these adversities, they withdraw and reduce contact with individuals and situations that evoked sadness and humiliation. Their new inner world provides them with a more significant and potentially rewarding existence than the one experienced in reality

Predisposing Factors Evidence suggests that schizotypal personality disorder

Studies have revealed a higher incidence of paranoid personality disorder among relatives of clients with schizophrenia than among control subjects (Sadock, Sadock, & Ruiz, 2015). Psychological predisposing factors, as is the case with many personality disorders, include a history of childhood trauma including neglect. People with paranoid personality disorder may have been subjected to parental antagonism and harassment. They learned to perceive the world as harsh and unkind, a place calling for protective vigilance and mistrust. They entered the world with a "chip-on-the-shoulder" attitude and were met with many rebuffs and rejections from others. Anticipating humiliation and betrayal by others, they learned to defend themselves by attacking first.

Predisposing Factors Research has indicated a possible hereditary link in paranoid personality disorder.

Schizoid personality disorder is characterized primarily by a profound defect in the ability to form personal relationships. People with this condition are often seen by others as eccentric, isolated, or lonely (Sadock et al., 2015). These individuals display a lifelong pattern of social withdrawal, and their discomfort with human interaction is apparent. The prevalence of schizoid personality disorder is difficult to determine because, as with many other personality disorders, it may go undiagnosed unless it is recognized when the individual seeks health care for other reasons. Estimates within the general population vary between 3 and 5 percent. Many people with the disorder are never observed in a clinical setting. Gender ratio of the disorder is unknown, although it is diagnosed more frequently in men.

Schizoid Personality Disorder Definition and Epidemiological Statistics

Individuals with schizotypal personality disorder were once described as "latent schizophrenics." Their behavior is odd and eccentric but does not decompensate to the level of schizophrenia. Schizotypal personality is marked by symptoms that are closer to those of schizophrenia than those in schizoid personality. The former individuals show significant peculiarities in thinking, behavior, and appearance. Studies indicate that schizotypal personality disorder has a prevalence of around 3 percent (Sadock et al., 2015).

Schizotypal Personality Disorder Definition and Epidemiological Statistics

Avoidant Personality Disorder Definition and Epidemiological Statistics

The individual with avoidant personality disorder is extremely sensitive to rejection and thus may lead a very socially withdrawn life. It is not that he or she is asocial; in fact, there may be a strong desire for companionship. The extreme shyness and fear of rejection, however, create the need for unusually strong assurances of unconditional acceptance. Prevalence of the disorder in the general population is about 2 to 3 percent, and it appears to be equally common in men and women.

Clinical Picture Individuals with narcissistic personality

This diagnosis appeared for the first time in the third edition of the Diagnostic and Statistical Manual of Mental Disorders. However, the concept of narcissism has its roots in the 19th century. It was viewed by early psychoanalysts as a normal phase of psychosexual development. The prevalence of narcissistic personality disorder is estimated at 1 to 6 percent (Sadock et al., 2015). It is diagnosed more often in men than in women. disorder appear to lack humility, be overly self-centered, and exploit others to fulfill their own desires. They often do not conceive of their behavior as being inappropriate or objectionable. Because they view themselves as "superior" beings, they believe they are entitled to special rights and privileges. Although often grounded in grandiose distortions of reality, their moods are usually optimistic, relaxed, cheerful, and carefree. This can easily change, however, because of fragile self-esteem. If they do not meet self-expectations, do not receive the positive feedback they expect from others, or draw criticism from others, they may respond with rage, shame, humiliation, or dejection. They may turn inward and fantasize rationalizations that convince them of their continued stature and perfection. The exploitation of others for self-gratification results in impaired interpersonal relationships. In selecting a mate, narcissistic individuals frequently choose a person who will provide them with the praise and positive feedback that they require and who will not ask much from their partner in return.

Sadock and associates (2015) identify the propensity for an increase in narcissistic personality disorders

among children whose parents had the disorder. Children may evolve into adults with narcissistic personality disorder through role modeling parent behavior, or as Sadock and associates suggest, these traits may be caused by a narcissistic parent's imparting an unrealistic omnipotence, grandiosity, beauty, and talent to their children. Narcissism may also develop from an environment in which parents attempt to live their lives vicariously through their child. They expect the child to achieve the things they did not achieve, possess that which they did not possess, and have life better and easier than they did. The child is not subjected to the requirements and restrictions that may have dominated the parents' lives and thereby grows up believing he or she is above that which is required for everyone else. Genetics and environment may both have a role in the development of narcissistic personality disorder. Research has identified a decreased volume of gray matter in areas of the brain responsible for empathy, emotional regulation, compassion, and cognitive functions (Gregory, 2016).

Predisposing Factors Although the causes are unknown, psychodynamic theories have suggested that narcissistic personality disorder

evolves from a parent-child dynamic of either excessive pampering or excessive criticism (Mayo Clinic, 2014). Children may then grow to project an image of invulnerability and self-sufficiency that conceals their true sense of emptiness and contributes to their inability to feel deep emotion. BOX 32-5 Diagnostic 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: Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements) Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love 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) Requires excessive admiration Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations) Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends) Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others Is often envious of others or believes that others are envious of him or her Shows arrogant, haughty behaviors or attitudes

Clinical Picture Individuals with dependent personality disorder

have a notable lack of self-confidence that is often apparent in their posture, voice, and mannerisms. They are typically passive and acquiescent to the desires of others. They are overly generous and thoughtful and underplay their own attractiveness and achievements. They may appear to others to "see the world through rose-colored glasses," but when alone, they may feel pessimistic, discouraged, and dejected. Others are not made aware of these feelings; their "suffering" is done in silence. Individuals with dependent personality disorder assume the passive and submissive role in relationships. They are willing to let others make their important decisions. Should a dependent relationship end, they feel fearful and vulnerable because they lack confidence in their ability to care for themselves. They may hastily and indiscriminately attempt to establish another relationship with someone they believe can provide them with the nurturance and guidance they need. They avoid positions of responsibility and become anxious when forced into them. They have feelings of low self-worth and are easily hurt by criticism and disapproval. They will do almost anything, even if it is unpleasant or demeaning, to earn the acceptance of others. The DSM-5 diagnostic criteria for dependent personality disorder are presented in Box 32-7.

Definition and Epidemiological Statistics Antisocial personality disorder

is a pattern of socially irresponsible, exploitative, and guiltless behavior that reflects a general disregard for the rights of others. These individuals exploit and manipulate others for personal gain and are unconcerned with obeying the law. They have difficulty sustaining consistent employment and developing stable relationships. This is one of the oldest and best-researched personality disorders and has been included in all editions of the Diagnostic and Statistical Manual of Mental Disorders. In the United States, prevalence is estimated to be about 3 percent in the general population, but in prison populations, the prevalence is 50 percent or higher (Hatchett, 2015). It is more common in men than in women, among the lower socioeconomic classes, and especially among highly mobile inhabitants of impoverished urban areas. The DSM-5 currently identifies antisocial personality and psychopathy as synonymous terms, but recent research reveals that these are better understood as distinct disorders (Hatchett, 2015; Thompson, Ramos, & Willett, 2014). Substance use disorder is commonly identified as a comorbid disorder.

Paranoid personality disorder

is defined as a pattern of pervasive mistrust and suspiciousness of others, and misinterpretation of others' motives as malevolent (APA, 2013, p. 649). This pattern begins by early adulthood and remains present in a variety of contexts. Prevalence has been estimated at 1 to 4 percent of the general population, and often is diagnosed only when the individual seeks treatment for a mood or anxiety disorder (Black & Andreasen, 2014). The disorder is more commonly diagnosed in men than in women.

Clinical Picture People with histrionic personality disorder tend to be

self-dramatizing, attention-seeking, overly gregarious, and seductive. They use manipulative and exhibitionistic behaviors in their demands to be the center of attention. People with histrionic personality disorder often demonstrate, to an extreme, what our society tends to foster and admire in its members: to be well liked, successful, popular, extroverted, attractive, and sociable. However, beneath these surface characteristics is a driven quality—an all-consuming need for approval and a desperate striving to be conspicuous and evoke affection or attract attention at all costs. Failure to evoke the attention and approval they seek often results in feelings of dejection and anxiety. Individuals with this disorder are highly distractible and flighty by nature. They have difficulty paying attention to detail. They can portray themselves as carefree and sophisticated on the one hand and as inhibited and naive on the other. They tend to be highly suggestible, impressionable, and easily influenced by others. They are strongly dependent. Interpersonal relationships are fleeting and superficial. The person with histrionic personality disorder, having failed throughout life to develop the richness of inner feelings and without resources from which to draw, lacks the ability to provide another with genuinely sustained affection. Somatic complaints are not uncommon in these individuals, and fleeting episodes of psychosis may occur during periods of extreme stress.