Personality Disorders

Personality Disorders these concepts while also addressing recent diagnostic

and therapeutic developments.

1. General Considerations
2. Terms and Definitions
Until the 1980s, both the scientific and the therapeutic
aspect of personality disorders constituted a rather The most comprehensive term in this field must surely
underdeveloped field despite their great significance be ‘personality.’ One of the most complex terms in our
for clinic and practice. Since the introduction of language, it can be defined in a variety of ways.
separate Axis II personality registration used in DSM- Popularly, personality is often used as an ethical-
III (APA 1980) and the subsequent editions, DSM-III- pedagogical value judgment to mean character or
R and DSM-IV (APA 1987, 1994), research and temper, as when referring to someone as a strong
publication worldwide have been considerably stepped personality or a person of character. Moral judgments
up, leading to the inception of professional journals are likewise made, as when we say that all human
and scientific societies devoted solely to the field of beings are persons, but we do not mean that everyone
personality disorders. As of the beginning of the is a personality, which is characterized by a conscious
twenty-first century there is a veritable deluge of and sustained exercise of thought and will.
theoretical concepts and therapeutic methods. The current psychological and psychiatric definition
More than in any other area of psychiatry, one still of personality is: the sum of all mental and behavioural
sees many inaccurate terms and concepts, and hard characteristics which make each of us a unique
data on nosology, etiology, and pathogenesis of the individual.
various personality disorders remain rare. To be sure, On the other hand, a personality disorder occurs if,
there is a wealth of isolated pieces of etiological and due to degree and\or a particular combination of
pathogenetic knowledge on factors influencing the psychopathologically relevant features in any of these
formation and progress of accentuated personality areas, there is considerable suffering and\or lasting
traits, but a comprehensive theoretical or empirical impairment of social adaptiveness (Saß 1987). Ac-
model remains as elusive as ever. We can therefore cording to DSM-IV, only when personality traits are
only address certain points and make some qualified inflexible and maladaptive and cause either significant
references, as the exceedingly complex nature of the functional impairment or subjective distress do they
subject still does not allow any more definite state- constitute personality disorders (Table 1).
ments.
‘Personality disorder’ is a value-free term which 3. A History of the Concepts of Abnormal
encompasses all those deviations from a normal Personality
personality development which require treatment.
There are, necessarily, fluid borders to mental health The concept of psychopathy arises from a confluence
on the one hand and mental disorder on the other. of views entertained by the French, the German, and
Concepts with meaning similar or identical to the Anglo-American psychiatric traditions. Sociocul-
personality disorder are psychopathy, abnormal per- tural factors caused these conceptions of psychopathy
sonality, psychopathic development, psychopathic or to develop more or less independently well into the
dissocial personality, sociopathy, etc. In Sect. 3, the twentieth century. The following section deals with all
author will give an overview of the historical roots of three traditions.

Table 1
General diagnostic criteria for personality disorder
A. A lasting pattern of inner experiences and behavior which deviates markedly from the expectations of the
culture the individual lives in. This pattern is manifested in two or more of the following areas:
1. cognition (i.e., ways of perceiving and interpreting oneself, others, and events)
2. emotiveness (i.e., range, intensity, stability, and appropriateness of emotional response)
3. interpersonal functioning
4. impulse control
B. The pattern is inflexible and pervasive across a broad range of personal and social situations.
C. The pattern leads to clinically significant distress or impairment in social, occupational, or other important
areas.
D. The pattern is stable and longlasting, and its onset can be traced back to adolescence or early adulthood.
E. The pattern is not better accounted for as a manifestation or consequence of another mental disorder.
F. The pattern is not due to direct physiological effects of a substance (e.g., drug or medication) or a general
medical condition (e.g., head trauma).

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3.1 French Concepts characterized by antisocial traits and soon became

part of the Anglo-American concept of personality
Pinel’s (1809) concept of manie sans deT lire includes
disorder.
instances of ‘deranged personality’ and can be looked
Rush (1812) was the first Anglo-American psy-
upon as the beginning of the scientific study of
chiatrist to study individuals whose disturbances were
personality disorder as a nosological entity. In the
primarily characterized by irresponsibility and ag-
eighteenth century, all mental diseases were regarded
gressiveness; who showed, as he put it, a ‘moral
as fundamental disturbances of the intellect. Pinel was
alienation of the mind.’ He believed that these rep-
one of the first to point out that in some disorders, the
rehensible acts were the manifestations of mental
emotions were primarily involved. Nevertheless, the
disease, that they were unmotivated and driven by ‘a
early nineteenth-century definitions of madness re-
kind of involuntary power.’
mained centered mostly around the intellect. Indeed,
Partridge (1930) defined the concept of psycho-
to this day, psychiatric phenomenology neglects the
pathic personality as a persistent maladjustment which
disorders of affect.
cannot be corrected by ordinary methods of education
Esquirol (1838) developed the concept of mono-
or by punishment. From Partridge on, the emphasis
mania, a diagnostic category based on the partial,
has been on description, and etiological speculation
primary–and independent–involvement of the intel-
has taken the back seat. To this day, a view of
lectual, emotional, and\or volitional functions of the
psychopathy as sociopathy dominates Anglo-
mind, including states where a single behavioral
American psychiatry. A parallel concept, that of the
disturbance became the sole diagnostic criterion for
antisocial personality disorder, appeared in DSM-III
the condition (e.g., pyromania or kleptomania). Not
(APA 1980) and was kept in DSM-III-R (APA 1987)
surprisingly, monomania was one of the sources of the
and DSM-IV (APA 1994).
concept of psychopathy. Since its inception, the
concept of monomania has been criticized on clinical
and medicolegal grounds both in France and abroad.
Morel’s (1857) idea of degeneration was a pseudo- 3.3 German Concepts
biological account strongly tinged with the idea of
In Germany, the concept of psychopathy embraces
original sin. He proposed that: (a) degenerative altera-
most forms of abnormal personality. The current
tions are pathological deviations from the normal; (b)
German definition can be traced back to Koch, whose
mental illness is mostly hereditary; and (c) degener-
monograph Psychopathische Minderwertigkeiten
ation is both quantitative and qualitative, i.e., new
[Psychopathic Inferiorities] (1891–93) was as decisive
disorders may appear. According to Morel’s model,
in shaping the concept of abnormal personality in
all types of mental and neurological disorders can be
Germany as Pinel’s work was in France, Rush’s in the
traced back to one common hereditary origin. His idea
USA, and Prichard’s in Great Britain. German ideas
of progressive and polymorphic degeneration was
of psychopathy also influenced French and Anglo-
accepted as an explanation of mental illness.
American views, especially after the 1930s, when many
German-speaking psychiatrists and psychoanalysts
emigrated to these countries.
Kraepelin’s concept of psychopathy, influenced by
3.2 Anglo-American Concepts
the French theory of degeneration, formed the basis of
Prichard (1835) defined moral insanity as ‘madness Kurt Schneider’s typology, and via the latter, of
consisting of a morbid perversion of the natural today’s German doctrine of psychopathy. In suc-
feelings, affections, inclinations, temper, habits, moral cessive editions of his textbook, Kraepelin elaborated
dispositions and natural impulses without any re- on his concept of ‘psychopathic states’ as abnormal
markable disorder or defect of the interest or the personality. He employed the term ‘psychopathic
reasoning faculties, and particularly without any personalities’ in a predominantly social sense, in-
illusion or hallucinations.’ During the early nineteenth cluding also innate delinquents, unstable liars, swind-
century, the word ‘moral’ had many uses, in the lers, and pseudo-querulous individuals.
psychological sense chiefly to denote the affective and During this period, there also appeared various
the conative (rather than the purely intellectual) ‘systematic’ typologies to draw ‘psychopathic’ cate-
functions. gories from prototypic personality theories. Foremost
The British concept of psychopathy was shaped by amongst these is Kretschmer’s konstitutionstypo-
D. K. Henderson (1939), who saw ‘psychopathic logisches Modell (1919). He suggested a specific cor-
states’ as a condition of ‘constitutional abnormality.’ relation between body type and personality.
In contrast to other (especially German) psychiatrists, Kretschmer (1921) and Ewald (1924) also introduced
he thought of constitution as deriving from both the concept of Reaktionstypologiento account for
heredity and environment. There were three psycho- specific styles of dealing with experience. Systematic
pathic states, the predominantly aggressive, the in- typologies lost influence after the publication of
adequate, and the creative. The former two were Schneider’s monograph in 1923.

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Kurt Schneider is known especially for his famous The prognosis depends on the particular type of
monograph Die psychopathischen PersoW nlichkeiten personality disorder, on any eventual comorbidity,
[The Psychopathic Personalities] (1923). He used a and on the degree of severity. Further prognostic
‘typological approach’ to personality types and tried factors are psychostructural maturity as well as the
to avoid value judgments by not including antisocial level of psychological and social functioning. Prognos-
forms of behavior. Schneider defines abnormal per- tically favorable characteristics are motivation, trust
sonalities as statistical deviations from an estimated in others, flexibility, and insight into one’s own role in
average norm, although the concept of norm is poorly difficulties with interpersonal contact. Cases are com-
formulated in his work. In his model, eminently plicated by concomitant illness, especially addiction
creative and intelligent individuals are also abnormal; and affective disorders. Thus, the mortality rate for
hence, not all abnormal personalities could be said to patients with personality disorders and substance
have psychiatric implications. Schneider defined ‘psy- abuse is three times that of patients with a single
chopathic personalities [as] those abnormal personali- personality disorder (Bohus et al. 1999).
ties that suffer from their abnormality or whose Generally speaking, the risk of suicide is three times
abnormality causes society to suffer.’ It is very im- higher for individuals with a personality disorder than
portant to stress that Schneider did not consider for the general population, with borderline, narcissis-
psychopathy a form of mental illness, which by tic, and antisocial personality disorders showing the
definition must be associated with a brain lesion or a highest incidence. These groups also show the highest
recognized disease process. In this, he opposed degree of psychosocial impairment, with deviant
Kretschmer and Bleuler, who believed that psychosis actions, decreased capacity for work, and deficient
and psychopathy were just different degrees on the skills at establishing dependable interpersonal rela-
same spectrum of derangement. Schneider’s doctrine tions.
influenced all subsequent typologies, and current
classification systems include essential parts of his
concept of psychopathy. The appendix to DSM-IV 5. Diagnostic Problems
even includes the ‘depressive type’ to encourage
further research on this subject. In view of the complexity of the concept of personality,
it becomes clear that difficulties exist in distinguishing
between a normal range of varying personality traits
4. Epidemiology, Course of Illness, and Prognosis (as many as 1800 features have been identified which
might aid in characterizing possible personality traits)
According to German and American studies, 3–10 and personality disorders which might be of psy-
percent of the general population meet the diagnostic chiatric relevance. Towards the end of the twentieth
criteria of a personality disorder. Compared to century there has been a trend towards reducing the
numbers in earlier manuals, these are rather high. myriad personality traits to 3, 5, or 7 essential
However, simply meeting these criteria need not imply dimensions from which the individual variations can
that the individuals in question are so dysfunctional be derived (Table 2).
and impaired as to require treatment. Interestingly, the factor structure of behavior and
Prevalence rates are much higher among unselected its abnormalities seems to be essentially the same in the
psychiatric patients. After the first classification general population and in clinical groups of behav-
systems appeared, clinical studies found surprisingly iourally abnormal patients. The differences lie mainly
high frequencies for personality disorders—50–80 in the degree and the particular combination of the
percent—while more recent studies reported preva- various dimensions, not in a fundamental difference of
lence rates of 40–60 percent on the average. Forensic- personality traits.
psychiatric random samples yielded prevalence rates Categorical classifications are based on somatic
of up to 80 percent. In a large-scale international models where the various diseases can be clearly
WHO study (Loranger et al. 1994), 39.5 percent of 716 separated from each other; personality disorders,
psychiatric patients examined showed at least one however, show fluid borders, both between the various
personality disorder according to ICD-10, individual types and towards normality. Dimensional personality
prevalence rates falling between 15.2 percent (anxious models, developed especially for scientific research,
personality disorder) and 1.8 percent (schizoid per- measure degree—or severity—by means of trait fac-
sonality disorder). tors and thus assign it a position corresponding to its
Clinical experience has shown that increasing age extent along various dimensional axes. It must be kept
and decreasing vitality tend to attenuate ‘sharp’ in mind that there is no inherent qualitative difference
personality traits, especially those which seriously in personality traits between the general population
impair social functioning, such as inconstancy, anti- and clinical groups of patients with personality dis-
social behavior, and impulsiveness. Other traits can orders, only a difference in degree or severity, or
become sharper with advancing age, above all ob- eventually in a particular combination of traits. By
stinacy and rigidity. means of factor analyses, these personality models

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Table 2
Factor models of dimensional personality description
3-factor personality models 5-factor personality models 7-factor personality model
Eysenck (1977) Costa and McCrae (1990) Cloninger (1994)
neuroticism extroversion harm avoidance
extroversion neuroticism novelty seeking
psychoticism agreeability reward dependence
conscientiousness persistence
Millon (1981) openness to new experiences self-directedness
joy\pain cooperativeness
self\other-centeredness self-transcendence
activity\passivity von Zerssen (1988)
extroversion
Widiger et al. (1994) neuroticism
free-floating aggressivity
anxiety\eccentric behavior conscientiousness
assertiveness\dominance openness
social integration (devoutness)
DSM-IV (1994)
eccentricity
dramatic affect
fear

Table 3 alike to opt for one of the two systems. While the two
Classification of personality disorders systems resemble each other in many aspects, there are
others where they completely disagree. Table 3 gives
DSM-IV ICD-10 an overview of the most important discrepancies (see
paranoid paranoid Differential Diagnosis in Psychiatry).
schizoid schizoid
schizotypical —
antisocial dissocial 6. Therapy of Personality Disorders
borderline impulsive
histrionic histrionic Following a thorough anamnesis, there are two main
narcissistic — options: psychotherapy and therapy with psychophar-
avoidant anxious maceuticals. In detail:
obsessive-compulsive obsessive-compulsive
not otherwise specified not otherwise specified
and others 6.1 Thorough Initial Examination
The general procedure in treating personality dis-
reduce the myriad personality traits to a few essential orders follows the usual rules of psychiatry. It is
personality dimensions, independent of culture, from important that a thorough initial examination be done,
which the individual variants may then be derived. with an exact medical and psychiatric anamnesis. Due
However, given the clinical usefulness of the cat- to the lacking self-dystonia, the patient’s self-per-
egorical approach, and hence the widespread hesitancy ception may be lower than in cases showing acute
in abandoning it, recent efforts have tended more psychopathological symptoms. Hence, anamnesis by
towards a synthesis of the categorical and dimensional significant others can also be helpful in assessing social
elements. conflict when dealing with personality disorders.
The classification systems used today, which in-
creasingly determine personality diagnosis, are the
Diagnostic and Statistical Manual of Mental Disorders,
6.2 Psychotherapy of Personality Disorders
4th Edition (DSM-IV), published by the American
Psychiatric Association (APA 1994), and the Inter- In the psychotherapy of personality disorders, the
national Classification of Diseases, 10th Edition (ICD- choice of the therapeutic procedure will depend on the
10), published by the World Health Organization particular form of personality disorder, its severity, as
(WHO 1992). Both are used for making diagnoses, well as any concomitant mental disorders. Currently
thus forcing clinicians, practitioners, and researchers accepted forms of therapy include: cognitive\

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behavioral therapeutic and supportive techniques, Due to the dangers of side effects and habituation or
depth psychology, disorder-oriented and interdisci- dependence associated with it, long-term pharmaceu-
plinary therapies with treatments for specific problem tical therapy of personality disorders must always be
areas of a personality, pedagogic or psychogogic viewed critically. Likewise, the therapist must be aware
therapies, sociotherapy, and dialogue sessions for of the danger that the patient may start believing in
couples or families. An important element of every external control or attribute therapeutic success solely
therapy is that disorder-related behavior and inter- to the action of the psychopharmaceuticals.
action abnormalities also be dealt with in the patient– Moreover, there are special counterindications:
therapist relation, so that a big step in the therapy will alcohol and medicine abuse, social unreliability, bad
consist in opening up new self-awareness and possibili- compliance (incoming to therapy or in taking the
ties of change to the patient via the therapeutic medication). Due to the danger of late dyskinesias
interaction itself. following long-term use, neuroleptics should be em-
Psychotherapy of personality disorders usually re- ployed judiciously and substances of low or medium
quires a long time, since it involves a gradual reshaping potency be considered. With benzodiazepines there is
of long-lasting characteristics in the areas of experi- a particularly high risk of addiction, which is why they
encing, feeling, and social behavior. Short-term crisis are generally not indicated for the treatent of per-
intervention can also be helpful if the problematic sonality disorders. Medication can also be tricky with
personality traits bring situations to a head and cause some patients, who may harbor unrealistical expecta-
social conflicts. Building up a regular, trusting relation tions or fear to lose control. Due to these difficulties,
is of great importance. The frequency usually chosen is such individuals may have to be admitted as inpatients
one to two hours per week. Aside from discussing before psychopharmaceutical therapy can be initiated
current life conflicts, exploring past issues is also (see Psychotherapy and Pharmacotherapy, Combined ).
important as it can outline the development of the
personality traits which are at the root of the trouble.
Group therapy is well suited for many personalities 7. The Most Important Personality Disorders
(provided they are not seriously deranged) since According to DSM-IV
observing other patients allows learning by example.
The positive feedback or criticism from the other This section offers classification of personality dis-
group members can reinforce desirable behavior and orders, followed by an overview of the most important
put undesirable behavior in perspective (see Cogniti
e forms of abnormal personalities in DSM-IV. Please
and Interpersonal Therapy: Psychiatric Aspects). consult the manual for a complete list of the diagnostic
criteria for the following personality disorders. The
differential diagnosis refers solely to the Axis-I dis-
6.3 Pharmacotherapy orders (because of limited space).
The second important therapy for personality dis-
orders, one which in recent years has been increasingly
developed, consists in the use of psychopharmaceu- 7.1 Paranoid Personality Disorder
ticals. It rests on the assumption that personality According to DSM-IV, persons with a paranoid
disorders can also have a biological cause which may personality disorder show a pattern of distrust and
be either constitutional or due to functional anomalies suspicion, reading malevolence into the motives of
which were acquired later. others without sufficient basis for that supposition.
The aim is to reduce the vulnerability to affective They often doubt the loyalty of their friends, partners,
and cognitive dysfunctions neurochemically and to or associates and are reluctant to confide in others for
modify certain behavioral reaction patterns, the target fear that the information might be used against them.
symptoms or syndromes being: Persons with a paranoid personality disorder quickly
(a) the characteristics of the personality disorder react to perceived insults with excessive force, counter-
(e.g., cognitive deficits, impulsive behavior, strong attacks, and\or long-lasting enmity. Mistakes are
mood swings); usually blamed on others. Persons with this disorder
(b) complications due to the personality disorder usually have recurrent suspicions regarding the fidelity
(e.g., suicidal tendencies, aggressivity towards others, of their spouse or partner. These persons are easily
deficient social skills); and insulted, emotionally rigid, and persevering while at
(c) the axis I disorders associated with these (e.g., the same time appearing humorless and restrictive in
depressive or anxiety syndromes, compulsion, eating their expression of warm emotions.
disorders).
The pharmacological treatment of personality dis-
orders is by no means an alternative to psychotherapy.
7.2 Schizoid Personality Disorder
Rather, it is used in support and preparation for
psychotherapy, as well as for crisis intervention (es- The chief characteristics of the schizoid personality
pecially with suicidal tendencies). disorder are an inability to develop close emotional

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attachments to others, seclusiveness, and a reduced leads to sudden, short-lived bursts of extreme mood
capacity for emotional experience and expression in swings. The affective outbursts usually take place
interpersonal settings. Schizoid personalities neither under conditions which are perceived as threatening,
desire nor enjoy close relationships, have little, if any, such as real or imagined abandonment or rejection.
interest in sexual experiences, and do not have friends Especially characteristic for borderline personality
or confidants. Persons with a schizoid personality disorder is an alternating lifelong pattern of impul-
disorder are shy, show emotional coldness and de- sively inflicting harm on oneself or others, including
tachment, and are seemingly indifferent to praise or self-inflicted wounds, bulimic binge-and-purge at-
criticism. They take pleasure in few activities and tacks, periods of excessive alcohol consumption, or
distinctly prefer solitary ones. They may function fights. Repetitive suicide threats and attempts are
adequately at work, especially if their job requires little common.
social contact. Unlike antisocial personalities, most patients try to
restrain or suppress their impulses, although these
attempts often fail. This leads to unpredictable swings
between a tense holding back of affective impulses on
7.3 Schizotypal Personality Disorder the one hand and sudden outbursts on the other.
The schizotypal personality disorder is characterized Predominant emotions are dysphoria, anxiety, anger,
by strong deficits in establishing interpersonal contact. and chronic feelings of emptiness.
Persons with schizotypal personality disorder show a Borderline personality disorder patients are fur-
pronounced fear of social situations and actively avoid thermore characterized by a highly unstable image
them. They do not have close friends or confidants. and perception of themselves, which can also include
Their interpersonal deficits are marked by acute aspects of gender identity, deficient orientation and
discomfort with close relationships, constricted affect, plans for the future, as well as indiscriminate choice of
cognitive and perceptual distortions, and eccentricities social groups or partners. In their unstable and intense
of behavior, as in their choice of dress and movement. interpersonal relationships they often alternate be-
Persons with this disorder often develop magical tween extremes of idealization and devaluation (split-
thinking and a belief in the occult, and sometimes ting). A last and important area are the transient,
ideas of reference or paranoid ideation may influence stress-related dissociative or (pseudo)psychotic sym-
their behavior. Regarding language, there are unclear, ptoms or paranoid ideas (see Borderline Personality
strange, or stereotyped expressions and incorrect use Disorder).
of words, though not to the point of associative
loosening and incoherence.
Phenomenological, biological, genetic, and out-
come data (e.g., the Danish adoption studies) show a 7.6 Histrionic Personality Disorder
relation between schizotypal personality disorder and
schizophrenia. Therefore, it is often considered a The main characteristics of this personality disorder
schizophrenia-spectrum disorder. are a strong need to be at the center of attention and to
gain recognition. Persons with histrionic personality
disorder show a pattern of excessive emotionality with
self-dramatization, theatricality, and coquetry that
7.4 Antisocial Personality Disorder may be reflected in their style of speech, which is
impressionistic and lacking in detail.
The main characteristic of the antisocial personality There is a tendency for affective instability and
disorder is a permanent and deep-seated tendency to superficiality, displaying rapidly shifting emotions.
violate and abuse the rights of others occuring from Most patients are largely suggestible and unable to
the age 15 years on. These persons show little maintain a steadfast pursuit of goals or value orien-
introspection and self-criticism, lack empathy, show tation. They are thus inconstant, especially in relation-
coldness, egotism, an exaggerated sense of entitlement, ships. Persons with histrionic personality disorder
a paradoxical idea of adaptation, and weak or faulty often interact with others in an inappropriate, sexually
social norms. Their behavior is marked by impulsive- seductive or provocative manner, using their physical
ness, unreliability, weak commitment, and absence of appearance to draw attention to themselves. Relation-
guilt feelings. They are practically beyond therapy and ships are often considered to be more intimate than
prognosis is generally unfavorable. they actually are.
Also clinically relevant, though uncommon, are the
sometimes drastic ‘pseudohysterical’ cases showing
aggravation, conversion, dramaticism, and improper
7.5 Borderline Personality Disorder
behavior.
The borderline personality disorder shows a pattern of Manic states may be accompanied by exaggerated
interpersonal and affective instability which often expression of emotion and impressionistic behavior,

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but can be distinguished from histrionic personality might result in a loss of support or approval. This
disorder by the temporary nature of these symptoms leads to submissive behavior, sometimes to the point
and, of course, the presence of other specific\typical of being self-effacing and obsequious. In a relation-
symptoms of mania. ship, these patients experience a constant fear of loss
and abandonment, and urgently seek out somebody
for support and care when a close relationship ends.
They further show a cognitive distortion known as
7.7 Narcissistic Personality Disorder catastrophizing, which is a fearful and exaggerated
estimate of the worst possible consequences of the
According to DSM-IV, individuals with a narcissistic relation ending.
personality disorder have an exaggerated sense of
self-importance, are preoccupied with fantasies of
grandiosity or superiority, and require excessive
admiration. They believe that they are ‘special’ and
can only be understood by other special people. 7.10 Obsessi
e-compulsi
e Personality Disorder
Patients with narcissistic personality disorder tend The main characteristics of the obsessive-compulsive
to exploit others involuntarily, thinking that their own personality disorder are conscientiousness, perfection-
qualities and abilities entitle them to special treatment. ism, conformism, and devotedness to work, which can
There is a lack of empathy which becomes obvious in be overvalued to the point of adversely affecting
the unwillingness to identify with the feelings and professional productivity and interpersonal relation-
needs of others. Further symptoms are a basically ships. They dislike teamwork or delegating tasks
fragile self-esteem and feelings of envy and distrust unless the others conform exactly to their way of
towards others. With a clearly increased self-aware- thinking or acting. These persons show a severity and
ness and egotism, social discomfort and fear of rigidity both with themselves and with others which
negative opinions predominate. A particular problem often interferes with social functioning. They are
is a tendency for depressive crises and resolute suici- overconscientious, inflexible, and rule-minded about
dality following an imagined insult. matters of morality or ethics.
Obsessive-compulsive personalities are unable to
separate the important from the unimportant (e.g.,
they cannot bring themselves to throw away old,
7.8 A
oidant Personality Disorder worthless objects even when these have no sentimental
The avoidant-insecure personality disorder is charac- value) and they have an inability to make decisions.
terized by a pervasive pattern of low self-esteem and Where money is concerned, they are miserly both with
hypersensivity to negative evaluation. Despite their themselves and with others.
strong wish for affection, persons with avoidant- Of great importance are the interactions between
insecure personality disorder avoid social relations, the obsessive-compulsive personality disorder and
being insecure, shy, tense, and anxious. Their feelings depression. On the one hand, obsessive-compulsive
of inferiority and inadequacy in social contact lead to personality traits can intensify during depression or
a severe restriction of their social skills and roles, first become disturbing, as in the form of depressive
causing them to be reluctant to take personal risks or insecurity or difficulties in making decisions; on the
to engage in any new activities because they may prove other hand, obsessive-compulsive behavior can lead to
embarrassing. Patients with avoidant personality dis- difficulties, and hence to reactive depression, where
order often show restraint with intimate relationships obsessive-compulsive personality traits and depressive
out of a strong fear of shame. symptoms are closely interwoven.

7.9 Dependent Personality Disorder 7.11 Personality Disorders not Otherwise Specified
The dependent personality disorder is characterized This category applies to personality disorders which
by an overpowering feeling of not being able to are not designated by a DSM-IV diagnosis, but which
conduct one’s own life. With a self-image of weakness cause clinically significant distress or impairment. It
and helplessness, patients will seek support from may also be used when the features of more than one
others in all situations, especially from their partners. Axis II disorder are present but the full criteria for any
Persons with a dependent personality disorder need one disorder are not met. It also includes the depressive
others to assume responsibility in most major areas of and passive-aggressive (negativistic) personality dis-
their life. They have difficulties doing things on their order, which are actually found in the appendix to
own or making everyday decisions without advice DSM-IV, being currently under research to determine
from others, and fear that expressing disagreement whether they should be included in DSM-V or not.

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8. Concluding Remarks Frances A J, Hales R E (eds.) 1986 Re
iew of Psychiatry, Vol 5.

American Psychiatric Press, Washington, DC
Concluding, it should be noted that that all typolo- Henderson D 1939 Psychopathic States. Norton, New York
gically arranged classifications of personality disorders Jang K L, Livesley W J, Vernon P A, Jackson D N 1996
are merely conventions. By giving a good description Heritability of personality disorder traits: A twin study. Acta
of the reality of life, they may acquire a certain Psychiatrica Scandina
ica 94: 438–44
plausibility, self-evidence, and clinical usefulness. A Koch J L A 1891–3 Die psychopathischen Minderwertigkeiten.
Maier, Ravensburg, Germany
nosological diagnosis and therapy of personality
Kraepelin E 1903–4 Psychiatrie. Ein Lehrbuch fuW r Studierende
disorders can only be expected for special forms, and und Aq rzte. Barth, Leipzig, Germany
even then only as long as it can be shown that they Kretschmer E 1921 KoW rperbau und Charakter. Springer, Berlin
were caused by illnesses. Linehan M 1993 Cogniti
e-Beha
ioral Treatment of Border-
Most personality disorders, however, lie at the line-Personality Disorder. Guilford, New York
fringe of mental health. Instead of pathological pro- Loranger A W, Sartorius N, Andreoli A, Berger P, Buchheim P,
cesses, one has to deal with difficult developments in Channabasauanna S M, Coid B, Dahl A, Diekstra R F,
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International Encyclopedia of the Social & Behavioral Sciences ISBN: 0-08-043076-7