Personality Disorders

Being able to predict people's offset responses is essential, not only can save you a lot of time and trouble but can help substanciate projection and thus be beneficial to those who could really use a little understanding.

Psychologist Theodore Millon, who has written numerous popular works on personality, proposed the following description of personality disorders:

Type of personality disorder Description
Paranoid Guarded, defensive, distrustful and suspicious. Hypervigilant to the motives of others to undermine or do harm. Always seeking confirmatory evidence of hidden schemes. Feel righteous, but persecuted. Experience a pattern of pervasive distrust and suspicion of others that lasts a long time. They are generally difficult to work with and are very hard to form relationships with. They are also known to be somewhat short-tempered.
Schizoid Apathetic, indifferent, remote, solitary, distant, humorless, contempt, odd fantasies. Neither desire nor need human attachments. Withdrawn from relationships and prefer to be alone. Little interest in others, often seen as a loner. Minimal awareness of the feelings of themselves or others. Few drives or ambitions, if any. Is an uncommon condition in which people avoid social activities and consistently shy away from interaction with others. It affects more males than females. To others, they may appear somewhat dull or humorless. Because they don't tend to show emotion, they may appear as though they don't care about what's going on around them.
Schizotypal Eccentric, self-estranged, bizarre, absent. Exhibit peculiar mannerisms and behaviors. Think they can read thoughts of others. Preoccupied with odd daydreams and beliefs. Blur line between reality and fantasy. Magical thinking and strange beliefs. People with schizotypal personality disorder are often described as odd or eccentric and usually have few, if any, close relationships. They think others think negatively of them.
Antisocial Impulsive, irresponsible, deviant, unruly. Act without due consideration. Meet social obligations only when self-serving. Disrespect societal customs, rules, and standards. See themselves as free and independent. People with antisocial personality disorder depict a long pattern of disregard for other people's rights. They often cross the line and violate these rights.
Borderline Unpredictable, egocentric, emotionally unstable. Frantically fears abandonment and isolation. Experience rapidly fluctuating moods. Shift rapidly between loving and hating. See themselves and others alternatively as all-good and all-bad. Unstable and frequently changing moods. People with borderline personality disorder have a pervasive pattern of instability in interpersonal relationships.
Histrionic Hysteria, dramatic, seductive, shallow, egocentric, attention-seeking, vain. Overreact to minor events. Exhibitionistic as a means of securing attention and favors. See themselves as attractive and charming. Constantly seeking others' attention. Disorder is characterized by constant attention-seeking, emotional overreaction, and suggestibility. Their tendency to over-dramatize may impair relationships and lead to depression, but they are often high-functioning.
Narcissistic Egotistical, arrogant, grandiose, insouciant. Preoccupied with fantasies of success, beauty, or achievement. See themselves as admirable and superior, and therefore entitled to special treatment. Is a mental disorder in which people have an inflated sense of their own importance and a deep need for admiration. Those with narcissistic personality disorder believe that they're superior to others and have little regard for other people's feelings.
Avoidant Hesitant, self-conscious, embarrassed, anxious. Tense in social situations due to fear of rejection. Plagued by constant performance anxiety. See themselves as inept, inferior, or unappealing. They experience long-standing feelings of inadequacy and are very sensitive of what others think about them.
Dependent Helpless, incompetent, submissive, immature. Withdrawn from adult responsibilities. See themselves as weak or fragile. Seek constant reassurance from stronger figures. They have the need to be taken care of by a person. They fear being abandoned or separated from important people in their life.
Obsessive–compulsive Restrained, conscientious, respectful, rigid. Maintain a rule-bound lifestyle. Adhere closely to social conventions. See the world in terms of regulations and hierarchies. See themselves as devoted, reliable, efficient, and productive.
Depressive Somber, discouraged, pessimistic, brooding, fatalistic. Present themselves as vulnerable and abandoned. Feel valueless, guilty, and impotent. Judge themselves as worthy only of criticism and contempt. Hopeless, suicidal, restless. This disorder can lead to aggressive acts and hallucinations.
Passive–aggressive (Negativistic) Resentful, contrary, skeptical, discontented. Resist fulfilling others’ expectations. Deliberately inefficient. Vent anger indirectly by undermining others’ goals. Alternately moody and irritable, then sullen and withdrawn. Withhold emotions. Will not communicate when there is something problematic to discuss.
Sadistic Explosively hostile, abrasive, cruel, dogmatic. Liable to sudden outbursts of rage. Gain satisfaction through dominating, intimidating and humiliating others. They are opinionated and closed-minded. Enjoy performing brutal acts on others. Find pleasure in abusing others. Would likely engage in a sadomasochist relationship, but will not play the role of a masochist.
Self-defeating (Masochistic) Deferential, pleasure-phobic, servile, blameful, self-effacing. Encourage others to take advantage of them. Deliberately defeat own achievements. Seek condemning or mistreatful partners. They are suspicious of people who treat them well. Would likely engage in a sadomasochist relationship.

In addition to classifying by category and cluster, it is possible to classify personality disorders using additional factors such as severity, impact on social functioning, and attribution. This involves both the notion of personality difficulty as a measure of subthreshold scores for personality disorder using standard interviews and the evidence that those with the most severe personality disorders demonstrate a “ripple effect” of personality disturbance across the whole range of mental disorders.

In addition to subthreshold (personality difficulty) and single cluster (simple personality disorder), this also derives complex or diffuse personality disorder (two or more clusters of personality disorder present) and can also derive severe personality disorder for those of greatest risk.

Level of Severity Description Definition by Categorical System
0 No Personality Disorder Does not meet actual or subthreshold criteria for any personality disorder.
1 Personality Difficulty Meets sub-threshold criteria for one or several personality disorder.
2 Simple Personality Disorder Meets actual criteria for one or more personality disorders within the same cluster.
3 Complex (Diffuse) Personality Disorder Meets actual criteria for one or more personality disorders within more than one cluster.
4 Severe Personality Disorder Meets criteria for creation of severe disruption to both individual and to many in society.

There are several advantages to classifying personality disorder by severity:

Currently, there are no definitive proven causes for personality disorders. However, there are numerous possible causes and known risk factors supported by scientific research that vary depending on the disorder, the individual, and the circumstance. Overall, findings show that genetic disposition and life experiences, such as trauma and abuse, play a key role in the development of personality disorders.

Borderline personality disorder

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self, and strong emotional reactions. Those affected often engage in self-harm and other dangerous behaviors, often due to their difficulty with returning their emotional level to a healthy or normal baseline. They may also struggle with a feeling of emptiness, fear of abandonment, and detachment from reality.

Symptoms of BPD may be triggered by events considered normal to others. BPD typically begins by early adulthood and occurs across a variety of situations. Substance use disorders, depression, and eating disorders are commonly associated with BPD. Approximately 10% of people affected with the disorder die by suicide. The disorder is often stigmatized in both the media and the psychiatric field and as a result is often underdiagnosed. The causes of BPD are unclear but seem to involve genetic, neurological, environmental, and social factors. It occurs about five times more often in a person who has an affected close relative. Adverse life events appear to also play a role.

About 1.6% of people have BPD in a given year, with some estimates as high as 6%. Women are diagnosed about three times as often as men. The disorder appears to become less common among older people. Up to half of those with BPD improve over a ten-year period. Those affected typically use a high amount of healthcare resources. There is an ongoing debate about the naming of the disorder, especially the suitability of the word borderline.

Overall, the most distinguishing symptoms of BPD are pervasive patterns of instability in interpersonal relationships and self-image, alternating between extremes of idealization and devaluation of others, along with varying moods and difficulty regulating strong emotional reactions. Dangerous or impulsive behavior is also correlated with the disorder. Other symptoms may include feeling unsure of one's identity, morals, and values; having paranoid thoughts when feeling stressed; depersonalization; and, in moderate to severe cases, stress-induced breaks with reality or psychotic episodes.

Individuals with BPD often have comorbid conditions, such as depressive and bipolar disorders, substance use disorders, eating disorders, post-traumatic stress disorder, and attention-deficit/hyperactivity disorder.

Subtype Features
Discouraged borderline (including avoidant and dependent features) Pliant, submissive, loyal, humble; feels vulnerable and in constant jeopardy; feels hopeless, depressed, helpless, and powerless.
Petulant borderline (including negativistic features) Negativistic, impatient, restless, as well as stubborn, defiant, sullen, pessimistic, and resentful; easily feels "slighted" and quickly disillusioned.
Impulsive borderline (including histrionic or antisocial features) Captivating, capricious, superficial, flighty, distractable, frenetic, and seductive; fearing loss, the individual becomes agitated; gloomy and irritable; and potentially suicidal.
Self-destructive borderline (including depressive or masochistic features) Inward-turning, intropunitive (self-punishing), angry; conforming, deferential, and ingratiating behaviors have deteriorated; increasingly high-strung and moody; possible suicide.

Long-term psychotherapy is currently the treatment of choice for BPD. While psychotherapy, in particular Dialectical behavior therapy (DBT) and psychodynamic approaches, is effective, the effects are slow: many people have to put in years of work to be effective. More rigorous treatments are not substantially better than less rigorous treatments. There are six such treatments available: dynamic deconstructive psychotherapy (DDP), Mentalization-based treatment (MBT), transference-focused psychotherapy, dialectical behavior therapy (DBT), general psychiatric management, and schema-focused therapy. Long-term therapy of any kind is better than no treatment, especially in reducing urges to self-injure.

Cognitive behavioral therapy (CBT) is also a type of psychotherapy used for treatment of BPD. This type of therapy relies on changing people's behaviors and beliefs by identifying problems from the disorder. CBT is known to reduce some anxiety and mood symptoms as well as reduce suicidal thoughts and self-harming behaviors. Some research indicates that mindfulness meditation may bring about favorable structural changes in the brain, including changes in brain structures that are associated with BPD. Mindfulness-based interventions also appear to bring about an improvement in symptoms characteristic of BPD, and some clients who underwent mindfulness-based treatment no longer met a minimum of five of the DSM-IV-TR diagnostic criteria for BPD.

The features of BPD include emotional instability; intense, unstable interpersonal relationships; a need for intimacy; and a fear of rejection. As a result, people with BPD often evoke intense emotions in those around them. Pejorative terms to describe people with BPD, such as "difficult", "treatment resistant", "manipulative", "demanding", and "attention seeking", are often used and may become a self-fulfilling prophecy, as the negative treatment of these individuals triggers further self-destructive behavior.

Schizotypal personality disorder

Schizotypal personality disorder (STPD), also known as schizotypal disorder, is a mental and behavioural disorder. DSM classification describes the disorder specifically as a personality disorder characterized by thought disorder, paranoia, a characteristic form of social anxiety, derealization, transient psychosis, and unconventional beliefs. People with this disorder feel pronounced discomfort in forming and maintaining social connections with other people, primarily due to the belief that other people harbour negative thoughts and views about them.

There is now evidence to suggest that parenting styles, early separation, trauma/maltreatment history (especially early childhood neglect) can lead to the development of schizotypal traits. Neglect or abuse, trauma, or family dysfunction during childhood may increase the risk of developing schizotypal personality disorder. Over time, children learn to interpret social cues and respond appropriately but for unknown reasons this process does not work well for people with this disorder.

This is a disorder characterized by eccentric behavior and anomalies of thinking and affect which resemble those seen in schizophrenia, though no definite and characteristic schizophrenic anomalies have occurred at any stage. There is no dominant or typical disturbance, but any of the following may be present:

The disorder runs a chronic course with fluctuations of intensity. Occasionally it evolves into overt schizophrenia. There is no definite onset and its evolution and course are usually those of a personality disorder. It is more common in individuals related to people with schizophrenia and is believed to be part of the genetic "spectrum" of schizophrenia.

Theodore Millon proposes two subtypes of schizotypal personality. Any individual with schizotypal personality disorder may exhibit either one of the following somewhat different subtypes (Note that Millon believes it is rare for a personality with one pure variant, but rather a mixture of one major variant with one or more secondary variants):

Subtype Description Personality traits
Insipid schizotypal A structural exaggeration of the passive-detached pattern. It includes schizoid, depressive and dependent features. Sense of strangeness and nonbeing; overtly drab, sluggish, inexpressive; internally bland, barren, indifferent, and insensitive; obscured, vague, and tangential thoughts.
Timorous schizotypal A structural exaggeration of the active-detached pattern. It includes avoidant and negativistic features. Warily apprehensive, watchful, suspicious, guarded, shrinking, deadens excess sensitivity; alienated from self and others; intentionally blocks, reverses, or disqualifies own thoughts.

According to Theodore Millon, the schizotypal is one of the easiest personality disorders to identify but one of the most difficult to treat with psychotherapy. Persons with STPD usually consider themselves to be simply eccentric or nonconformist; the degree to which they consider their social nonconformity a problem and the degree to which psychiatry does differ. It is difficult to gain rapport with people who suffer from STPD due to the fact that increasing familiarity and intimacy usually increase their level of anxiety and discomfort.

Group therapy is recommended for persons with STPD only if the group is well structured and supportive. Otherwise, it could lead to loose and tangential ideation. Support is especially important for schizotypal patients with predominant paranoid symptoms, because they will have a lot of difficulties even in highly structured groups.

Reported prevalence of STPD in community studies ranges from 0.6% in a Norwegian sample, to 4.6% in an American sample. A large American study found a lifetime prevalence of 3.9%, with somewhat higher rates among men (4.2%) than women (3.7%). It may be uncommon in clinical populations, with reported rates of up to 1.9%.

Together with other cluster A personality disorders, it is also very common among homeless people who show up at drop-in centres, according to a 2008 New York study. The study did not address homeless people who do not show up at drop-in centres.

Antisocial personality disorder

Antisocial personality disorder (ASPD or infrequently APD) is a personality disorder characterized by a long-term pattern of disregard for, or violation of, the rights of others as well as a difficulty sustaining long-term relationships. A weak or nonexistent conscience is often apparent, as well as a history of rule-breaking that can sometimes lead to law-breaking, a tendency towards substance abuse, and impulsive and aggressive behaviour. Antisocial behaviors often have their onset before the age of 8, and in nearly 80% of ASPD cases, the subject will develop their first symptoms by age 11. The Prevalence of ASPD peaks in people age 24 to 44 years old, and often decreases in people age 45 to 64 years. In the United States, the rate of antisocial personality disorder in the general population is estimated between 0.5 and 3.5 percent.

Antisocial personality disorder is defined by a pervasive and persistent disregard for morals, social norms, and the rights and feelings of others. Although behaviors vary in degree, individuals with this personality disorder will typically have limited compunction in exploiting others in harmful ways for their own gain or pleasure, and frequently manipulate and deceive other people. While some do so through a façade of superficial charm, others do so through intimidation and violence. They may display arrogance, think lowly and negatively of others, and lack remorse for their harmful actions and have a callous attitude towards those they have harmed. Irresponsibility is a core characteristic of this disorder; most have significant difficulties in maintaining stable employment as well as fulfilling their social and financial obligations, and people with this disorder often lead exploitative, unlawful, or parasitic lifestyles.

Those with antisocial personality disorder are often impulsive and reckless, failing to consider or disregarding the consequences of their actions. They may repeatedly disregard and jeopardize their own safety and the safety of others, which can place both themselves and other people in danger. They are often aggressive and hostile, with poorly regulated tempers, and can lash out violently with provocation or frustration. Individuals are prone to substance use disorders and addiction, and the non-medical use of various psychoactive substances is common in this population. These behaviors can in some instances lead such individuals into frequent conflict with the law, and many people with ASPD have extensive histories of antisocial behavior and criminal infractions stemming back to adolescence or childhood.

Antisocial personality disorder is characterized by at least 3 of the following:

Theodore Millon suggested 5 subtypes of ASPD. However, these constructs are not recognized in the DSM and ICD.

Subtype Features
Nomadic antisocial (including schizoid and avoidant features) Drifters; roamers, vagrants; adventurer, itinerant vagabonds, tramps, wanderers; they typically adapt easily in difficult situations, shrewd and impulsive. Mood centers in doom and invincibility.
Malevolent antisocial (including sadistic and paranoid features) Belligerent, mordant, rancorous, vicious, sadistic, malignant, brutal, resentful; anticipates betrayal and punishment; desires revenge; truculent, callous, fearless; guiltless; many dangerous criminals, including serial killers.
Covetous antisocial (including negativistic features) Rapacious, begrudging, discontentedly yearning; hostile and domineering; envious, avaricious; pleasures more in taking than in having.
Risk-taking antisocial (including histrionic features) Dauntless, venturesome, intrepid, bold, audacious, daring; reckless, foolhardy, heedless; unfazed by hazard; pursues perilous ventures.
Reputation-defending antisocial (including narcissistic features) Needs to be thought of as infallible, unbreakable, indomitable, formidable, inviolable; intransigent when status is questioned; overreactive to slights.

Elsewhere, Millon differentiates ten subtypes (partially overlapping with the above) – covetous, risk-taking, malevolent, tyrannical, malignant, disingenuous, explosive, and abrasive – but specifically stresses that "the number 10 is by no means special ... Taxonomies may be put forward at levels that are more coarse or more fine-grained."

ASPD is considered to be among the most difficult personality disorders to treat. Rendering an effective treatment for ASPD is further complicated due to the inability to look at comparative studies between psychopathy and ASPD due to differing diagnostic criteria, differences in defining and measuring outcomes and a focus on treating incarcerated patients rather than those in the community. Because of their very low or absent capacity for remorse, individuals with ASPD often lack sufficient motivation and fail to see the costs associated with antisocial acts.

They may only simulate remorse rather than truly commit to change: they can be seductively charming and dishonest, and may manipulate staff and fellow patients during treatment. Studies have shown that outpatient therapy is not likely to be successful, but the extent to which persons with ASPD are entirely unresponsive to treatment may have been exaggerated. Most treatment done is for those in the criminal justice system to whom the treatment regimes are given as part of their imprisonment. Those with ASPD may stay in treatment only as required by an external source, such as parole conditions.

Psychotherapy also known as talk therapy is found to help treat patients with ASPD. Schema therapy is also being investigated as a treatment for ASPD. A review by Charles M. Borduin features the strong influence of Multisystemic therapy (MST) that could potentially improve this imperative issue. Therapists working with individuals with ASPD may have considerable negative feelings toward patients with extensive histories of aggressive, exploitative, and abusive behaviors. Rather than attempt to develop a sense of conscience in these individuals, which is extremely difficult considering the nature of the disorder, therapeutic techniques are focused on rational and utilitarian arguments against repeating past mistakes.

Boys are twice as likely to meet all of the diagnostic criteria for ASPD than girls (40% versus 25%) and they will often start showing symptoms of the disorder much earlier in life. Children that do not show symptoms of the disease through age 15 will not develop ASPD later in life. If adults exhibit milder symptoms of ASPD, it is likely that they never met the criteria for the disorder in their childhood and were consequently never diagnosed. Overall, symptoms of ASPD tend to peak in late-teens and early twenties, but can often reduce or improve through age 40.

ASPD is ultimately a lifelong disorder that has chronic consequences, though some of these can be moderated over time. There may be a high variability of the long-term outlook of antisocial personality disorder. The treatment of this disorder can be successful, but it entails unique difficulties. It is unlikely to see rapid change especially when the condition is severe. In fact, past studies revealed that remission rates were small, with up to only 31% rates of improvement instead of remittance.

Without proper treatment, individuals suffering with ASPD could lead a life that brings about harm to themselves or others. This can be detrimental to their families and careers. ASPD victims suffer from lack of interpersonal skills (e.g., lack of remorse, lack of empathy, lack of emotional-processing skills). As a result of the inability to create and maintain healthy relationships due to the lack of interpersonal skills, individuals with ASPD may find themselves in predicaments such as divorce, unemployment, homelessness and even premature death by suicide.

Histrionic personality disorder

Histrionic personality disorder (HPD) is defined by the American Psychiatric Association as a personality disorder characterized by a pattern of excessive attention-seeking behaviors, usually beginning in early childhood, including inappropriate seduction and an excessive desire for approval. People diagnosed with the disorder are said to be lively, dramatic, vivacious, enthusiastic, extroverted and flirtatious. People with HPD have a high desire for attention, make loud and inappropriate appearances, exaggerate their behaviors and emotions, and crave stimulation. They may exhibit sexually provocative behavior, express strong emotions with an impressionistic style, and can be easily influenced by others. Associated features include egocentrism, self-indulgence, continuous longing for appreciation, and persistent manipulative behavior to achieve their own wants.

People with HPD are usually high-functioning, both socially and professionally. They usually have good social skills, despite tending to use them to manipulate others into making them the center of attention. HPD may also affect a person's social and romantic relationships, as well as their ability to cope with losses or failures. They may seek treatment for clinical depression when romantic (or other close personal) relationships end. Individuals with HPD often fail to see their own personal situation realistically, instead dramatizing and exaggerating their difficulties. They may go through frequent job changes, as they become easily bored and may prefer withdrawing from frustration (instead of facing it). Because they tend to crave novelty and excitement, they may place themselves in risky situations. All of these factors may lead to greater risk of developing clinical depression.

Additional characteristics may include:

Some people with histrionic traits or personality disorder change their seduction technique into a more maternal or paternal style as they age.

A mnemonic that can be used to remember the characteristics of histrionic personality disorder is shortened as "PRAISE ME"

Little research has been done to find evidence of what causes histrionic personality disorder. Although direct causes are inconclusive, various theories and studies suggest multiple possible causes, of a neurochemical, genetic, psychoanalytic, or environmental nature. Traits such as extravagance, vanity, and seductiveness of hysteria have similar qualities to women diagnosed with HPD. HPD symptoms typically do not fully develop until the age of 15, while the onset of treatment only occurs, on average, at approximately 40 years of age.

Theodore Millon identified six subtypes of histrionic personality disorder. Any individual histrionic may exhibit one or more of the following:

Subtype Description Personality Traits
Appeasing histrionic Including dependent and compulsive features Seeks to placate, mend, patch up, smooth over troubles; knack for settling differences, moderating tempers by yielding, compromising, conceding; sacrifices self for commendation; fruitlessly placates the unplacatable.
Vivacious histrionic The seductiveness of the histrionic mixed with the energy typical of hypomania. Some narcissistic features can also be present Vigorous, charming, bubbly, brisk, spirited, flippant, impulsive; seeks momentary cheerfulness and playful adventures; animated, energetic, ebullient.
Tempestuous histrionic Including negativistic features Impulsive, out of control; moody complaints, sulking; precipitous emotion, stormy, impassioned, easily wrought-up, periodically inflamed, turbulent.
Disingenuous histrionic Including antisocial features Underhanded, double-dealing, scheming, contriving, plotting, crafty, false-hearted; egocentric, insincere, deceitful, calculating, guileful.
Theatrical histrionic Variant of “pure” pattern Affected, mannered, put-on; postures are striking, eyecatching, graphic; markets self-appearance; is synthesized, stagy; simulates desirable/dramatic poses.
Infantile histrionic Including borderline features Labile, high-strung, volatile emotions; childlike hysteria and nascent pouting; demanding, overwrought; fastens and clutches to another; is excessively attached, hangs on, stays fused to and clinging.

Treatment is often prompted by depression associated with dissolved romantic relationships. Medication does little to affect the personality disorder, but may be helpful with symptoms such as depression Treatment for HPD itself involves psychotherapy, including cognitive therapy. Another way to treat histrionic personality disorder after identification is through functional analytic psychotherapy. The job of a Functional Analytic Psychotherapist is to identify the interpersonal problems with the patient as they happen in session or out of session. Initial goals of functional analytic psychotherapy are set by the therapist and include behaviors that fit the client's needs for improvement.

This personality is seen more often in women than in men. Approximately 65% of HPD diagnoses are women while 35% are men. Many symptoms representing HPD in the DSM are exaggerations of traditional feminine behaviors. In a peer and self-review study, it showed that femininity was correlated with histrionic, dependent and narcissistic personality disorders. Although two thirds of HPD diagnoses are female, there have been a few exceptions. Those with HPD are more likely to look for multiple people for attention, which leads to marital problems due to jealousy and lack of trust from the other party. This makes them more likely to become divorced or separated once married.

The prevalence of histrionic personality disorder in women is apparent and urges a re-evaluation of cultural notions of normal emotional behaviour. The diagnostic approach classifies histrionic personality disorder behaviour as “excessive”, considering it in reference to a social understanding of normal emotionality.

Narcissistic personality disorder

Narcissistic personality disorder is a mental disorder characterized by a life-long pattern of exaggerated feelings of self-importance, an excessive craving for admiration, and a diminished ability to empathize with other's feelings. These personality traits are often overcompensation for a fragile ego, an intolerance of criticism, and a weak sense of self. Narcissistic personality disorder differs from self-confidence which is associated with a strong sense of self.

People with NPD exaggerate their skills, accomplishments, and their degree of intimacy with people they consider high-status. Such a sense of personal superiority may cause them to monopolize conversations, or to become impatient and disdainful when other persons talk about themselves. This attitude connects to an overall worse functioning in areas of life like work and intimate romantic relationships.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition(DSM-5, 2013) describes NPD as possessing at least five of the following nine criteria.

  1. A grandiose sense of self-importance
  2. Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love
  3. Believing that they are "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
  4. Requiring excessive admiration
  5. A sense of entitlement (unreasonable expectations of especially favorable treatment or automatic compliance with their expectations)
  6. Being interpersonally exploitative (taking advantage of others to achieve their own ends)
  7. Lacking empathy (unwilling to recognize or identify with the feelings and needs of others)
  8. Often being envious of others or believing that others are envious of them
  9. Showing arrogant, haughty behaviors or attitudes

To the extent that people are pathologically narcissistic, the person with NPD can be a self-absorbed control freak who passes blame by psychological projection and is intolerant of contradictory views and opinions; is apathetic towards the emotional, mental, and psychological needs of other people; and is indifferent to the negative effects of their behaviors, whilst insisting that people should see them as an ideal person. To protect their fragile self-concept, narcissists use psychosocial strategies, such as the tendency to devalue and derogate and to insult and blame other people, usually with anger and hostility towards people's responses to the narcissist's anti-social conduct.

This is an actor portrayal of a patient with narcissistic personality disorder.

Narcissistic personalities are more likely to respond with anger or aggressiveness when presented with rejection. Because they are sensitive to perceived criticism or defeat, people with NPD are prone to feelings of shame, humiliation, and worthlessness over minor incidents of daily life and imagined, personal slights, and usually mask such feelings from people, either by way of feigned humility, or by responding with outbursts of rage and defiance, or by seeking revenge. The merging of the inflated self-concept and the actual self is evident in the grandiosity component of narcissistic personality disorder; also inherent to that psychological process are the defence mechanisms of idealization and devaluation and of denial.

Theodore Millon suggested five subtypes of narcissist; however, there are few, pure subtypes of narcissist.

Environmental and social factors also exert significant influence upon the onset of NPD in a person. In some people, pathological narcissism may develop from an impaired emotional attachment to the primary caregivers, usually the parents. That lack of psychological and emotional attachment to a parental figure can result in the child's perception of themselves as unimportant and unconnected to other people, usually, family, community and society. Typically, the child comes to believe that they have a personality defect that makes them an unvalued and unwanted person; in that vein, either overindulgent and permissive parenting or insensitive and over-controlling parenting are contributing factors towards the development of NPD in a child.

In Gabbard's Treatments of Psychiatric Disorders (2014), the following factors are identified as promoting the development of narcissistic personality disorder:

Moreover, the research reported in "Modernity and Narcissistic Personality Disorders" (2014) indicates that cultural elements also influence the prevalence of NPD, because narcissistic personality traits more commonly occur in modern societies than in traditionalist conservative societies. The lifetime rates of narcissistic personality disorder are estimated at 1% in the general population; and between 2% and 16% in the clinical population. A 2010 metareview of 7 studies found that the mean prevalence of NPD was 1.06 in community samples, and that the yearly number of new cases of NPD in men is slightly greater than in women.

Avoidant personality disorder

Those affected display a pattern of severe social anxiety, social inhibition, feelings of inadequacy and inferiority, extreme sensitivity to negative evaluation and rejection, and avoidance of social interaction despite a strong desire for intimacy. People with AvPD often consider themselves to be socially inept or personally unappealing and avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked. They often avoid becoming involved with others unless they are certain they will be liked.

Childhood emotional neglect (in particular, the rejection of a child by one or both parents) and peer group rejection are associated with an increased risk for its development; however, it is possible for AvPD to occur without any notable history of abuse or neglect. Some with this disorder fantasize about idealized, accepting and affectionate relationships because of their desire to belong. They often feel themselves unworthy of the relationships they desire, and shame themselves from ever attempting to begin them.

If they do manage to form relationships, it is also common for them to preemptively abandon them out of fear of the relationship failing. Individuals with the disorder tend to describe themselves as uneasy, anxious, lonely, unwanted and isolated from others. They often choose jobs of isolation in which they do not have to interact with others regularly. Avoidant individuals also avoid performing activities in public spaces for fear of embarrassing themselves in front of others.

Symptoms include:

Causes of AvPD are not clearly defined, but appear to be influenced by a combination of social, genetic and psychological factors. The disorder may be related to temperamental factors that are inherited. Specifically, various anxiety disorders in childhood and adolescence have been associated with a temperament characterized by behavioral inhibition, including features of being shy, fearful and withdrawn in new situations.

These inherited characteristics may give an individual a genetic predisposition towards AvPD. Childhood emotional neglect and peer group rejection are both associated with an increased risk for the development of AvPD. Some researchers believe a combination of high-sensory-processing sensitivity coupled with adverse childhood experiences may heighten the risk of an individual developing AvPD.

Theodore Millon identified four adult subtypes of avoidant personality disorder.

Subtype and description Personality traits
Phobic avoidant (including dependent features) General apprehensiveness displaced with avoidable tangible precipitant; qualms and disquietude symbolized by a repugnant and specific dreadful object or circumstances.
Conflicted avoidant (including negativistic features) Internal discord and dissension; fears dependence; unsettled; unreconciled within self; hesitating, confused, tormented, paroxysmic, embittered; unresolvable angst.
Hypersensitive avoidant (including paranoid features) Intensely wary and suspicious; alternately panicky, terrified, edgy, and timorous, then thin-skinned, high-strung, petulant, and prickly.
Self-deserting avoidant (including depressive features) Blocks or fragments self-awareness; discards painful images and memories; casts away untenable thoughts and impulses; possibly jettisons self (suicidal).

In 1993, Lynn E. Alden and Martha J. Capreol proposed two other subtypes of avoidant personality disorder:

Subtype Features
Cold-avoidant Characterised by an inability to experience and express positive emotion towards others.
Exploitable-avoidant Characterised by an inability to express anger towards others or to resist coercion from others. May be at risk for abuse by others.

Treatment of avoidant personality disorder can employ various techniques, such as social skills training, psychotherapy, cognitive therapy, and exposure treatment to gradually increase social contacts, group therapy for practicing social skills, and sometimes drug therapy. A key issue in treatment is gaining and keeping the patient's trust since people with an avoidant personality disorder will often start to avoid treatment sessions if they distrust the therapist or fear rejection.

The primary purpose of both individual therapy and social skills group training is for individuals with an avoidant personality disorder to begin challenging their exaggerated negative beliefs about themselves. Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort. Data from the 2001–02 National Epidemiologic Survey on Alcohol and Related Conditions indicates a prevalence of 2.36% in the American general population. It appears to occur with equal frequency in males and females. In one study, it was seen in 14.7% of psychiatric outpatients.

Dependent personality disorder

Dependent personality disorder (DPD) is characterized by a pervasive psychological dependence on other people. This personality disorder is a long-term condition in which people depend on others to meet their emotional and physical needs, with only a minority achieving normal levels of independence. Dependent personality disorder is a cluster C personality disorder, which is characterized by excessive fear and anxiety. It begins by early adulthood, and it is present in a variety of contexts and is associated with inadequate functioning. Symptoms can include anything from extreme passivity, devastation or helplessness when relationships end, avoidance of responsibilities and severe submission.

People who have dependent personality disorder are overdependent on other people when it comes to making decisions. They cannot make a decision on their own as they need constant approval from other people. Consequently, individuals diagnosed with DPD tend to place needs and opinions of others above their own as they do not have the confidence to trust their decisions. This kind of behaviour can explain why people with DPD tend to show passive and clingy behaviour. These individuals display a fear of separation and cannot stand being alone. When alone, they experience feelings of isolation and loneliness due to their overwhelming dependence on other people. Generally people with DPD are also pessimistic: they expect the worst out of situations or believe that the worst will happen.

People with a history of neglect and an abusive upbringing are more susceptible to develop DPD, specifically those involved in long-term abusive relationships. Those with overprotective or authoritarian parents are also more at risk to develop DPD. Having a family history of anxiety disorder can play a role in the development of DPD as a 2004 twin study found a 0.81 heritability for personality disorders collectively. The exact cause of dependent personality disorder is unknown. A study in 2012 estimated that between 55% and 72% of the risk of the condition is inherited from one's parents. The difference between a "dependent personality" and a "dependent personality disorder" is somewhat subjective, which makes diagnosis sensitive to cultural influences such as gender role expectations.

Clinicians and clinical researchers conceptualize dependent personality disorder in terms of four related components:

There are similarities between individuals with dependent personality disorder and individuals with borderline personality disorder, in that they both have a fear of abandonment. Those with dependent personality disorder do not exhibit impulsive behaviour, unstable affect, and poor self-image experienced by those with borderline personality disorder, differentiating the two disorders. People who have DPD are generally treated with psychotherapy. The main goal of this therapy is to make the individual more independent and help them form healthy relationships with the people around them. This is done by improving their self-esteem and confidence.

Theodore Millon identified five adult subtypes of dependent personality disorder. Any individual dependent may exhibit none or one of the following:

Subtype Description Personality Traits
Disquieted dependent Including avoidant features Restlessly perturbed; disconcerted and fretful; feels dread and foreboding; apprehensively vulnerable to abandonment; lonely unless near supportive figures.
Selfless dependent Including masochistic features Merges with and immersed into another; is engulfed, enshrouded, absorbed, incorporated, willingly giving up own identity; becomes one with or an extension of another.
Immature dependent Variant of "pure" pattern Unsophisticated, half-grown, unversed, childlike; undeveloped, inexperienced, gullible, and unformed; incapable of assuming adult responsibilities.
Accommodating dependent Including histrionic features Gracious, neighborly, eager, benevolent, compliant, obliging, agreeable; denies disturbing feelings; adopts submissive and inferior role well.
Ineffectual dependent Including schizoid features Unproductive, gainless, incompetent, meritless; seeks untroubled life; refuses to deal with difficulties; untroubled by shortcomings.

Sadistic personality disorder

Sadism involves deriving pleasure through others undergoing discomfort or pain. The opponent-process theory is one way to help explain how an individual may come to not only display, but also enjoy committing sadistic acts. Individuals possessing sadistic personalities tend to display recurrent aggression and cruel behavior. Sadism can also include the use of emotional cruelty, purposefully manipulating others through the use of fear, and a preoccupation with violence.

Theodore Millon claimed there were four subtypes of sadism, which he termed enforcing sadism, explosive sadism, spineless sadism, and tyrannical sadism.

Subtype Description Personality traits
Spineless sadism Including avoidant features Insecure, bogus, and cowardly; venomous dominance and cruelty is counterphobic; weakness counteracted by group support; public swaggering; selects powerless scapegoats.
Tyrannical sadism Including negativistic features Relishes menacing and brutalizing others, forcing them to cower and submit; verbally cutting and scathing, accusatory and destructive; intentionally surly, abusive, inhumane, unmerciful.
Enforcing sadism Including compulsive features Hostility sublimated in the "public interest," cops, "bossy" supervisors, deans, judges; possesses the "right" to be pitiless, merciless, coarse, and barbarous; task is to control and punish, to search out rule breakers.
Explosive sadism Including borderline features Unpredictably precipitous outbursts and fury; uncontrollable rage and fearsome attacks; feelings of humiliation are pent-up and discharged; subsequently contrite.

Sadistic personality disorder has been found to occur frequently in unison with other personality disorders. Studies have also found that sadistic personality disorder is the personality disorder with the highest level of comorbidity to other types of psychopathological disorders. One personality disorder that is often found to occur alongside sadistic personality disorder is conduct disorder, not an adult disorder but one of childhood and adolescence.

Numerous theorists and clinicians introduced sadistic personality disorder to the DSM in 1987 and it was placed in the DSM-III-R as a way to facilitate further systematic clinical study and research. It was proposed to be included because of adults who possessed sadistic personality traits but were not being labeled, even though their victims were being labeled with a self-defeating personality disorder. Theorists like Theodore Millon wanted to generate further study on SPD, and so proposed it to the DSM-IV Personality Disorder Work Group, who rejected it. Millon writes that "Physically abusive, sadistic personalities are most often male, and it was felt that any such diagnosis might have the paradoxical effect of legally excusing cruel behavior."

There is renewed interest in studying sadism as a personality trait. Sadism joins with subclinical psychopathy, narcissism, and Machiavellianism to form the so-called "dark tetrad" of personality.

Obsessive–compulsive personality disorder

Obsessive–compulsive personality disorder (OCPD) is a cluster C personality disorder marked by an excessive need for orderliness, neatness, and perfectionism. Symptoms are usually present by the time a person reaches adulthood, and are visible in a variety of situations. The cause of OCPD is thought to involve a combination of genetic and environmental factors, namely problems with attachment.

Obsessive–compulsive personality disorder (OCPD) is marked by an excessive obsession with rules, lists, schedules, and order; a need for perfectionism that interferes with efficiency and the ability to complete tasks; a devotion to productivity that hinders interpersonal relationships and leisure time; rigidity and zealousness on matters of morality and ethics; an inability to delegate responsibilities or work to others; restricted functioning in interpersonal relationships; restricted expression of emotion and affect; and a need for control over one's environment and self.

Some of OCPD's symptoms are persistent and stable, whilst others are unstable. The obsession with perfectionism, reluctance to delegate tasks to others, and rigidity and stubbornness are stable symptoms. On the other hand, the symptoms that were most likely to change over time were the miserly spending style and the excessive devotion to productivity. This discrepancy in the stability of symptoms may lead to mixed results in terms of the course of the disorder, with some studies showing a remission rate of 58% after a 12 month period, whilst others suggesting that the symptoms are stable and may worsen with age.

This preoccupation with details and rules makes the person unable to delegate tasks and responsibilities to other people unless they submit to their exact way of completing a task because they believe that there is only one correct way of doing something. They stubbornly insist that a task or job must be completed their way, and only their way, and may micromanage people when they are assigned a group task. They are frustrated when other people suggest alternative methods. A person with this disorder may reject help even when they desperately need it as they believe that only they can do something correctly.

People with OCPD are obsessed with maintaining perfection. The perfectionism and the extremely high standards that they establish are to their detriment and may cause delays and failures to complete objectives and tasks. Every mistake is thought of as a major catastrophe that will soil their reputation for life. For example, a person may write an essay for a college, and then believe that it fell short of "perfection", so they continue rewriting it until they miss the deadline. They may never complete the essay due to the self-imposed high standards. They are unaware that other people may become frustrated and annoyed by the repeated delays and hassles that this behavior causes.

Individuals with OCPD devote themselves to work and productivity at the expense of interpersonal relationships and recreation. Economic necessity, such as poverty, cannot account for this behavior. They may believe that they do not have sufficient time to relax because they have to prioritize their work above all. They may refuse to spend time with friends and family because of that. They may find it difficult to go on a vacation, and even if they book a vacation, they may keep postponing it until it never happens. They may feel uncomfortable when they do go on a vacation and will take something along with them so they can work.

Individuals with OCPD are overconscientious, scrupulous and rigid, and inflexible on matters of morality, ethics and other areas of life. They may force themselves and others to follow rigid moral principles and strict standards of performance. They are self-critical and harsh about their mistakes. These symptoms should not be accounted for or caused by a person's culture or religion. Their view of the world is polarised and dichotomous; there is no grey area between what is right and what is wrong. Whenever this dichotomous view of the world cannot be applied to a situation, this causes internal conflict as the person's perfectionist tendencies are challenged.

Individuals with this disorder may display little affection and warmth; their relationships and speech tend to have a formal and professional approach, and not much affection is expressed even to loved ones, such as greeting or hugging a significant other at an airport or train station. They are extremely careful in their interpersonal interactions. They have little spontaneity when interacting with others, and ensure that their speech follows rigid and austere standards by excessively scrutinising it.

They filter their speech for embarrassing or imperfect articulation, and they have a low bar for what they consider to be such. They lower their bar even further when they are communicating with their superiors or with a person of high status. Communication becomes a time-consuming and exhausting effort, and they start avoiding it altogether. Others regard them as cold and detached as a result

Theodore Millon described 5 types of obsessive–compulsive personality disorder, which he shortened to compulsive personality disorder:

Subtype Description
The Conscientious Compulsive Millon described those with conscientious compulsive traits as displaying a dependent form of compulsive personality disorder. Those with conscientious compulsivity view themselves as helpful, co-operative, and compromising. They downplay their achievements and abilities and base their confidence on the opinions and expectations of others; this compensates for their feelings of insecurity and instability. They assume that devotion to work and striving for perfection will lead to them receiving love and reassurance. They believe that making a mistake or not achieving perfection will lead to abandonment and criticism. This mindset causes perpetual feelings of anxiety and an inability to appreciate their work.
The Puritanical Compulsive The puritanical compulsive is a blend of paranoid and compulsive features. They have strong internal impulses that are countered vociferously through the use of religion. They are constantly battling their impulses and sexual drives, which they view as irrational. They attempt to purify and pacify the urges by adopting a cold and detached lifestyle. They create an enemy which they use to vent their hostility, such as "non-believers", or "lazy people". They are patronizing, bigoted, and zealous in their attitude toward others. Their beliefs are polarized into "good" and "evil".
The Bureaucratic Compulsive The bureaucratic compulsive displays signs of narcissistic traits alongside the compulsivity. They are champions of tradition, values, and bureaucracy. They cherish organizations that follow hierarchies and feel comforted by definitive roles between subordinates and superiors, and the known expectations and responsibilities. They derive their identity from work and project an image of diligence, reliability, and commitment to their institution. They view work and productivity in a polarized manner; either done or not. They may use their power and status to inflict fear and obedience in their subordinates if they do not strictly follow their rules and procedures, and derive pleasure from the sense of control and power that they acquire by doing so.
The Parsimonious Compulsive The parsimonious compulsive is hoarding and possessive in nature; they behave in a manner congruent with schizoid traits. They are selfish, miserly, and are suspicious of others' intentions, believing that others may take away their possessions. This attitude may be caused by parents who deprived their child of wants or wishes but provided necessities, causing the child to develop an extreme protective approach to their belongings, often being self-sufficient and distant from others. They use this shielding behavior to prevent having their urges, desires, and imperfections discovered.
The Bedevilled Compulsive This form of compulsive personality is a mixture of negativistic and compulsive behavior. When faced with dilemmas, they procrastinate and attempt to stall the decision through any means. They are in a constant battle between their desires and will, and may engage in self-defeating behavior and self-torture in order to resolve the internal conflict. Their identity is unstable, and they are indecisive.

The cause of OCPD is thought to involve a combination of genetic and environmental factors. There is clear evidence to support the theory that OCPD is genetically inherited, however, the relevance and impact of genetic factors vary with studies placing it somewhere between 27% and 78%. Other studies have found links between attachment theory and the development of OCPD. According to this hypothesis, those with OCPD have never developed a secure attachment style, had overbearing parents, were shown little care, and were unable to develop empathetically and emotionally.

Paranoid personality disorder

Paranoid personality disorder (PPD) is a mental illness characterized by paranoid delusions, and a pervasive, long-standing suspiciousness and generalized mistrust of others. People with this personality disorder may be hypersensitive, easily insulted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions that may validate their fears or biases. They are eager observers. They think they are in danger and look for signs and threats of that danger, potentially not appreciating other interpretations or evidence.

They tend to be guarded and suspicious and have quite constricted emotional lives. Their reduced capacity for meaningful emotional involvement and the general pattern of isolated withdrawal often lend a quality of schizoid isolation to their life experience. People with PPD may have a tendency to bear grudges, suspiciousness, tendency to interpret others' actions as hostile, persistent tendency to self-reference, or a tenacious sense of personal right.

A genetic contribution to paranoid traits and a possible genetic link between this personality disorder and schizophrenia exist. A large long-term Norwegian twin study found paranoid personality disorder to be modestly heritable and to share a portion of its genetic and environmental risk factors with the other cluster A personality disorders, schizoid and schizotypal. Psychosocial theories implicate projection of negative internal feelings and parental modeling. Cognitive theorists believe the disorder to be a result of an underlying belief that other people are unfriendly in combination with a lack of self-awareness.

PPD is characterized by at least three of the following symptoms:

Includes: expansive paranoid, fanatic, querulant and sensitive paranoid personality disorder. Theodore Millon has proposed five subtypes of paranoid personality:

Subtype Features
Obdurate paranoid (including compulsive features) Self-assertive, unyielding, stubborn, steely, implacable, unrelenting, dyspeptic, peevish, and cranky stance; legalistic and self-righteous; discharges previously restrained hostility; renounces self-other conflict.
Fanatic paranoid (including narcissistic features) Grandiose delusions are irrational and flimsy; pretentious, expensive supercilious contempt and arrogance toward others; lost pride reestablished with extravagant claims and fantasies.
Querulous paranoid (including negativistic features) Contentious, caviling, fractious, argumentative, faultfinding, unaccommodating, resentful, choleric, jealous, peevish, sullen, endless wrangles, whiny, waspish, snappish.
Insular paranoid (including avoidant features) Reclusive, self-sequestered, hermitical; self-protectively secluded from omnipresent threats and destructive forces; hypervigilant and defensive against imagined dangers.
Malignant paranoid (including sadistic features) Belligerent, cantankerous, intimidating, vengeful, callous, and tyrannical; hostility vented primarily in fantasy; projects own venomous outlook onto others; persecutory delusions.

Paranoid personality disorder can involve, in response to stress, very brief psychotic episodes (lasting minutes to hours). The paranoid may also be at greater than average risk of experiencing major depressive disorder, agoraphobia, social anxiety disorder, obsessive-compulsive disorder and substance-related disorders. Criteria for other personality disorder diagnoses are commonly also met, such as: schizoid, schizotypal, narcissistic, avoidant, borderline and negativistic personality disorder.

Because of reduced levels of trust, there can be challenges in treating PPD. However, psychotherapy, antidepressants, antipsychotics and anti-anxiety medications can play a role when a person is receptive to intervention. PPD occurs in about 0.5–2.5% of the general population. It is seen in 2–10% of psychiatric outpatients. It is more common in males.

Schizoid personality disorder

Schizoid personality disorder is a personality disorder characterized by a lack of interest in social relationships, a tendency toward a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment and apathy. Affected individuals may be unable to form intimate attachments to others and simultaneously possess a rich and elaborate but exclusively internal fantasy world.

Other associated features include stilted speech, a lack of deriving enjoyment from most activities, feeling as though one is an "observer" rather than a participant in life, an inability to tolerate emotional expectations of others, apparent indifference when praised or criticized, a degree of asexuality, and idiosyncratic moral or political beliefs. Symptoms typically start in late childhood or adolescence.

People with SPD are often aloof, cold and indifferent, which causes interpersonal difficulty. Most individuals diagnosed with SPD have trouble establishing personal relationships or expressing their feelings meaningfully. They may remain passive in the face of unfavorable situations. Their communication with other people may be indifferent and terse at times.

Schizoid personality types often lack the ability to assess the impact of their own actions in social situations. A person with SPD may feel suffocated when their personal space is violated and take actions to avoid this feeling. People who have SPD tend to be happiest when in relationships in which their partner places few emotional or intimate demands on them and does not expect phatic or social niceties. It is not necessarily people they want to avoid, but negative or positive emotional expectations, emotional intimacy and self-disclosure.

The related schizotypal personality disorder and schizophrenia are reported to have ties to creative thinking, and it is speculated that the internal fantasy aspect of schizoid personality disorder may also be reflective of this thinking. Alternatively, there has been an especially large contribution of people with schizoid symptoms to science and theoretical areas of knowledge, including maths, physics, economics, etc. At the same time, people with SPD are helpless at many practical activities due to their symptoms.

Many schizoid individuals display an engaging, interactive personality, contradicting the observable characteristic emphasized by the DSM-5 and ICD-10 definitions of the schizoid personality. Guntrip (using ideas of Klein, Fairbairn and Winnicott) classifies these individuals as "secret schizoids", who behave with socially available, interested, engaged and involved interaction yet remain emotionally withdrawn and sequestered within the safety of the internal world.

Klein distinguishes between a "classic" SPD and a "secret" SPD, which occur "just as often" as each other. Klein cautions one should not misidentify the schizoid person as a result of the patient's defensive, compensatory interaction with the external world. He suggests one ask the person what their subjective experience is, to detect the presence of the schizoid refusal of emotional intimacy and preference for objective fact.

A pathological reliance on fantasizing and preoccupation with inner experience is often part of the schizoid withdrawal from the world. Fantasy thus becomes a core component of the self in exile, though fantasizing in schizoid individuals is far more complicated than a means of facilitating withdrawal. Fantasy is also a relationship with the world and with others by proxy.

It is a substitute relationship, but a relationship nonetheless, characterized by idealized, defensive and compensatory mechanisms. This is self-contained and free from the dangers and anxieties associated with emotional connection to real persons and situations. Klein explains it as "an expression of the self struggling to connect to objects, albeit internal objects. Fantasy permits schizoid patients to feel connected, and yet still free from the imprisonment in relationships. In short, in fantasy one can be attached (to internal objects) and still be free."

Theodore Millon restricted the term "schizoid" to those personalities who lack the capacity to form social relationships. He characterizes their way of thinking as being vague and void of thoughts and as sometimes having a "defective perceptual scanning". Because they often do not perceive cues that trigger affective responses, they experience fewer emotional reactions.

For Millon, SPD is distinguished from other personality disorders in that it is "the personality disorder that lacks a personality." He criticizes that this may be due to the current diagnostic criteria: They describe SPD only by an absence of certain traits, which results in a "deficit syndrome" or "vacuum". Instead of delineating the presence of something, they mention solely what is lacking. Therefore, it is hard to describe and research such a concept.

Millon identified four subtypes of SPD. Any individual schizoid may exhibit none or one of the following:

Subtype Features
Languid schizoid (including dependent and depressive features) Marked inertia; deficient activation level; intrinsically phlegmatic, lethargic, weary, leaden, lackadaisical, exhausted, enfeebled. Unable to act with spontaneity or seeks simplest pleasures, may experience profound angst, yet lack the vitality to express it strongly.
Remote schizoid (including avoidant features) Distant and removed; inaccessible, solitary, isolated, homeless, disconnected, secluded, aimlessly drifting; peripherally occupied. Seen among people who would have been otherwise capable of developing normal emotional life but having been subjected to intense hostility lost their innate capability to form bonds. Some residual anxiety is present. Often seen among the homeless; many are dependent on public support.
Depersonalized schizoid (including schizotypal features) Disengaged from others and self; self is disembodied or distant object; body and mind sundered, cleaved, dissociated, disjoined, eliminated. Often seen as simply staring into the empty space or being occupied with something substantial while actually being occupied with nothing at all.
Affectless schizoid (including compulsive features) Passionless, unresponsive, unaffectionate, chilly, uncaring, unstirred, spiritless, lackluster, unexcitable, unperturbed, cold; all emotions diminished. Combines the preference for rigid schedule (obsessive-compulsive feature) with the coldness of the schizoid.

Suicide may be a running theme for schizoid individuals, in part due to the knowledge of the large-scale ostracism that would result if their idiosyncratic views were revealed and their experience that most, if not all people, are unrelatable or have polar opposite reactions to them on societally sensitive issues, though they are not likely to actually attempt it. They might be down and depressed when all possible connections have been cut off, but as long as there is some relationship or even hope for one the risk will be low.

The idea of suicide is a driving force against the person's schizoid defenses. As Klein says: "For some schizoid patients, its presence is like a faint, barely discernible background noise, and rarely reaches a level that breaks into consciousness. For others, it is an ominous presence, an emotional sword of Damocles. In any case, it is an underlying dread that they all experience." Often among people with SPD, there is a rationally grounded and reasoned position on why they want to die, and this "suicidal construct" takes a stable position in the mind.

A study which looked at the body mass index (BMI) of a sample of both male adolescents diagnosed with SPD and those diagnosed with Asperger syndrome found that the BMI of all patients was significantly below normal. Clinical records indicated abnormal eating behaviour by some patients. Some patients would only eat when alone and refused to eat out. Restrictive diets and fears of disease were also found. It was suggested that the anhedonia of SPD may also cover eating, leading schizoid individuals to not enjoy it. Alternatively, it was suggested that schizoid individuals may not feel hunger as strongly as others or not respond to it, a certain withdrawal "from themselves".

SPD is uncommon in clinical settings (about 2.2%) and occurs more commonly in males. It is rare compared with other personality disorders, with a prevalence estimated at less than 1% of the general population. A 2008 study assessing personality and mood disorder prevalence among homeless people at New York City drop-in centres reported an SPD rate of 65% among this sample.

The study did not assess homeless people who did not show up at drop-in centres, and the rates of most other personality and mood disorders within the drop-in centres was lower than that of SPD. The authors noted the limitations of the study, including the higher male-to-female ratio in the sample and the absence of subjects outside the support system or receiving other support (e.g., shelters) as well as the absence of subjects in geographical settings outside New York City, a large city often considered a magnet for disenfranchised people.

[I believe many people suffering from SPD are victims of society / social ostracism, been surpressed without creative function, people who have been terrorised beside themselves, obfuscated from their own sense of projection.]

Self-defeating personality disorder

Self-defeating personality disorder (also known as masochistic personality disorder) was a proposed personality disorder. It was discussed in an appendix of the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) in 1987, but was never formally admitted into the manual.

Self-defeating personality disorder is:

A) A pervasive pattern of self-defeating behavior, beginning by early adulthood and present in a variety of contexts. The person may often avoid or undermine pleasurable experiences, be drawn to situations or relationships in which they will suffer, and prevent others from helping them, as indicated by at least five of the following:

  1. chooses people and situations that lead to disappointment, failure, or mistreatment even when better options are clearly available
  2. rejects or makes ineffective the attempts of others to help them
  3. following positive personal events (e.g., new achievement), responds with depression, guilt, or a behavior that produces pain (e.g., an accident)
  4. incites angry or rejecting responses from others and then feels hurt, defeated, or humiliated (e.g., makes fun of spouse in public, provoking an angry retort, then feels devastated)
  5. rejects opportunities for pleasure, or is reluctant to acknowledge enjoying themselves (despite having adequate social skills and the capacity for pleasure)
  6. fails to accomplish tasks crucial to their personal objectives despite having demonstrated ability to do so (e.g., helps fellow students write papers, but is unable to write their own)
  7. is uninterested in or rejects people who consistently treat them well
  8. engages in excessive self-sacrifice that is unsolicited by the intended recipients of the sacrifice
  9. The person may often avoid or undermine pleasurable experiences

[and] rejects opportunities for pleasure, or is reluctant to acknowledge enjoying themself

B) The behaviors in A do not occur exclusively in response to, or in anticipation of, being physically, sexually, or psychologically abused.

C) The behaviors in A do not occur only when the person is depressed.

Historically, masochism has been associated with feminine submissiveness. This disorder became politically controversial when associated with domestic violence which was considered to be mostly caused by males. However a number of studies suggest that the disorder is common. In spite of its exclusion from DSM-IV in 1994, it continues to enjoy widespread currency amongst clinicians as a construct that explains a great many facets of human behaviour.

Theodore Millon has proposed four subtypes of masochist. Any individual masochist may fit into none, one or more of the following subtypes:

Subtype Description Personality traits
Virtuous masochist Including histrionic features Proudly unselfish, self-denying, and self-sacrificial; self-ascetic; weighty burdens are judged noble, righteous, and saintly; others must recognize loyalty and faithfulness; gratitude and appreciation expected for altruism and forbearance.
Possessive masochist Including negativistic features Bewitches and ensnares by becoming jealous, overprotective, and indispensable; entraps, takes control, conquers, enslaves, and dominates others by being sacrificial to a fault; control by obligatory dependence.
Self-undoing masochist Including avoidant features Is "wrecked by success"; experiences "victory through defeat"; gratified by personal misfortunes, failures, humiliations, and ordeals; eschews best interests; chooses to be victimized, ruined, disgraced.
Oppressed masochist Including depressive features Experiences genuine misery, despair, hardship, anguish, torment, illness; grievances used to create guilt in others; resentments vented by exempting from responsibilities and burdening "oppressors".

Conclusion

When viewing personality disorders doctors have focused on the compartmentalized patient expressing fixations, etc, yet every doctor has been unable to observe their history, their environment that has pushed their personality types to extremities where they are become disorderly, often not to themselves, but to the functioning of society in general and a generalized contempt, a cultivated and collectivized ego that pushes character into far reaches of absurdity through obscurity.

Telescope psychologists such as Million, self defined by a subjective logic emersed in a secretive world of hidden purpose working with undefinable logic. I have talked to over hundred of these pen pushers, none of them helped to endure or heal the wounds from what damage the cults had done, beyond their piecing stare of stigmatisim, waiting for me to run drama all over their expressionless faces, sterilizing themselves from interpersonalisation as if a cold stone wall was an all revealer.

Perhaps the answer to the question is, and has always been, obscured from with the psychologist. The camera operator is rarely seen in the picture, and often aloof, shy away from spotlight attention. Perhaps in their own dark reassesses there is the answer they have been looking for beyond their perspective, a hall of mirrors, where consequences are unparalleled to coincidences. To obsessed with extremities to withdraw and take a step away from their normal lives, synchronised into their normal worlds.

“Personality disorders are cultivated, as unholy ghosts.”.

I asked the reader, reading this page in self diagnosis, to ask themselves, which box are they typecasting you into by the extremities that belligerent society has overborne upon you. There are no answers to be found with this branch of psychology, as these disorders are merely climaxes of personality traits narrowed into corners. The work of the everyday psychologist is to merely to put the cork on the bottle, and teach you to be still, in the face of a freezing wind, that numbs you void, frozen from the inherent worth of your life.

Mental Health, the last stigmatisim, are you sure?