Chapter 12: Personality Issues

Raskin explores personality and personality disorders, providing a deep dive into how personality traits, diagnostic models, historical ideas, biological mechanisms, psychological approaches, and sociocultural factors shape our understanding of enduring interpersonal patterns. Personality is defined as stable traits and temperaments that influence thought, feeling, and behavior, with the Five-Factor Model (FFM)—extraversion, agreeableness, conscientiousness, neuroticism, and openness—serving as the dominant framework. DSM-5-TR continues to classify ten categorical personality disorders in Clusters A (paranoid, schizoid, schizotypal), B (antisocial, borderline, histrionic, narcissistic), and C (avoidant, dependent, obsessive-compulsive), but it also proposes the Alternative Model of Personality Disorders (AMPD), which integrates dimensional assessment through trait domains such as negative affectivity, detachment, antagonism, disinhibition, and psychoticism. ICD-11 goes further, eliminating categories altogether and adopting a fully dimensional model that diagnoses “personality disorder” by severity and traits, with a borderline pattern specifier included to bridge transitions. Alternative frameworks such as HiTOP, PDM-2, and the Power Threat Meaning Framework (PTMF) challenge DSM/ICD assumptions, emphasizing personality as dimensional, psychodynamic, or socially constructed. Historical perspectives trace personality concepts from Hippocrates’ humors and Theophrastus’ character sketches, through Pinel’s “mania without delusion,” Prichard’s “moral insanity,” and Kraepelin’s “psychopathic personalities,” to Schneider’s influential ten personality types. Biological research investigates neurotransmitters (serotonin in ASPD and BPD, dopamine in STPD), polypharmacy, brain structure differences (amygdala and hippocampal reductions in BPD and ASPD, frontal anomalies in STPD), heritability estimates (40–70%), candidate genes (DRD2, DRD3, MAOA, 5-HTTLPR), evolutionary hypotheses like frequency-dependent selection of psychopathy and the obsessive trait complex hypothesis for OCPD, and links between immune inflammation, trauma, and aggression. Psychological perspectives highlight psychodynamic theories of narcissism as a defense against shame, borderline splitting of ego states, and obsessive-compulsive rigidity, while structured therapies such as transference-focused psychotherapy, mentalization-based treatment (MBT), and intensive short-term dynamic psychotherapy (ISTDP) show promise. Cognitive-behavioral perspectives emphasize maladaptive beliefs and learning, with schema therapy targeting early maladaptive schemas and modes, and dialectical behavior therapy (DBT) integrating mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Humanistic therapists reframe “personality disorders” as fragile processes emerging from failures of empathy and unconditional regard, focusing on growth through person-centered therapy. Sociocultural perspectives examine cross-cultural differences in personality constructs, gender bias in diagnoses (histrionic and borderline in women, antisocial in men), trauma and socioeconomic disadvantage as root causes, and racial disparities in diagnosis. Service user narratives highlight the stigma of PD labels, self-stigmatization, and the survivor movement’s rejection of pathologizing approaches. Systems perspectives trace family dynamics, identifying borderline families as chaotic, rejecting, or idealizing/denying, and adapting DBT for families and couples to improve communication and reduce destructive patterns. Closing reflections question whether personality disorders are legitimate entities, moral judgments, or cultural constructions, while acknowledging that recurrent relational patterns cause genuine distress.