Personality Disorders
Introduction 
     The purpose of this paper is to conduct a literature search on a major clinical syndrome and write a scholarly research paper by synthesizing relevant information from the current research obtained from academic peer reviewed journals. In addition to this, I will also identify symptoms of personality disorders as well as discuss the differential diagnoses associated with these types of disorders. I will continue with a discussion in regards to the biological, psychological and social theories in explaining the etiology of personality disorders as well as provide insight into these disorders from a human development perspective. Finally, my paper will conclude with a discussion of the various therapeutic approaches in treating these types of disorders.

				      Personality Disorders 
     Personality disorders are a chronic disturbance in one’s relationships with self, others and their environment that results in distress or failure to fulfill social roles and obligations. According to the DSM-IV-TR, these disorders are categorized into three different groups which include the dramatic, odd and anxious type of personality disorders.   
     The group of dramatic personality orders includes the antisocial, borderline, histrionic and narcissistic personality disorders. Individuals afflicted with these types of disorders are overly dramatic, emotional and/or erratic to the point that it is difficult for them to maintain any healthy interpersonal relationships (Comer, 2004). Odd personality disorders consist of the paranoid, schizoid and schizotypal personality disorders.  Individuals with these disorders typically display odd or eccentric patterns of thinking and behavior, extreme suspiciousness and social withdrawal. This group of personality disorders is also closely related to schizophrenia. The last group of personality disorders is the anxious cluster that includes the avoidant, dependent and obsessive-compulsive personality disorders. Individuals afflicted with these types of disorders display anxious and fearful types of behaviors and experience discomfort in social situations. These individuals are typically overwhelmed by feelings of inadequacy, and extremely sensitive to negative evaluations. Often many of them are so fearful of rejection and disapproval that they will go to extremes to avoid social situations and interpersonal relationships. Most have few close friends though they long for intimacy and friendship. As a result of this they often report feeling rejected and depressed.  In order to compensate for this, many of these individuals will create an inner world of fantasy. These individuals also tend to be timid, nervous and hesitant and they seldom take risks or try out new activities. As a result of their sensitivity to negative evaluations, difficulties with interpersonal relationships and discomfort in social situations, many also develop social phobias.  
				
        Theories of Personality Disorders
     Modern concepts of personality disorders can be traced back to Pinels’ concept of manic sans delire (madness without confusion of the mind) (Pinel 1801/1962 as cited by Cooke & Hart, n.d.). In 1923, Kurt Schneider, in his seminal volume Psychopathic Personalities further elaborated on the distinction between personality disorders and other mental illnesses then with the publication of the DSM-III 9APA 1980) growing clinical awareness in both diagnosing and researching personality disorders arrived to the forefront of the psychological and academic agendas. Current theories are varied and include psychoanalytical, psychosocial, cognitive, sociocultural, information processing, behavioral and social cognitive ethological and ecological theories. 
     Freud (1856-1939) believed that personality disorders develop as a result of an individual failing to successfully progress through a series of stages detailed in his psychosexual theory of development. According to the psychoanalytical theory, “behavior is merely a surface characteristic, and the symbolic workings of the mind have to be analyzed to understand behavior” (Santrock, 2006, p. 42). 
     Erikson (1950, 1968) believed that difficulties during their psychosocial stages of development result in the development of personality disorders. He believed that each individual is confronted with a series of unique developmental tasks which must be successfully resolved. During the first stage, trust versus mistrust (infancy to 1st year of development) infants learn to trust their providers and as a result experience “physical comfort and a minimal amount of fear and apprehension about the future” (p. 44). His 2nd stage (1 to 3 years) focuses on autonomy versus shame in which children begin to exert their independence. If their providers are too harsh or they are punished frequently, they experience a sense of shame and doubt. The 3rd stage, initiative versus guilt (3 to 5 years) occurs as children begin to develop a sense of responsibility and initiative. If children fail to successfully develop through this stage, uncomfortable guilt and anxious feelings will develop. Industry versus inferiority, the 4th stage in Erikson’s theory opens an array of new experiences and intellectual skills in children. Children who experience difficulties in this stage often report feelings of inferiority and incompetence. These children may fear new experiences which may have a direct impact on the development of social phobias. The 5th stage of development, identity versus identity confusion (11 to 20 years) progresses as adolescents begin discovering their identities, sharing dating experiences and making decisions about their future. Identity confusion results when parents fail to allow their adolescents to develop their own identities. The next stage, intimacy versus isolation (20’s – 30’s years) young adults begin forming intimate interpersonal relationships. If they experience continued difficulties in forming and maintaining these relationships, isolation may result. Erikson’s 7th stage of development, generativity versus stagnation (40’s – 50’s years) adults begin experiencing concerns about whether they have left a positive influence on younger generations. This stage leads into the final stage, integrity versus despair (60’s – onward years) in which they begin to reflect on their lives. “If the older adult resolved many of the earlier stages negatively, the retrospective glances likely will yield doubt or gloom” (p. 45). 
     Piaget’s (1954) theory of cognitive development focuses on cognitive construction through processes of organization and adaptation. He believed that individuals adapt to the world by building “blocks” of information or knowledge through assimilation and accommodation. Assimilation occurs when new information is learned and added to previous information and accommodation occurs when individuals adjust their cognitive structures to new information. His four stages of development: sensorimotor, preoperational, concrete operational and formal operational occurs through a series of age related stages and is marked by distinct ways of thinking. 
     Vygotsky’s (1896-1934) Sociocultural Cognitive Theory emphasizes how culture and social interaction influence an individual’s cognitive development. He believed that knowledge is situated and collaborative and that “knowledge is not generated within the individual but rather is constructed through interaction with other people and objects in the culture, such as books” (p. 47).
     The Information-Processing Theory provides an analogy with computers and human development. This theory states that individuals “manipulate information, monitor it and strategize about it” (p. 47) similar to how a computer processes information. 
     Behavioral and social cognitive theories focus on Pavlov (1927), Skinner (1938) and Bandura (1925- ) work. Pavlov’s famous experiments with dogs and conditioning their responses to food stimulants with unconditional stimulants (ringing of a bell) showed that animals are capable of learning responses to unconditional stimulants. His work with Albert, an infant child reinforced his findings when he taught him to become afraid of white rats. 
     Bandura’s Social Cognitive Theory emphasizes that behavior is influenced through the environment which then affects cognition. His work with young children and aggression in which they viewed violent cartoons then displayed more aggressive tendencies during observed play episodes, made evident that environmental influences have a critical influence on behavior. 
     In support of the social and cognitive theories, the etiology of personality disorders has been “impacted through their links with child abuse, spousal assault, suicide, school drop-out, employment problems, homelessness, raised mortality in early adulthood and relationship problems” (Cooke & Hart, n.d.). In addition, adverse childhood experiences such as child maltreatment, abuse and neglect are frequently implicated in the development of personality disorders. In a separate study that examined these influences, the rates of childhood maltreatment amongst patients with personality disorders were high (73% reported abuse and 82% reported neglect) (Battle et al., 2004).  In addition, early life poor social skills (Mitropoulou et al., 2005) were also implicated as a possible contributing factor. Evidence also suggests that psychopathic personality disorders (antisocial) maybe more prevalent in highly individualistic cultures.  Collectivistic cultures promote the development of interdependent self-identity, which places high emphasis on interpersonal relationships within the family and others which is in contrast to individualistic cultures that emphasize traits such as distinctiveness, status, self-confidence, honor, competition, and freedom from obligations. It is interesting to note that extreme manifestations of these traits include conceit, manipulativeness, irresponsibility, pathological dominance and aggressiveness; characteristics that resemble symptoms of antisocial personality disorders.  
     Ethological theories emphasize the importance of genetic and biology in the development of personality disorders. One of the primary difficulties in identifying genetic contributing factors is the lack of a clear definition of a phenotype, which is a prerequisite in determining genetic inheritance. In a study that focused on twins with personality disorders, the results indicated that “40-50% of phenotypical variation was attributed to additive genetic factors and that little variation scan could be attributed to shared environmental factors and the remaining variation relates to non-shared environmental factors” (Jang & Vernon, 2001 as cited in Cooke & Hart, n.d.). In a separate study conducted by the Minnesota Multiphasic Personality Inventory (MMPI), dimensions in twin pairs reared apart and recruited in the general population indicated that heritability estimates ranged from 28% (paranoia), 34% (social introversion) and 61% for psychopathic deviates  (DiLalla et al., 1996 as cited in Cooke & Hart, n.d.).   
     In a separate study that examined the physiological causes of personality disorders, the left Heschl’s gyrus gray matter volume was 21% smaller in schizotypal personality disorder subjects than in comparison subjects. Heschl’s gyrus is a part of the primary auditory areas that are responsible for auditory verbal hallucinations. This study also revealed a correlation between poor logical memory and smaller left Heschl’s gyrus volume (Dickey et al., 2002).  
           Finally, in a different study that examined the neuropsychological performance in schizotypal subjects, the subjects displayed a “modest cognitive impairment on a variety of cognitive measures” (Mitropoulou et al., 2005). These areas of impairment were specific to variables within the subjects working memory, episodic memory, and delayed recall areas which was also consistent with findings in previous reports of schizophrenic subjects (Mitropoulou et al., 2005). The association between deficits in working memory have been correlated with deficits in social functioning, information processing and the inability to adapt to different social environments or situational demands which may explain the odd behavior of schizotypal individuals (social isolation) (Mitropoulou et al., 2005).
     The last theory, Brofenbrenner’s (1986, 2000, 2004; Brofenbrenner & Morris, 1998) Ecological theory stresses both biological and environmental influences. His environmental system of development consists of five systems which include: the microsystem (family, school, peers, health services, church groups and neighborhoods), the mesosystem (which interacts with the microsytem and the exosystem), the exosystem (friends of family, neighbors, media, social welfare and legal services), the macrosystem (attitudes and ideologies of the culture) and the chronosystem (environmental events and transitions as well as time or sociohistorical conditions which influence a generation), all interact together. 

	            	          Treatment of Personality Disorders
     Treatments for personality disorders focus on both the pharmacological and the psychosocial areas. Psychosocial treatments vary according to the theoretical orientation, treatment modality and setting of therapy utilized. Theoretical orientations focus on the underlying model of pathology and mechanism for change and include supportive, psycho educational, psychodynamic, cognitive-behavioral and interpersonal methods. Psychodynamic theorists focus mainly on the general sense of shame while cognitive theorists believe harsh criticism and rejection in early childhood may lead certain individuals to develop anxious personality disorders. Treatments focus on gaining and building trust, recognizing and resolving their unconscious conflicts (psychodynamic approach) and building social skills using training approaches such as exposure treatments and group therapy (cognitive approach). Treatment modalities are delivered either individually and within couple, family or group settings though it must be noted that certain personality disorders do not fare well within the group setting (extreme anti-social disorders).Treatments may also include in, out or partial hospitalization. Length of treatment can be lengthy or brief dependent on the severity of the symptoms and the cost/time commitment the patient is willing to commit themselves to.   
     During therapy, a therapist will attempt to assist their clients in reconnecting with the world. Other goals of therapy include increasing positive social contacts, easing loneliness, reducing over stimulation while assisting these individuals in becoming more aware of their personal feelings. Clients are also taught how to evaluate their inappropriate patterns of thinking and behavior (Comer, 2004).    
     Most pharmacological treatments include nefazadone, a selective serotonin reuptake inhibitor (SSRIs) in addition to serotonin and noradrenalin reuptake inhibitors (SNRIs). Mood stabilizers are also used which include lithium and antidepressants such as tricyclics. Although limited evidence of improved symptomatology is provided by these medications, they are affective in reducing impulsive behavior and in particularly impulsive aggression and impulsive self-harm as well as instability and somatic complaints. One of the disadvantages of using this form of treatment is that it usually entails a long term commitment and gradual dosages may have to be increased over extended periods of time due to increased intolerances. Another disadvantage is that mediation often “masks” the symptoms without providing an actual cure.  In many clinical cases however, both patients and their families find this “temporary” relief of their symptoms critical in maintaining a relatively “normal” life.  
     In closing, when discussing personality theories, often an eclectic theoretical orientation is the best approach in that such an approach encompasses aspects from all of the theories. Human and personality development and the unique influences and experiences that contribute to the development of personality disorders is a result of psychoanalytical, psychosocial, cognitive, sociocultural, information processing, behavioral and social cognitive ethological and ecological influences. 
   Personality disorders are a world wide phenomenon and the costs to society (health, social welfare, criminal justice systems) are astronomical. It is estimated that their prevalence will more then likely, in the future, will continue to grow. As this prevalence continues, one issue that will gain increased focus will be the study of psychopharmacology and ethnicity including the interrelation of culture and biology in that the physiological differences among various ethnic groups will be vital in determining the most ideal pharmaceutical treatment method for these patients. Also important will be determining the most efficient and effective assessment and diagnostic criterion for these disorders which will benefit not only the patients themselves but the numerous agencies involved in the process as well.    

					   References

     Battle, C. l., Shea, M. T., Johnson, D. M. & Yen, S. (2004). Childhood maltreatment associated with adult personality disorders: findings from the collaborative longitudinal personality disorders study. Journal of Personality Disorders, 18, 2, pp. 193-212. Retrieved August 23, 2007 from ProQuest Psychology Journals database.  

     Cooke, D. J. & Hart, S. D. (n.d.). Personality Disorders. Retrieved August 23, 2007 from ProQuest Psychology Journals database.  
     
     Comer, R. J. (2004). Abnormal psychology (5th ed.). New York, NY: Worth Publishers.

     Mitropoulou, V., Harvey, P. D., Zegarelli, G., Silverman, J. M. & Siever, L. J. 
(2005). Neuropsychological performance in schizotypal personality disorder: importance of working memory. Journal of Psychiatry, 162, 10, pp. 1896-1903. Retrieved August 23, 2007 from http://ajp.psychiatryonline.org

     Santrock, J. (2006). Lifespan Development. (10th ed.). New York: McGraw-Hill.