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9.2 Cluster A Personality Disorders

Section Learning Objectives

  • Describe the symptoms associated with each cluster A personality disorder.
  • Describe the epidemiology of cluster A personality disorders.
  • Describe the treatments for cluster A personality disorders.

9.2.1 Clinical Descriptions

9.2.1.1 Paranoid Personality Disorder

Paranoid personality disorder is characterized by a severe distrust or suspicion of others. Individuals interpret and believe that other’s motives and interactions are intended to harm them, and therefore, they are skeptical about establishing close relationships outside of family members — although at times even family members’ actions are believed to be malevolent (APA, 2013). Individuals with paranoid personality disorder often feel as though they have been deeply and irreversibly hurt by others even though there is little to no evidence to support that others intended to, or actually did, hurt them. Because of these persistent suspicions, they will doubt relationships that show true loyalty or trustworthiness.

Individuals with paranoid personality disorder are also hesitant to share any personal information or confide in others as they fear the information will be used against them (APA, 2013). Additionally, benign remarks or events are often interpreted as demeaning or threatening. For example, if an individual with paranoid personality disorder was accidentally bumped into at the store, they would interpret this action as intentional, with the purpose of causing them injury. Because of this, individuals with paranoid personality disorder are quick to hold grudges and unwilling to forgive insults or injuries – whether intentional or not (APA, 2013). They are known to quickly, and angrily counterattack either verbally or physically in situations where they feel they were insulted.

9.2.1.2 Schizoid Personality Disorder

Individuals with schizoid personality disorder display a persistent pattern of avoidance from social relationships along with a limited range of emotion among social relationships (APA, 2013). Similar to those with paranoid personality disorder, individuals with schizoid personality disorder do not have many close relationships; however, unlike paranoid personality disorder, this lack of relationship is not due to suspicious feelings, but rather, the lack of desire to engage with others and the preference to engage in solitary behaviors. Individuals with schizoid personality disorder are often viewed as “loners” and prefer activities where they do not have to engage with others (APA, 2013). Established relationships rarely extend outside that of the family as those diagnosed with schizoid personality disorder make no effort to start or maintain friendships. This lack of establishing social relationships also extends to sexual behaviors, as those with schizoid personality disorder report a lack of interest in engaging in sexual experiences with others.

With regard to the limited range of emotion, individuals with schizoid personality disorder are often indifferent to criticisms or praises of others and appear to not be affected by what others think of them (APA, 2013). They will rarely show any feelings or expression of emotions and are often described as having a “bland” exterior (APA, 2013). In fact, individuals with schizoid personality disorder rarely reciprocate facial expressions or gestures typically displayed in normal conversations such as smiles or nods. Because of this lack of emotions, there is limited need for attention or acceptance.

9.2.1.3 Schizotypal Personality Disorder

Schizotypal personality disorder is characterized by a range of impairment in social and interpersonal relationships due to discomfort in relationships, along with odd cognitive and/or perceptual distortions and eccentric behaviors (APA, 2013). Similar to those with schizoid personality disorder, these individuals also seek isolation and have few, if any established relationships outside of family members.

One of the most prominent features of schizotypal personality disorder is ideas of reference or the belief that unrelated events pertain to them in a particular and unusual way. This is a milder version of the delusions of reference that were discussed in the previous chapter. Ideas of reference also lead to superstitious behaviors or preoccupation with paranormal activities that are not generally accepted in their culture (APA, 2013). The perception of special or magical powers such as the ability to mind read or control other’s thoughts has also been documented in individuals with schizotypal personality disorder. Unusual perceptual experiences such as sensing the presence of another person or hearing one’s name (subthreshold hallucinations), as well as unusual speech patterns such as derailment or incoherence are also symptoms of this disorder.

Similar to the other personality disorders within cluster A, there is also a component of paranoia or suspiciousness of other’s motives in schizotypal personality disorder. Additionally, individuals with this disorder also display inappropriate or restricted affect, thus impacting their ability to appropriately interact with others in a social context. Significant social anxiety is often also present in social situations, particularly in those involving unfamiliar people. The combination of limited affect and social anxiety contributes to their inability to establish and maintain personal relationships; most individuals with schizotypal personality disorder prefer to keep to themselves in efforts to reduce this anxiety.

9.2.2 Epidemiology

The cluster A personality disorders have a prevalence rate of around 3-5%. More specifically, paranoid personality disorder is estimated to affect approximately 4.4% of the general population, with no reported diagnosis discrepancy between genders (APA, 2013). Schizoid personality disorder occurs in 3.1% of the general population, whereas the prevalence rate for schizotypal personality disorder is 3.9%. Both schizoid and schizotypal personality disorders are more commonly diagnosed in males than females, with males also reportedly being more impaired by the disorder than females (APA, 2013).

Note: Due to the overlap among comorbidities and etiological factors we will reserve our discussion of those until the end of the chapter and will proceed directly to the treatment of the cluster A personality disorders.

9.2.3 Treatment

Individuals with personality disorders within cluster A often do not seek out treatment as they do not identify themselves as someone who needs help (Millon, 2011). Of those that do seek treatment, the majority do not enter it willingly. Furthermore, due to the nature of these disorder, individuals in treatment often struggle to trust the clinician as they are suspicious of the clinician’s intentions (paranoid and schizotypal personality disorder) or are emotionally distant from the clinician as they do not have a desire to engage in treatment due to a lack of overall emotion and desire for relationships (schizoid personality disorder; Kellett & Hardy, 2014, Colli, Tanzilli, Dimaggio, & Lingiardi, 2014). Because of this, treatment is known to move very slowly, with many clients dropping out of treatment before any resolution of symptoms can be met.

When clients are enrolled in treatment, cognitive behavioral strategies are most commonly used with the primary intention of reducing anxiety-related symptoms. Additionally, attempts at cognitive restructuring – both identifying and changing maladaptive thought patterns – are also helpful in addressing the misinterpretations of other’s words and actions, particularly in those with paranoid personality disorder (Kellett & Hardy, 2014). Clients with schizoid personality disorder may be engaged in CBT techniques to help them experience more positive emotions and engage in more satisfying social experiences; whereas the goal of CBT for schizotypal personality disorder is to evaluate unusual thoughts or perceptions objectively and to ignore the inappropriate thoughts (Beck & Weishaar, 2011). Finally, behavioral techniques such as social-skills training may also be implemented to address ongoing interpersonal problems displayed in the disorders.

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