The Personality Disorder Star

The Personality Disorders (PDs) are among the most common and difficult to treat conditions seen by mental health professionals. The DSM-IVR identifies 10 diagnosable personality disorders, and clusters them into three domains of: A) odd, eccentric; B) dramatic erratic; and C) anxious, fearful. This post outlines a new way of thinking about the PDs by clustering them on three relational dimensions of Freedom (Cluster A), Power (Cluster B), and Love (Cluster C). It also depicts major personality disorders on a “star” and shows how some PDs (e.g., Antisocial and Dependent) should be thought of as diametric opposites.

To understand what personality disorders are, we need to first have at least a working conception of what is meant by the term ‘personality’. Kurt Lewin famously described human behavior as being the function of the person and the environment [i.e., B = f(P, E)]. Whereas social psychologists tend to emphasize the ‘E’ in the equation, personality psychologists emphasize the ‘P’. Personality refers to the developing organized constellation of psychological systems within an individual that makes them identifiable and unique. It consists of a number of subsystems, including basic temperamental dispositions (i.e., traits such as extraversion and neuroticism), characteristic ways of responding to particular situations (which include habitual, affective, and relational patterned responses to situations), and identity (the individual’s self-concept and philosophy about the world).

Personality disorders describe adults who have longstanding difficulties establishing deep, meaningful, and positive relationships with others. Such individuals often show unusual, extreme, or rigid patterns of thought, emotional reactivity, and/or impulsive behavior that consistently lead to problems. The DSM distinguishes PDs (Axis II) from traditional clinical syndromes (Axis I) because PDs are conceptualized as more “structural”. Akin to a building’s basic design features, when clinicians diagnose someone as having a personality disorder, the metaphor is that the fundamental structures of the individual’s personality are contributing to the current distress and dysfunction. Not surprisingly, personality disorders are notoriously difficult to treat. They are also very common, with approximately half of the population presenting for treatment at mental health clinics meeting criteria for a PD.

Although it is currently a point of significant controversy for the DSM-V, the current system operates from a categorical (as opposed to dimensional) classification system. As mentioned, there are 10 diagnosable personality disorders in the DSM-IVR, which are divided up into three broad clusters. Cluster A is the odd, eccentric cluster and consists of schizoid, paranoid and schizotypal types; Cluster B is the dramatic, erratic cluster and consists of antisocial, narcissistic, histrionic, and borderline types; and Cluster C is the anxious, fearful cluster and consists of avoidant, dependent, and obsessive compulsive types.

There is a better way to conceptualize the clusters of PDs: one offers better descriptors of the core of the clusters and that is more grounded in modern personality theory. The approach also identifies three broad cluster domains that align somewhat with the clusters in the DSM, but it is conceptually clearer. It starts with a general model of the human relationship system, and builds out from that.

Mapping the Human Relationship System: relational value and three relational dimensions

The human relational system is the system by which people represent themselves in relationship to others in social exchanges. John Bowlby’s attachment theory is an excellent example of work on the human relationship system. Bowlby argued that human infants have needs for protection and security and connectedness and develop internal working models based on experience that guide expectancies in how others will respond.

The Influence Matrix is an integrative model of the human relationship system that builds off of work done on attachment theory, as well as the Interpersonal Circumplex, modern psychodynamic theory, sociometer theory, among others. It is described in more detail here. A key feature of the Matrix is that it maps the dimensions on which people represent themselves in relationship to others (i.e., maps the structure on which internal working models develop). The Matrix makes two central points. The first is that humans are motivated to seek and approach high relational value in regards to people who are important to them. That is they desire to be loved, admired, and respected. Likewise, they seek to avoid loss of relational value (being rejected, criticized, or ostracized). The motive for relational value is represented by the black line in the middle of the diagram.

The boxes represent the idea that people will have schema for high and low relational value, which they will be inclined to approach and avoid respectively. To get a sense of the nature of these schema, think about the way children [and adults] depict themselves in positive fantasies. Like so many children, my 10-year-old son, Jon, has dreams of being a football star and fantasizes about winning the Superbowl. Accomplishing something very difficult for which other people admire and love you for is a prototype template for high relational value.

How does this idea relate to the concept of personality disorders? It is directly relevant because people with personality disorders consistently behave in ways that reduce the relational value of themselves and/or others. That is what makes the patterned behavior of PDs functionally maladaptive and associated with so much distress.

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The second point the Matrix makes is that people navigate the dynamics of relational value on three separable process dimensions of Power (the blue line of Dominance-Submission), Love (the red line of Affiliation and Hostility), and Freedom (the green line of Autonomy and Dependency). This means that there are separate pathways to relational value. We can compete with others to achieve high status. Or we can give to others and achieve affilation or love. And we need to negotiate our involvement with others, such that if the relational exchange is disadvantageous, we can sacrifice power or love for freedom

Now return for a moment to the three clusters of personality disorders, labeled in the atheoretical descriptive terminology of the DSM as A (odd/eccentric), B (dramatic/erratic), and C (anxious/fearful). Even a quick glance will reveal an obvious alignment. The Cluster A group hangs together because they are extreme on the Freedom dimension of relating. The detachedness of the schizoid, the nonconformist thinking of the schizotypal, and the extreme mistrust sensitivity to being controlled of the paranoid can all be understood as having themes of extreme autonomy, or an extreme tendency to move away from others. Individuals in the Cluster B are experienced as competitive, manipulative, controlling, and selfish, mapping directly onto the Power dimension. Individuals in the Cluster C group (especially Avoidant and Dependent PDs) are deeply concerned with affiliation. People with Dependent PD will excessively self-sacrifice and self-efface to maintain connection with important others. People with Avoidant PD also deeply desire connection, but isolate because they fear they are unworthy and will be criticized or rejected if they reach out. They both long for affiliative connections with others and thus are well characterized as having extreme and rigid tendencies on the Love dimension of relating. (Note that the central problem of OCPD is more along the lines of rigid needs for cognitive organization, and is less related to the dimensions of the IM than the other PDS).

We can take the insight about the clusters further and develop a way of thinking explicitly how the PDs relate to each other.

The Personality Disorder Star

Karen Horney was an influential psychodynamic theorist who argued that there were three primary ways of relating to others. Moving toward, moving against and moving away. Moving toward was characterized by strong feelings of affiliation, need, and self-effacement. Moving against was characterized by strong tendencies to compete, aggress, and self-enhance. Moving away was characterized by tendencies to separate, distance oneself and individuate from others. Horney’s characterization of these three types precisely parallels the three dimensions of the IM (Power is moving against, Love is moving toward, and Freedom is moving away).With this insight, we are now in a position to construct the Personality Disorder Star, depicted here.

What is striking to me is that there are personality types that are prototypes of the three styles the Horney identified. The prototype of ‘move against’ is the Narcissistic PD. These individuals are hypercompetitive and are constantly needing to demonstrate their superiority to others (see, e.g., Steve Jobs). The prototype of ‘move away’ is the Schizoid PD. The central defining feature of the schizoid PD is a fundamental detachment and lack of emotional connection and responsiveness to others. And, finally, the prototype of the ‘move toward’ is the Dependent PD, who desperately fears abandonment, submits to the will of others to avoid rejection and foster caretaking in the part of others.

With these prototypes in place, we can then identify their polar opposites. Thus, Antisocal PDs are high on move against and move away, but rarely move toward. Opposite of the schizoid, Histrionic PDs move toward and against, but not away. And opposite of the Narcisstic PD, Avoidants move toward and away, but not against.

What about PDs that are not represented? A very common PD is Borderline PD. Where is that? Well, the central feature of a BPD is difficulty with emotional regulation and a fragmented relational system. Folks with BPD often fluctuate between strong displays of dependency and neediness followed by extreme displays of reactive hostility, as represented in the title of a famous book on the condition, I love you, I hate you. From this perspective, BPD is not so much a rigid relational style, but represents extreme emotional lability, a weak or fragmented identity, and strong needs for power, love and freedom, structured around a fundamentally insecure sense of self (low relational value).

My doctoral students and I are working on a measure of the Influence Matrix, and I look forward to exploring future work examining its validity for profiling the PDs.