Clinical formulations and case conceptualisations are introduced in this post.

These are all generalisations and theories of how NPD develops, not something that is supposed to be true for everyone with NPD.

Psychodynamic model

Freud suggests parents either overvaluing or neglecting (or both) a child can lead to NPD & especially inability to form healthy, lasting relationships and regulate self-esteem

"In other words, [NPD] is the outcome of insufficient gratification of the normal narcissistic needs of infancy and childhood."

Kohut theorises that narcissists' ability to form a cohesive sense of self and others was developmentally arrested in childhood, resulting in grandiosity & idealising others

"Narcissistic injury" = fragmentation of the self

Kernberg suggests grandiosity & exploitation result from maternal emotional abuse

Grandiosity is an "emotional escape valve"

Grandiosity & entitlement mask the "real self" that is "split off"

The real self unconsciously holds rage, fear, envy, deprivation

Defensive structure is same as BPD but difference is grandiosity

Biosocial model

NPD is primarily the result of environment, especially "parental indulgence and overvaluation, learned exploitive behavior, and only-child status"

Special treatment from caregivers leads children to believe that the "world revolves around them", and therefore they expect the same outside the home

When special treatment outside the home doesn't happen, they "experiment with demanding and exploitive tactics and subsequently develop considerable skill in manipulating others"

"At the same time they come to believe that most others are inferior, weak, and exploitable."

NPD is self-perpetuating through sense of superiority, lack of self control, sense of entitlement, and dismissing of those who reject their world / self-view

Cognitive-Behavioural model

Key feature of NPD is self-aggrandisement

Core beliefs:

> Deserving of special treatment

> Not bound by social norms and rules

Conditional beliefs:

> Others should be punished for not recognising their specialness

> To maintain that special status others should be subservient to them

Instrumental belief:

> Always strive to demonstrate their superiority

> See themselves as special, superior, entitled to special favors and treatment, and vulnerable to loss of status

> View others as inferior but potential admirers

Main pattern of behaviour is "seeking prestige, power, position, and wealth as a way of reinforcing their image of superiority", using "manipulation and guile" if necessary

The primary schema is superior & special (/ entitlement & grandiosity)

> Superior schema "shaped by flattery, indulgence, and favoritism"

> Special schema shaped by "rejection, limitations, exclusion, or deficits"

> Common denominator is the belief that the individual is different in some way

Three subtypes:

> Self-centered impulsive type

> Ruthless impression-management type

> Acceptance-oriented impression-management type

> Each type is centred around an impulse control deficit developed in childhood

> "Specifically, these individuals learned to seek reinforcers without having to work for them. This resulted in their development as self-indulgent, egocentric, and impulsive individuals."

> Ruthless & Acceptance-oriented types focus on creating favourable impressions with others, but struggle with long-lasting healthy relationships because of their empathy deficits

Interpersonal model

People with NPD were raised in an environment of "selfless not contingent" love, leading to insensitivity to others' needs

The caregiver was over-adoring, but there was also a constant threat of a "fall from grace", with pressure to be the perfect child

The constant overbearing love means that any criticism or disappointment hits very hard

"In short, there is extreme vulnerability to criticism or being ignored, together with a strong wish for love, support, and admiration from others. Noncontingent love and presumptive control of others is expected and even demanded. If support is withdrawn, or lack of perfection is evident, the self-concept degrades into severe self-criticism."

Integrative model

People with NPD are hypersensitive

Seen as exceptional children, leading to pressure to perform

As children likely had highly developed speech and interpersonal skills

Life purpose: "I’m special and unique, and I am entitled to extraordinary rights and privileges whether I have earned them or not."

World-view: "Life is a banquet table to be sampled at will. People owe me admiration and privilege."

Goal: "Therefore, I’ll expect and demand this specialness."

Defense mechanisms: rationalisation and projective identification

Parental injunction: "Grow up and be wonderful—for me."

"The illusion of specialness, disdain for others’ views, and a sense of entitlement lead to an underdeveloped sense of social interest and responsibility. This, in turn, leads to increased self-absorption and confirmation of narcissistic beliefs."

These are the defining characteristics of PDs, each of which are different depending on the PD in question.

Triggering event(s).

The situations that trigger a maladaptive response that is reflected in the person’s behavioral, interpersonal, cognitive, and affective styles. Triggering events can be intrapersonal (e.g. failing an exam), or interpersonal (e.g. being criticised).

ASPD: Social standards and rules.

AVPD: Close relationships; being social/in public.

BPD: The expectation of meeting goals; maintaining close relationships; real or imagined abandonment.

DPD: The expectation that they can rely on themselves; being alone.

HPD: Relationships, particularly with those they're attracted to.

NPD: Self-evaluation, either by themselves or others.

OCPD: Unstructured situations; meeting other’s standards (in all aspects of life: work, family, etc).

PPD: Close relationships; personal questions.

STPD: Close relationships.

SZPD: Close relationships.

Behavioral style

The way in which the person reacts to a triggering event.

ASPD: Impulsive, irritable, aggressive; irresponsible and struggles to keep commitments; relies on themselves, uses cunning and force; risk-taking and thrill-seeking.

AVPD: Tense and self-conscious; controlled speech & behaviour; appear apprehensive and awkward; self-criticising and overly humble.

BPD: Self-damaging behaviours (self-harm, self-sabotage, suicidal ideation); aggression; achieve less than they could (e.g. in work or school); chronic insomnia & irregular circadian rhythms (”body clocks”); feel helpless & empty void.

DPD: Docile, passive, non-assertive, insecure, and submissive; doubts themselves & lacks self-confidence.

HPD: Charming, dramatic, expressive; demanding, self-indulgent, inconsiderate; attention-seeking, mood swings, impulsive, unpredictable, and superficial.

NPD: Self-centred, egotistical, self-assured; dominates conversations; seeks approval and attention; impatient, arrogant, hypersensitive.

OCPD: Perfectionists; workaholics; dependable, stubborn, possessive; indecisive, prone to procrastination.

PPD: Always tense and hypervigilant; defensive, argumentative, guarded.

STPD: Eccentric, bizarre; strange speech; struggles with work and school and often become drifters and wanderers; avoids long-term commitment and looses touch with society’s expectations; dissociative.

SZPD: Lethargic, inattentive, eccentric; slow and monotone speech; rarely spontaneous; indifferent.

Interpersonal style

The way they relate to others.

ASPD: Deceitful; irritable, antagonistic and aggressive; disregards their and other’s safety; distrustful; lacks empathy; competitive.

AVPD: Sensitive to rejection; want acceptance but are too scared; withdraw and avoid when afraid; test people to see if they’re safe to interact with.

BPD: “Paradoxical instability”; splitting (idealise & cling vs devalue & dismiss); sensitive to rejection; “abandonment depression” & separation anxiety; superficial yet quickly developed and intense relationships; “extraordinarily intolerant” of being alone.

DPD: People-pleasers, self-sacrificing, clingy & needs reassurance; over-compliant & over-reliant on others; want others to be in control of their lives; avoids arguments; puts themselves down so they can receive the support of others; urgently seeks a new relationship when one ends.

HPD: Needs attention; flirtatious, manipulative; lacks empathy; overestimates intimacy of relationships.

NPD: Exploitative; self-indulgent; charming, pleasant & endearing; lacks empathy; irresponsible; jealous; needs approval and admiration.

OCPD: Very aware of social hierarchy; deferential to superiors and haughty to subordinates; polite and loyal; insist that their way is the right way to do things, because they are anxious to ensure perfection; stubborn; devoted to work which interferes with relationships.

PPD: Distrustful, secretive, suspicious, tend to isolate themselves and avoid intimacy; hypersensitive to criticism; bears grudges and blames others; reluctant to open up for fear of vulnerability.

STPD: Loners; socially anxious, apprehensive, suspicious and paranoid, which doesn’t fade as they get to know people; tends to live on the margins of society and relationships; often choose jobs with minimal social interaction that are usually below their skill level; indifferent to social norms.

SZPD: Aloof, loners, reserved, solitary; socially awkward; tend to fade into the background; happy to remain alone.

Cognitive style

How the person perceives and thinks about a problem and its solution.

ASPD: Impulsive; realistic; very aware of social cues; prone to executive dysfunction.

AVPD: Hypervigilant; distracted and preoccupied with their fears of rejection.

BPD: Inflexible (splitting) & impulsive; difficulty learning from the past; external loss of control leads them to blame others to avoid feeling powerless; emotions fluctuate between hope and despair; unstable self-image and fragmented sense of self; unable to tolerate frustration; brief psychotic episodes; dissociation; intense rage; difficulty focusing & processing information.

DPD: Suggestible and persuadable; optimistic, sometimes to the point of naïveté; uncritical; minimises difficulties and are easily taken advantage of.

HPD: Impulsive, dramatic; vague; suggestible; relies on intuition; avoids reflection and introspection as so to avoid realising their dependency on others; needs approval from others; has separate real/inner/private & constructed/outer/public selves; tendency to mimic speech patterns.

NPD: Focuses on feelings rather than facts; compulsive lying (to themselves as well as others); inflexible, impatient, persistent; superiority; unrealistic goals of success, power, ideal love.

OCPD: Rule & detail oriented; difficulty with prioritising; inflexible, unimaginative; conflicted between assertiveness & defiance vs obedience & pleasing people.

PPD: Mistrustful; hypervigilant; focuses on feelings (of paranoia) rather than facts; brief psychotic episodes; their need to find evidence for their paranoid suspicions gives them a tendency for authoritarianism.

STPD: Scattered; obsessive and tends to ruminate; superstitious, bizarre fantasies; vague ideas of reference (thinking things are about them when they’re not, e.g. someone laughing is directed at them) and magical thinking (thinking they caused something to happen by thinking about it); dissociative.

SZPD: Distracted; difficulty organising their thoughts; vague and indecisive; difficulty with introspection and reflection.

Affective style

How the person expresses and experiences emotions.

ASPD: Superficially expresses emotions; avoids emotions that will make them vulnerable; rarely feels guilt, shame or remorse; unable to tolerate boredom, depression, & frustration and needs stimulation.

AVPD: Shy & apprehensive; feels empty, sad, lonely & tense; depersonalisation.

BPD: Mood swings; inappropriately intense anger; feelings of emptiness, boredom, a “void”; emotional dysregulation.

DPD: Insecure & anxious; lacks self-confidence & fears being alone; fears abandonment & rejection; often sad or somber.

HPD: Displays intense, extreme emotions but may only feel them shallowly; sensitive to rejection; mood swings; need reassurance that they are loved.

NPD: Presents as self-confident and nonchalant; when criticised or rejected (”narcissistic injury”) they experience extreme shame which is often redirected into anger (”narc rage”/shame redirect); splitting; lacks empathy and so has difficulty with commitments.

OCPD: Somber, difficulty expressing feelings; avoids emotions that will make them vulnerable; comes across as stiff and stilted.

PPD: Cold, aloof, humourless; difficulty expressing feelings; tendency for anger and jealousy.

STPD: Cold, humourless, aloof; difficult to engage with; suspicious and mistrustful; hypersensitive; may react inappropriately for the situation or not at all.

SZPD: Humourless, cold, aloof; indifferent; lacks empathy; emotionally and socially distant; difficulty responding to other people’s feelings.

Temperament

The response pattern that reflects the person’s energy level, emotions and intensity of emotions, and how quick they react.

ASPD: Irresponsible, aggressive and impulsive.

AVPD: Irritable.

BPD: Passive (dependent subtype); hyperreactive (histrionic subtype); irritable (passive-aggressive subtype).

DPD: Low energy; fearful, sad or withdrawn; melancholic.

HPD: Hyperresponsive; needs attention from others.

NPD: Active and responsive; has special talents and developed language early.

OCPD: Irritable, difficult, anxious.

PPD: Active and hyperresponsive (narcissistic subtype); irritable (obsessive-compulsive and passive-aggressive subtypes).

STPD: Passive (schizoid subtype); fearful (avoidant subtype).

SZPD: Passive, difficulty experiencing pleasure and motivation (anhedonia).

Attachment style

Discussed in this post.

ASPD: Fearful-dismissing.

AVPD: Preoccupied-fearful.

BPD: Disorganised.

DPD: Preoccupied.

HPD: Preoccupied.

NPD: Fearful-dismissing.

OCPD: Preoccupied.

PPD: Fearful.

STPD: Fearful-dismissing.

SZPD: Dismissing.

Parental injunction

The expectation (explicit or implied) from caregivers for how the child should be or act.

ASPD: “The end justifies the means.”

AVPD: “We don’t accept you, and probably nobody else will either.”

BPD: “If you grow up, bad things will happen to me [caregiver].”; overprotective, demanding or inconsistent parenting.

DPD: “You can’t do it by yourself.”

HPD: “I’ll give you attention when you do what I want.”

NPD: “Grow up and be wonderful, for me.”

OCPD: “You must do/be better to be worthwhile.”

PPD: “You’re different. Keep alert. Don’t make mistakes.”

STPD: “You’re a strange bird.”

SZPD: “Who are you, what do you want?”

Self view

The way they view and conceptualise themselves.

ASPD: Cunning & entitled.

AVPD: Inadequate & frightened of rejection.

BPD: Identity problems involving gender, career, loyalties, and values; self-esteem fluctuates with emotions.

DPD: Pleasant but inadequate, fragile.

HPD: Needs to be noticed.

NPD: Special, unique and entitled; relies on others for self-esteem.

OCPD: Responsible for anything that goes wrong, so they must be perfect.

PPD: They're alone and disliked because they're different and better than others.

STPD: Different than other people.

SZPD: Different from others; self-sufficient; indifferent to everything.

World view

The way they view the world, others, and life in general.

ASPD: Life is dangerous and rules get in the way of their needs. They won’t be controlled or degraded.

AVPD: Life is unfair; even though they want to be accepted, people will reject them, so they'll be vigilant & demand reassurance; escapes using fantasies and daydreams.

BPD: Splits between people and the world as either all-good or all-bad, resulting in commitment issues.

DPD: Other people need to take care of them because they are unable to.

HPD: Life makes them nervous, so they need attention and reassurance that they're loved.

NPD: Life is full of opportunities; they expect admiration and respect.

OCPD: Life is unpredictable and expects too much, so they manage this by being in control and being perfectionists.

PPD: Life is unfair, unpredictable, demanding, and dangerous; they need to be suspicious and on guard against others, who are to blame for failures.

STPD: Life is strange and unusual; others have special magic intentions, so they are curious but also cautious when interacting with the world.

SZPD: Life is difficult and dangerous; if they trust no one and keep their distance from others, they won’t get hurt.

Maladaptive schema

Discussed in this post.

ASPD: Mistrust/abuse; entitlement; insufficient self-control; defectiveness; emotional deprivation; abandonment; social isolation.

AVPD: Defectiveness; social isolation; approval-seeking; self-sacrifice.

BPD: Abandonment; defectiveness; abuse/mistrust; emotional deprivation; social isolation; insufficient self-control.

DPD: Defectiveness; self-sacrifice; approval-seeking.

HPD: Approval-seeking; emotional deprivation; defectiveness.

NPD: Entitlement; defectiveness; emotional deprivation; insufficient self-control; unrelenting standards.

OCPD: Unrelenting standards; punitiveness; emotional inhibition.

PPD: Abuse/mistrust; defectiveness.

STPD: Alienation; abandonment; dependence; vulnerability to harm.

SZPD: Social isolation; emotional deprivation; defectiveness; subjugation; undeveloped self.

Optimal diagnostic criterion

One key criterion for each personality disorder, based on its ability to summarise all criteria for that PD, accurate description of behaviour, and the predictive value (ability to predict if the person has the PD or not).

ASPD: Aggressive, impulsive, irresponsible behavior.

AVPD: Avoids activities that involve being social out of fear of criticism, disapproval, or rejection.

BPD: Frantic efforts to avoid real or imagined abandonment.

DPD: Needs other people to be responsible for most major parts of their lives.

HPD: Uncomfortable not being the centre of attention.

NPD: Grandiose sense of self-importance.

OCPD: Perfectionism that interferes with life.

PPD: Paranoia, without evidence, that others are trying to harm, exploit or deceive them.

STPD: Thinking, speech, behavior, or appearance that is odd, eccentric, or peculiar.

SZPD: Doesn’t want or enjoy close relationships.

Clinical formulations and case conceptualisations are introduced in this post.

These are all generalisations and theories of how HPD develops, not something that is supposed to be true for everyone with HPD.

Psychodynamic model

Histrionics lack relationships with maternal caregivers so turn to paternal caregivers for love and attention

Learn that they can get attention through sexualised behaviours

Men with HPD may be hypomasculine (effeminate) or hypermasculine if their paternal caregiver is emotionally unavailable

Biosocial model

Mood swings, very emotional

Biggest influences are environmental: caregivers’ reinforcement of attention-seeking & manipulative behaviours and histrionic role models

Children learn they can use cuteness, charm, attractiveness & seductive behaviours to get what they want/need (attention from caregivers)

Histrionics are externally focused and largely ignore their internal worlds

Histrionic behaviours are self-perpetuating

Cognitive-Behavioural model

Two main underlying assumptions: “I am inadequate and unable to handle life by myself” and “I must be loved by everyone to be worthwhile.” 

Need attention and approval from others, and in a similar way to DPD feel they are inadequate to look after themselves and need others

Hypersensitive to rejection & criticism (similar to DPD, NPD and AvPD)

Feel they must perform for others to gain approval and self-esteem

Thinking is “impressionistic, global, and unfocused” and leads to over-generalisation, emotional dysregulation, and splitting

Two subtypes:

The controlling type, who tries to gain control through dramatics and manipulation; they struggle with reading others’ emotions and are shallow, self-centred, and uncomfortable without immediate assurance; lack empathy.

The reactive type tries to gain approval and reassurance.

Interpersonal model

People with HPD learnt that their entertainment value and appearance was more important to others than their worth as a person

Learnt that physical appearance and charm can be used to manipulate others

Their childhood homes were unpredictable and probably involved substance abuse

The unpredictability was dramatic and interesting (unlike the “primitive” and life-threatening chaos associated with BPD)

Histrionics were likely rewarded (i.e. had their physical and emotional needs met) for their disabilities, illnesses and complaints

Histrionics “exhibit a strange fear of being ignored, together with a wish to be loved and taken care of by important others, who can be controlled through charm or guile.”

Integrative model

Histrionics experience reactive mood swings and have high levels of energy

They are hyper-responsive and externally oriented

“The self-view of the histrionic will be some variant of the theme “I am sensitive and everyone should admire and approve of me.” The world-view will be some variant of “Life makes me nervous so I am entitled to special care and consideration.” Life goal is some variant of the theme “Therefore, play to the audience, and live in the moment.””

Cargivers’ style based in reciprocity, i.e. “I’ll give you attention if you do what I want”, with minimal or inconsistent discipline and probable neglect

Internal experiences of HPD are “denial of one’s real or inner self; a preoccupation with externals; the need for excitement and attention-seeking, which leads to a superficial charm and interpersonal presence; and the need for external approval. This, in turn, further reinforces the dissociation and denial of the real or inner self from the public self, and the cycle continues.”

Comparison of Personality Styles vs Personality Disorders

Attachment is the “emotional bond” between a child and their caregiver. It’s relevant to personality disorders since it influences the child’s “capacity to form mature intimate relationships in adulthood”. It “influences and organizes motivational, emotional, and memory processes that involve caregivers”. Attachment is associated with “emotional regulation, social relatedness” and the “development of self-reflection and narrative”, all things that are impacted by personality disorders.

Attachment Styles

Attachment styles are made up of two dimensions:

the distinction between self and others

“valence”: positive vs. negative evaluation

Most people will exhibit more than one attachment style.

The five styles are:

secure: positive view of self and others

preoccupied: negative view of self, positive view of others

dismissing: positive view of self, negative view of others

fearful: negative view of self and others

disorganized: fluctuating positive and negative views of self and others

Preoccupied style: DPD, OCPD & HPD

Negative view of self (“a sense of personal unworthiness”)

Positive view of others

Tend to be very “externally oriented in their self-definitions”, i.e. look to others to define them

Dismissing style: SZPD

Positive view of self (“a sense of self that is worthy and positive”)

Negative view of others, which “typically manifests as mistrust”

See themselves as “emotionally self-sufficient”

See others as emotionally unresponsive

Therefore they “dismiss the need for friendship and contact with others”

Fearful style: PPD

Negative view of self and others

Expectation that others are untrustworthy & will reject them

Don’t trust themselves or others

Believe themselves to be “special and different”

Hypervigilant against threats and “unexpected circumstances”

Preoccupied-fearful style: AVPD

Negative view of self

Fluctuates between negative and positive view of others

Want to be liked and accepted but fear rejection and abandonment, so they avoid and withdraw

Fearful-dismissing style: ASPD, NPD, STPD

Fluctuates between negative and positive view of self

Negative view of others

See themselves as “special and entitled”

Acknowledge their need for others, as well as others’ potential to hurt them

Use others to meet their needs but are fearful and dismissing of them

Disorganized style: BPD

Fluctuates between negative and positive view of self and others

This style develops from trauma

Associated with dissociation & PTSD

Seems to shift among the other attachment styles

(More on disorganised attachment & dissociation)

Prototypic descriptions are brief descriptions that "capture the essence of how a particular disorder commonly presents", i.e., a summary of the key features of the disorder. The following are the protoypic descriptions of the DSM-5-TR personality disorders, summarised from Sperry:

ASPD

Antisocials displayed symptoms of Conduct Disorder from early childhood, and their manipulative and irresponsible behaviour continued into adulthood. They lack empathy and use others for their own gain. Because they can’t tolerate boredom, they are reckless, impulsive thrill-seekers and disregard their safety and others'. ASPD is over-diagnosed in prisons and detention centres.

AVPD

Avoidants are frightened and anxious, which makes them socially awkward. They are hypersensitive to criticism and rejection, and the fear of being embarrassed and humiliated causes them to withdraw and avoid social interaction. They crave connection with others, and may have trusted people with whom they can relax and feel safe.

BPD

Borderlines are terrified of being abandoned, which leads to intense relationships that often end in disappointment when they split on their favourite person. They are prone to self-damaging behaviours, and self-harm and suicide attempts are common. They have a fragmented, confused sense of self. They are often impulsive and prone to anger.

DPD

Dependents feel inadequate and fragile and need others to rely on. They struggle with being alone and find it nearly impossible to make their own decisions. They are submissive and are more than willing to put others’ needs and views above their own. They will do whatever it takes to get others to care for them, to give them affection, and give direction to their lives.

HPD

Histrionics are dramatic, charming and intense people. Their emotions are both intense and shallow at the same time. Their interests and attitudes are easily influenced by what others think and value. They need attention and reassurance that they are loved from others, so they often overestimate the intimacy of relationships.

NPD

Narcissists have a grandiose sense of self-importance, specialness and uniqueness that leads them to feel entitled and privileged. They expect and need admiration and respect from others to fuel their self-esteem. They lack empathy, so they have difficulty recognising the needs, concerns, or feelings of others. Criticism, rejection and failure leads to massive feelings of shame which is often redirected into anger.

OCPD

Obsessive-compulsives are perfectionists and need to get every detail right. As such, they are anxious and want to be in control of situations, so to avoid mistakes. They find comfort in schedules, rules and details, but their devotion to perfection interferes with their relationships and life outside of work or school. They have a tendency to hoard and are unusually tight with money, just in case.

PPD

Paranoids believe that the world is dangerous and that others will try to harm, exploit and deceive them if they open up. They are always on guard to any sign of threat. They hold on to grudges, never forget a slight, nor pass up a chance for revenge.

STPD

Schizotypals are eccentric, disorganised people whose emotions and speech are strange and blunted. Their strange beliefs are associated with ideas of reference and magical thinking, but don't extend to full-blown psychosis. It's not uncommon for schizotypals to be misdiagnosed as being autistic.

SZPD

Schizoids are uncomfortable being around others and just want to be left alone. Connection with others is scary and difficult, so they tend to keep to themselves. They come across as awkward, distant, and overly formal, and may be described as “cold fish”.

Clinical formulations and case conceptualisations are introduced in this post.

These are all generalisations and theories of how AVPD develops, not something that is supposed to be true for everyone with AVPD.

Psychodynamic model

Shyness, shame, withdrawal & avoidance are defense mechanisms against embarrassment, rejection, humiliation and failure

Shame & fear of vulnerability/exposure of the self to others are interconnected

Avoidants feel ashamed about their perceptions of themselves as weak, incapable, defective

Shame a result of childhood experiences, and not living up to their ideal self

Shame is a defense mechanism designed to protect by perceiving others’ neutral or positive actions or words as negative, and by avoiding and withdrawing from social situations where they could be judged

Biosocial model

High sympathetic nervous system (flight & fight) vs low autonomic arousal (fawn & freeze)

Results in hypervigilance (fight) against threats (being judged), shyness, timidity and avoidance (flight)

AVPD results from caregivers and peer groups’ rejection

Caregiver rejection is frequent and/or intense

Peer rejection reinforces the caregiver rejection, and reduces self-worth and self-confidence, creating self-criticism

Results in avoidance, hypersensitivity and excessive introspection

Hypersensitivity means they interpret small criticisms or even positive or neutral statements as rejections, and this lowers their self-esteem even further

Cognitive-Behavioural model

Avoidants fear being rejected so they don’t initiate or accept relationships

The conflict between their need for connection and fear of rejection is unbearable, so they withdraw

They also withdraw cognitively and emotionally from things that would make them feel uneasy or dysphoric

View themselves as incompetent socially and in school & work, as inadequate and different from others

View others as criticising, judgemental and uncaring

View criticism as being based solely on their perceived inadequacies

Use strategies like distraction, rationalisation, and excuses for when they feel sad and anxious

Interpersonal model

Avoidants grew up with relatively normal attachment processes, but their caregivers were very controlling when it comes to social image and reputation

Noticeable flaws were seen as embarrassing and humiliating

They were expected to be seen as perfect, and they were mocked and degraded if they weren’t

Results in hypersensitivity to rejection and judgement

Integrative model

Avoidants were likely irritable and fearful as babies and were likely slow to warm up to caregivers

View themselves as inadequate and fear rejection

View the world as unfair and criticising, but they still want connection

They need reassurance, but stay hypervigilant for judgement, and use fantasies and daydreams as escape methods

Tendency for catastrophic thinking

Clinical formulations and case conceptualisations are introduced in this post.

These are all generalisations and theories of how ASPD develops, not something that is supposed to be true for everyone with ASPD.

Psychodynamic model

Similar to NPD, both form a pathological grandiose self

ASPD self is based on aggressive introject (internalised self), “stranger self-object”

Stranger self-object reflects caregiver as a stranger who can’t be trusted, is neglectful and abusive

Detachment from caregiver & lack of object permanency leads to detachment from relationships & emotions in adulthood

Attempts to bond with others are sadistic, destructive and controlling

Antisocials don’t see others as separate people so can’t feel empathy for them, or remorse for their actions

Biosocial model

Low serotonin creates tendency for impulsivity and aggression

Antisocials often have childhood trauma

Were difficult to comfort as babies, which may have interfered with normal attachment process

Low stimulation levels in the limbic system, responsible for emotions and behaviour, especially in survival situations (as abusive environments are)

Lack of capacity for fear results in impulsivity and inability to learn from experience

Caregiver abuse, absence and neglect intersects with antisocials’ behaviour as children and as adults; they feel abandoned and unwanted

From this they learn that they must look out for themselves since no one else will, which ties in with their manipulation and lack of remorse as adults

Cognitive-Behavioural model

Antisocials’ behaviour is “persistently irresponsible”

They view themselves as strong, clever and self-sufficient

View others as weak, vulnerable and exploitable, so they will manipulate or victimise them

Dismiss others’ thoughts and feelings as irrelevant to them

Difficulty planning for the future, so they orient themselves entirely in the present

Treatment revolves around managing impulsivity and anger

Core beliefs:

They must look out for themselves

They must be aggressive so others don’t try to dominate and abuse them

They are allowed to break rules

They rationalise their thoughts, feelings and actions (e.g., “I can’t afford this thing, and I want it, so stealing it is ok”)

Conditional beliefs:

If they don’t manipulate and exploit others, they won’t get what they want or need

Instrumental beliefs:

They must get others before they can get them

Take what they need, even if it doesn’t belong to them

Interpersonal model

Antisocials often experience childhood abuse and neglect

Results in adults with ASPD neglecting and exploiting others, and fiercely protecting their autonomy

Childhood trauma is internalised and often results in substance abuse, criminal behaviour, irresponsibility and neglecting duties

Likely as children to take over caregiver’s responsibilities, since no one else did

This results in continuing controlling behaviour and difficulty with emotional bonding as adults

People with ASPD may present as friendly and sociable, but emotionally detached and without regard for others

Integrative model

Antisocials often had “difficult child” temperaments during childhood; they were unpredictable, intense, tended to withdraw from situations, and had low, irritable moods

See themselves as strong, capable, cunning and tough

See the world as full of rules to keep them from getting what they want and need, so they disregard the rules

Defense mechanisms are often acting/lashing out and rationalising their behaviour, feelings and thoughts

Their caregivers were either abusive and hostile, or provided such good role models that their child could not and would not meet such high standards

Caregivers believed that “the ends justify the means”, which was modeled and reinforced in their child

Family structure tends to be disorganised and disengaged

Antisocials need to be powerful and in control, because they fear being abused and humiliated

This results in a denial of vulnerability and “soft” emotions, and being uncooperative