Chapter 13 Personality Disorders

inability to come up with an adaptive solutions to life tasks

DSM-5 reflects "adaptive failure" in terms of impaired self-idenitty and adaptive failure in establishing interpersonal relationships

1. To form stable, integrated and coherent representations of self and others (to see your self and others as they really are)

2. To develop capacity for intimacy (to have positive inter-relationships)

3. To engage in prosocial and cooperative behaviours (to function adaptively in society)

2. Self defeating, vicious cycle that perpetuate troubled ways of thinking and behaving

3. Structural instability, fragility, ‘cracking’ under stress

afflicted person has difficulty altering his/her behaviour according to changing situations

the person engages in self defeating behaviour that fosters vicious cycles

behaviour and cognitions exacerbate exiting conditions >self-defeating behaviour removes us further from our goals rather then closer

fragility of the self that cracks under stress

ex: student who functions well in the first part of the term and then cracks and loses inability to cope at the latter half when deadlines become closer

heterogeneous group of disorders that are regarded as long-standing , pervasive and inflexible patterns of behaviour and inner experience that deviate from the expectations of a person's culture and that impair social and occupational functioning

some cause emotional distress

new DSM category that reflects establishing whether a personality disorder first exists in general and then evaluating whether the criteria of a specific personality can also be applied

Eliminated Axis II (DSM-IV-TR)

Considered dimensional approach, which is described as an ‘alternative model’ in DSM-5 Section III

disordered personality reflects extreme levels of tendencies (traits)

Not fully adopted in DSM-5, remains a proposal

1. cognition

2. affectivity

3. interpersonal functioning

4. impluse control

B. inflexible and pervasive across personal and social situations

C. causes clinically sig digress

D. stable, long duration, onset traced to adolescence or early adulthood

E. not better explained by other mental disorderF. NOT attributed to physiological effects, substance or other medical condition

Cluster A > Paranoid, Schizoid, and Schizotypal

- Oddness and avoidance of social contact

Cluster B > Anti-social, Borderline, Histrionic, and Narcissistic

- Dramatic, emotional, or erratic

- Extrapunitive and hostile

Cluster C > Avoidant, Dependent, and Obsessive-Compulsive

- fearful

Paranoid

Schizoid

Schizotypal

- Oddness and avoidance of social contact

- Suspicious of others

- Expect to be mistreated or exploited by others

- Reluctant to confide in others

- Tend to blame others

- Can be extremely jealous

most common in men

- hallucinations and full-blown delusions are not present

- less impairment in social and occupational functioning than paranoid schizophrenia

Comorbid with schizotypal, avoidant, and paranoid personality disorders •

- No desire for or enjoyment of social relationships

- Appear dull, bland, and aloof

- Rarely report strong emotions

- Have no interest in sex

- Experience few pleasurable activities

- Indifferent to praise and criticism

- Loners with solitary interests

< 1%

Slightly more common in men

Comorbid with schizotypal, avoidant, and paranoid personality disorders

Similar interpersonal difficulties (social detachment and restricted affect) of schizoid personality

Key schizotypal features:

- eccentric thinking (considered identical to prodromal and residual phases of schizophrenia)

- Odd beliefs or magical thinking (e.g., belief they have telepathic powers)

- Recurrent illusions (e.g., sense the presence of a force not actually there)

- Odd speech (using words in unusual or unclear fashion)

- Ideas of reference (misinterpret event as having particular personal meaning)

- Suspiciousness, Paranoid ideation, Eccentric behaviour and appearance

3%

Slightly more frequent men

Comorbidity is higher than any other personality disorder

Comorbid with borderline, avoidant and paranoid personality disorders

Based upon family study research

Possible genetic links to schizophrenia

- Considered less severe variants of

Could be linked to a history of PTSD and childhood maltreatment

Anti-social

Borderline

Histrionic

Narcissistic

- Dramatic, emotional, or erratic

- Extrapunitive and hostile

Term: originally – ‘borderline’ between neurosis and schizophrenia but DSM no longer has this sense

- impulsivity and instability in relationships, mood, and self-image

- Attitudes and feelings toward others vary dramatically

- Emotions are erratic and can shift abruptly

- Argumentative, irritable, sarcastic, quick to take offence, etc.

1 to 2%

more common in women than in men

Comorbid with mood disorder, substance abuse, PTSD, eating disorders, and Cluster A PDs

inconsistent parental love causes insecure ego development

heritablitity ranged from 37-69%

3-4X greater likelihood of being diagnosed

over activation in the insula and posterior cingulate cortex

under activation across a region that stretches from the amygdala to the dorsolateral prefrontal cortex

> great demands on the family > invalidation by parents through punishment or ignoring demands > emotional outbursts by child to which parent attends

> cycle starts again

- Overly dramatic and attention-seeking

- Use physical appearance to draw attention

- Display emotion extravagantly

- Self-centred

- Overly concerned with their attractiveness

- Inappropriately sexually provocative and seductive

- Speech may be impressionistic and lacking in detail

2 to 3%

More common among women than among men

Comorbid with depression and BPD

seductiveness encouraged by parental upbringing

Family environment: talked about sex as ‘dirty’ but behaved as if exciting

- Grandiose view of own uniqueness and abilities

- Preoccupied with fantasies of great success

- Require almost constant attention and excessive admiration

- Lack empathy

- Envious of others

- Arrogant, exploitive, entitled

< 1%

Comorbid with BPD

immature grandiosity and dependent over-idealization of others – failure to develop healthy self-esteem

Product of our times and system of values?

1. Conduct disorder present before age 15 (i.e., truancy, running away from home, theft, arson)

2. Pattern of anti-social behaviour continues into adulthood

-Irresponsible and anti-social behaviour

- Work only inconsistently

- Break laws

- Physically aggressive

- lack of remorse (‘without conscience’), no sense of shame

- superficially charming

- manipulates others for own personal gain, exploits people

- thrill seeking All psychopaths are diagnosed with APD but many with APD do not meet the criteria for psychopathy

killers who were not simply persistently antisocial; they were remorseless predators, used charm, intimidation and cold-blooded violence to achieve their ends

- 20% of people with APD score higher on the Hare Psychopathy Checklist

- 75 to 80% of convicted felons meet criteria for APD but only 15 to 25% of convicted felons meet criteria for psychopathy

Psychopathic personality in adolescence predicts antisocial behaviour in adulthood

Children with psychopathic traits show abnormal prefrontal cortex responsiveness

- Lack of affection

- Severe parental rejection

- Physical abuse

- Inconsistencies in disciplining

- Failure to teach child responsibility toward others

1. Harsh or inconsistent disciplinary practices could be reactions child’s anti-social behaviour

2. Many individuals who come from disturbed backgrounds do not become psychopaths

Criminality and APD have heritable components

- higher concordance for MZ compared to DZ twin pairs

Increased parental conflictand increased negativity

decrease parental warmth predict antisocial behaviours

Familieswithout antisocial tendencies may become harsh in their disciplining inreaction to the child with antisocial tendencies

Unresponsive to punishments / no conditioned fear responses

- higher skin conductance in resting situations

- higher skin conductance is less reactive when confronted or anticipate intense or aversive stimuli

- normal heart rate under resting conditions but decreased heart rate when anticipating intense or aversive stimuli

Slow brain waves and spikes in the temporal area

Less activity in the amygdala/hippocampal formation

Decreased prefrontal activity

Avoidant

Dependent

Obsessive-Compulsive

- fearful

- fearful in social situations

- sensitive to possibility of criticism, rejection, or disapproval

- reluctant to enter relationships unless sure will be liked

Comorbid with dependent personality disorder, depression and generalized social phobia

- Lack self-reliance

- Overly dependent on others (sense of autonomy)

- Intense need to be taken care of

- Uncomfortable when alone

- Subordinate own needs

Comorbid with bipolar disorder, depression, anxiety disorders, and bulimia

Culture-laden? Connecting with others is more valued in collectivistic cultures (such as East Asia) compared with North American individualism

- Perfectionistic approach to life

- Preoccupied with details, rules, schedules, etc. - - Serious, rigid, formal, and inflexible

- Unable to discard worn out and useless objects

Obsessive Compulsive Personality Disorder (OCPD) does not have the obsessions and compulsions that define Obsessive Compulsive Disorder (OCD)

Comorbid with OCD (20%), panic disorder, depression, and avoidant personality disorder

•Not much is known about causes for personality disorders in this cluster

- Speculation focused on parent-child attachment relationships

Psychoanalytic theories: OCPD traits due to fixation at anal stage of psychosexual development

Schema therapy uses CBT approach to examine logical errors and dysfunctional attitudes

individuals with borderline personality disorder have troubles establishing trust

alternatively idealize then vilify therapist,

Strengthening client’s weak ego

Reducing ‘splitting’

Combines client-centred acceptance with a cognitive-behavioural focus

Challenge dichotomous (‘black and white’) thinking

teach assertiveness and emotion regulation

Psychopaths do not benefit from psychotherapy

They are unable to form trusting, honest relationships with therapists

Biological treatments are also mainly ineffective - large doses of anti-anxiety medication are used to reduce hostility

BPD develops when a biological diathesis (genetic) for having difficulty controlling their emotions are raised in a family environment that is invalidating

two main factors interact > dysregulation and invalidation

can interact with experiences that invalidate the child, leading to the development of a borderline personality

environment in which a person's wants and feelings are disregarded and efforts to communicate one's feelings are disregarded or even punished

extreme> abuse sexual or non

more common among ppl with BPD then amongst those diagnosed with other disorders

exception dissociative identity disorder > high rates of abuse as well