Lecture 8 Personality Disorders.pdf

Personality Disorders Apr 28 2022 Psychopathology of Everyday Life PSYC30014 Dr. Vanja Rozenblat [email protected] 1 Overview ❖ Definitions and core features of personality disorders ❖ DSM-5 Personality Disorder diagnoses & aetiology ❖ Cluster A ❖ Cluster B ❖ Cluster C Part 1 ❖ Alternative dimensional models ❖ Aetiology and cognitive models Part 2 ❖ Additional issues 2 Some definitions What is personality? Personality refers to individual differences in characteristic patterns of thinking, feeling and behaving What is personality disorder? An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture and is manifested in 2 or more of the following areas: • Cognition (ways of thinking and interpreting self, others, events) • Affectivity (range, intensity, lability and appropriateness of emotional response.) • Interpersonal functioning • Impulse control 3 Core features of PD 1. Functional inflexibility • Failure in adaptation to changing and varied life experience; • A tendency to rigidly apply a range of behavioural strategies or responses across diverse life situations - even when inappropriate 2. Self-defeating behaviour patterns • Typical ways of responding or coping that worsen the current situation or are explicitly damaging for the person. • Nevertheless, the person demonstrates limited capacity to intervene constructively or to learn from experience 3. Tenuous stability under stress • Marked instability in mood, thinking and behaviour during difficult periods 4 PDs in the DSM • First introduced in a systematic fashion by the DSM–III in 1980. • Considered “Axis II” disorder until DSM-5 removed axis system Psychosocial & enviro Axis 5 Medical Conditions Axis 4 Personality Disorders Axis 3 Clinical Disorders Axis 2 Axis 1 • Encouraging clinicians to think of PDs as co-existing with ‘Axis 1’ disorders • PDs as interacting with ‘Axis 1’ disorders – impact presentation, treatment adherence, response, etc Global Functioning Score 5 DSM-5 General diagnostic criteria DSM-5: General diagnostic criteria A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. The pattern is manifested in two (or more) of the following • Cognition (i.e., ways of perceiving and interpreting self, other people, and events) • Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response) • Interpersonal functioning • Impulse control B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations C. Leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood E. Not better explained as a manifestation or consequence of another disorder F. Not due to physiological effects of substance or medical condition 6 DSM-5 Personality Disorders Cluster A Cluster C • Paranoid PD • Avoidant PD • Schizoid PD • Dependent PD • Schizotypal PD • Obsessive-compulsive PD Cluster B • Antisocial PD • Borderline PD • Histrionic PD • Narcissistic PD Other • Personality change due to another medical condition • Other specified/unspecific personality disorder 7 Cluster A – Paranoid PD Diagnostic criteria (abrv.) A. A pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent o Inc: Suspicious of others, questions loyalty of friends/associates, reluctant to confide as expect to be exploited, reads hidden messages onto benign remarks, bears grudges, easily slighted and quick to retaliate, suspicious of fidelity of partner B. Does not occur exclusively during schizophrenia or other disorder w psychotic features, or medical condition • Begins by early adulthood • Unlikely to present for treatment • 2.3% - 4% of the population Prevalence data for this lecture: APA, 2013; Grant et al., 2004; Volkert et al., 2018 8 Cluster A – Paranoid PD Aetiology • Research sparse • More common in relatives of those with schizophrenia – genetic loading? • Low self-esteem • Deficits in emotional and social processing • Can find ecological niche where PD works in favour 9 Cluster A – Schizoid PD Diagnostic criteria (abrv.) A. Pervasive pattern of detachment from social relationships and restricted range of expression of emotions in interpersonal settings o Inc: No desire for close relationships, chooses solitary activities, little interest in sexual experiences, takes pleasure in few activities, lacks close friends or confidants, appears indifferent from praise/criticism, shows emotional coldness/detachment/flattened affectivity. B. Does not occur exclusively during schizophrenia or other disorder w psychotic features, or medical condition • Begins by early adulthood • 2.2%-4% of population 10 Cluster A – Schizoid PD Aetiology (abrv.) • Very little research – some calls for it to be removed from DSM-5 pre publication • Speculation that linked to Asperger's • Barren upbringing, underpowered limbic system • Not associated with schizophrenia spectrum disorders • High level of dysfunction 11 Cluster A – Schizotypal Diagnostic criteria (abrv.) A. Pervasive pattern of social and interpersonal deficits marked by acute discomfort and reduced capacity for close relationships, as well as by cognitive/perceptual distortions and eccentric behaviour o Inc: Ideas of reference, odd beliefs/magical thinking, unusual perceptual experiences, odd thinking and speech, suspiciousness/paranoid ideation, inappropriate/constrained affect, odd or eccentric behaviour or appearance, lack of close friends, social anxiety related to paranoia B. Does not occur exclusively during schizophrenia or other disorder w psychotic features, or medical condition • 1.5%-4.6% of population 12 Cluster A – Schizotypal Aetiology • Link with schizophrenia - milder form of schizophrenia • Cognitive abnormalities - attention, memory deficits; • Higher levels of dopamine neurotransmitter (Siever & Davis, 2004). • Crossover to schizophrenia-spectrum disorders 13 Case example (Cluster A) Mark attends therapy at the urging of others. He sits where instructed, erect but listless. When the therapist asks him how he feels about attending therapy, he shrugs and mumbles "OK, I guess". He rarely twitches or flexes his muscles or in any way deviates from the posture he has assumed early on. He shows no feelings when discussing his uneventful childhood, his parents ("of course I love them"), and sad and happy moments he recollects at the therapist’s request. Mark veers between being bored with the encounter and being annoyed by it. When asked how he would describe his relationships with other people, he states that he has none that he can think of. In whom does he confide? He eyes the therapist quizzically: "confide?" Who are his friends? Does he have a partner? No. He shares pressing problems with his mother and sister, he finally remembers. When was the last time he spoke to them? More than two years ago, he thinks. Does this best fit with Paranoid PD, Schizoid PD, or Schizotypal PD? 14 Cluster B – Antisocial PD Diagnostic criteria (abrv.) A. Pervasive pattern of disregard for and violation of the rights of others o Inc: Failure to conform to social norms/lawful behaviour (behaviour that is grounds for arrest), deceitfulness, impulsivity or failure to plan ahead, irritability and aggressiveness (repeated fights/physical assaults), reckless disregard for safety, consistent irresponsibility, lack of remorse. B. Individual at least 18 years of age C. Evidence of conduct disorder before 15 yrs D. Does not occur exclusively during schizophrenia/bipolar • Prevalence varies depending on sample. Community samples about 3%-3.5% • Over-represented in prison populations 15 Cluster B – Antisocial PD Aetiology • High sensation-seeking; childhood conduct disorder, low psycho-physiological arousal • Elevated in family members, as is higher levels of criminality, high levels of impulsivity (genetic contribution) • Low levels of serotonin; Frontal problems • High levels of childhood aggression and associated with physical abuse, harsh and neglectful parenting ❖ Link with psychopathy ❖ What should be the implications for sentencing? 16 Cluster B – Borderline PD Diagnostic criteria (abrv.) A. Pervasive pattern of instability of interpersonal relationships, self-image, and affects, marked impulsivity o Inc: Frantic efforts to avoid abandonment, unstable and intense interpersonal relationships, identity disturbance, impulsivity (e.g., spending, sex, binge eating, reckless driving), recurrent suicidal behaviour/self-harm, affective instability (marked reactivity of mood), chronic feelings of emptiness, inappropriate/intense anger, transient paranoid ideation Community samples - 1.6-5.9% 75% females Begins by early adulthood – adolescent diagnosis has diagnostic validity 17 Cluster B – Borderline PD Aetiology • Torgersen et al. (2000) found genetic contribution • Meta-analytic data indicating association with sexual & physical abuse, parental hostility/verbal abuse, and neglectful and invalidating environments • Increased hippocampal volumes and heightened activation in amygdala • Insecure attachment and fear of abandonment, desire intimacy but anxious about dependency on others Comorbidity • Mood disorders • Anxiety disorders • Substance use disorder Winsper et al. 2016 18 Cluster B – Borderline PD BPD & suicide • Risk of death by suicide 45 times higher than for general population • Review of cases to Coroner’s Court of Victoria between 2009 – 2013: • 6.3% of people had a recorded BPD diagnosis (further 2.5% ‘suspected’) • Mental health service contact: – 98.9% of those with BPD in 12 months prior, 88% 6-weeks prior – Note: Need service contact to receive a diagnosis • Strong help-seeking behaviour Chesney et al 2014 19 Cluster B – Borderline PD ❖ Some argument it is better defined as a mood/emotional regulation disorder or a form of PTSD • Cluster analysis revealed difference between BPD and complex PTSD inc. ‘frantic efforts to avoid abandonment’, ‘unstable sense of self’, ‘unstable and intense interpersonal relationships’, and ‘impulsiveness’ • BPD does not respond to mood stabilising medication as with mood disorders, and tx for BPD and complex PTSD also differ 20 Cluster B – Histrionic PD Diagnostic criteria (abrv.) A. Pervasive pattern of excessive emotionality and attention seeking o Inc: Uncomfortable when not centre of attention, interaction characterised by inappropriate sexually seductive or provocative behaviour, rapidly shifting and shallow emotional expression, uses physical appearance to draw attention to self, speech overly impressionistic and lacking in detail, is suggestible, considers relationships more intimate than they are Begins by adulthood Prevalence 0.8-1.8% More commonly diagnosed in females 21 Cluster B – Histrionic PD Aetiology • Little work • Family studies show higher rates of BPD, Antisocial and histrionic PD in relatives. • Theoretical accounts focus on encouragement of sexualisation, attentionseeking and role of intense, inconsistent and non-empathic parenting interactions 22 Cluster B – Narcissistic PD Diagnostic criteria (abrv.) A. Pervasive pattern of grandiosity, need for admiration, and lack of empathy. o Inc: Grandiose sense of self-importance, preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love, believes they are ‘special’ and can only associated/be understood by other special/high status people or institutions, requires excessive admiration, sense of entitlement, interpersonally exploitative (to achieve own ends), lacks empathy, envious of others, shows arrogant or haughty behaviours or attitudes Begins by early adulthood Not aligned with reality/actual achievements 1.2 - 6.2% 50%-75% males 23 Cluster B – Narcissistic PD Aetiology • Early childhood experiences: child’s needs for nurturing and affection were not met. • Kernberg says chronically cold caregivers display either indifference or aggression towards the child. Stone (1993) adds that compensatory beliefs can arise when a child is exposed to parental indifference • OR alternative theory – too much praise leading to inflated sense of ego • Livelsey et al. (1993) say this PD has the highest genetic loading 24 Narcissistic PD Factor analysis suggests two underlying subtypes (Wink, 1991): ❖ Grandiosity or Overt Narcissism • Associated with grandiosity, social charm, failure to respond to needs of others, invulnerability, entitlement, aggression, and dominance ❖ Vulnerability/Sensitivity or Covert Narcissism • Uses grandiose behaviour to mask hypersensitivity to criticism, self-doubt, deep feelings of inadequacy, incompetence, inferiority, worthlessness and negative affect (high neuroticism) • May present as more introverted 25 Case example (Cluster B) A student quickly formed a very intense relationship with another student she met in class. Immediately, the young woman wanted to spend all of her free time with the other student and spoke very highly of her new “best friend.” However, the first time the other student declined an offer to socialize, the young woman felt intensely afraid and hurt. She suddenly suspected that her new friend was abandoning her and lashed out at the other student, berating her and accusing her friend of deserting her. Understandably, the other student ended the relationship. Does this best fit with Anti-social PD, Borderline PD, Histrionic PD, or Narcissistic PD? 26 Cluster C – Avoidant PD Diagnostic criteria (abrv.) A. Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation o Inc: Avoid occupational activities with high interpersonal contact due to fear of criticism, unwilling to get involved with people unless certain of being liked, restraint in intimate relos due to fear of being shamed/ridiculed, preoccupied with social rejection/criticism, inhibited in new social settings, views self as inferior/socially inept, reluctant to take personal risks/new activities • 2.4% prevalence • Differences in cultural expectations 27 Cluster C – Avoidant PD Aetiology • High in restraint as children, high neuroticism, low extroversion, shyness in childhood; higher incidence of avoidant PD in first-degree relatives • Jovev and Jackson (2004) found schemas related to defectiveness and abandonment. 28 Cluster C – Dependent PD Diagnostic criteria (abrv.) A. Pervasive and excessive need to be taken care of, leads to submissive and clinging behaviour and fears of separation o Inc: Difficulty making daily decisions w/out reassurance, need for others to make decisions for them, difficulty expressing disagreement due to fear of rejection, difficulty starting things alone, goes to excessive lengths to obtain nurturance/support, feels uncomfortable/helpless when alone, urgently seeks another relationship if one ends, preoccupied with fears of being left to take care of themselves • <1% prevalence 29 Cluster C – Dependent PD Aetiology • Separation anxiety disorder and agoraphobia more elevated in family members; high neuroticism and low extroversion. • Speculation that overprotected attachment - the world is a dangerous place and that they are incompetent to be able to deal with it alone 30 Cluster C – Obsessive compulsive PD Diagnostic criteria (abrv.) A. Pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control, at the expense of flexibility, openness, and efficiency o Inc: Preoccupied with details, rules, lists, etc, until the point of the activity is lost, perfectionism interfering with task completion, excessively devoted to work and productivity to the exclusion of leisure activities/friendships, is overconscientious and inflexible re: morality, ethics, or values, hoarding, reluctant to delegate, miserly spending style – money viewed as something to be hoarded for future catastrophes, rigidity and stubbornness. • Prevalence 3.2% -7.9% • Diagnosed twice as often in males 31 Cluster C – Obsessive compulsive PD Aetiology • High perfectionism • Millon and Davis (1996) – the child learned to suppress feelings and perform approved behavioral routines in order to avoid punishment or disapproval by parental figures • Different from OCD • Personality style supported by Western culture 32 Case example (Cluster C) Sam presents to therapy encouraged by his partner, who feels Sam is not prioritising their relationship. Sam states that he loves his partner and spends time with them watching a movie at home every Saturday night at 8pm. He gets quite upset if this plan is changed, or if his partner wants to watch a movie on another night. He understands that his partner wishes they would socialise more with their friends, but Sam finds it quite difficult to find the time in his busy work schedule to accommodate this. Prior to living with his partner, Sam lived with his grandmother because of the cheap rent, and when moving in with his partner there was significant conflict due to him wanting to bring all of his childhood possessions into their new apartment. Despite having a job with regular work hours, Sam often stays back at work without extra compensation as it tends to take him a lot longer to write a report, which needs to meet his high standards. Does this best fit with Avoidant PD, Dependent PD, or Obsessive Compulsive PD? 33 Personality change due to another medical condition Diagnostic criteria (abrv.) A. Persistent personality disturbance that represents change from previous characteristic personality function B. Evidence change due to direct pathophysiological consequence of another medical condition C. Not better explained by other mental disorder/occurs exclusively during delirium D. Disturbance causes clinically significant distress or impairment in functioning o Types: Labile, disinhibited, aggressive, apathetic, paranoid, other, combined, unspecified • E.g., brain tumour, dementia • Distinct from other PDs 34 Other specified/unspecified personality disorder • PD that causes clinically significant distress or impairment but does not meet full criteria ➢ Other specified – Clinician choses to communicate reason criteria not met ➢ Unspecified – Clinician choses not to communicate reason criteria not met, or insufficient criteria 35 Some general issues when diagnosing PDs… Establishing prevalence over time Age requirements Role of gender norms Impact of cultural background Diagnosis process Overshadowing 36 Epidemiology: All PDs How many people meet criteria for at least one PD? ▪ Australian data: all PDs 6.5% adults (Jackson & Burgess, 2004) ▪ Best international studies: – Oslo, Norway: 13% (Torgensen et al., 2001) – Meta-analysis of Western countries: 12% (Volkert et al., 2018) – World wide pooled: 8%, high income: 9.5%, low/middle income: 4.3% (Winsper et al., 2019) Mental health settings: 25 - 40% (Bank & Silk, 2001) 37 PD diagnosis vs PD traits • People may presents with ‘traits’ of PDs, without meeting full criteria for a personality disorder • Dimensional approach to categorical system • Personality lies on a spectrum – DSM-5 disorders one end of this spectrum 38 Dimensional conceptualisations of personality disorders 39 Issues with DSM conceptualisation of PDs • Some DSM PD criteria are behaviours, e.g., criminal acts, others are traits, e.g., emptiness • Some DSM PD criteria are harder to assess (identity disturbance) than others, e.g., impulsivity. • Some features of PDs are found in other disorders and also in people without PDs • Diagnostic criteria determined by consensus Alternative DSM-5 Models for Personality Disorders ‘Dimensional’ model in DSM-5 appendix Focus on impairments in personality functioning and pathological personality traits. Includes: -Antisocial, Avoidant, Borderline, Narcissistic, Obsessive-compulsive, Schizotypal -General diagnosis of PD (PD-TS) 41 Main criteria of AMPD ❖ Criterion A: Level of Personality Functioning (+ level of impairment) ➢ Self (Identity, self-direction) ➢ Interpersonal (Empathy, intimacy) ❖ Criterion B: Pathological Personality traits ➢ Five broad trait domains (Negative affectivity, detachment, antagonism, disinhibition, psychoticism) ➢ 25 specific trait facets ❖ Criteria C & D: Pervasiveness and Stability ❖ Criteria E, F, G: Alternative Explanations for Personality Pathology 42 Criterion 2 – Based on Big 5 • Based on 5-factor model of personality 43 Example from AMPD 44 Example from AMPD 45 AMPD summary • Stronger empirical underpinning • Moving away from ‘Clusters’ • Emphasis on functioning • Encouraging consideration of multiple areas of personality variation (5 domains) and assessing these via a dimensional lens • Still not truly dimensional – adding dimensional element to existing categories 46 Push for dimensional categorisation Hopwood et al., 2018 47 Push for dimensional categorisation Hopwood et al (2018) argue: • No/poor empirical evidence supporting the hypothesis that personality disorders are categorical • Low reliability of categories • Substantial comorbidity • Individual can meet criteria for category in numerous ways • Little treatment progress • Tx for BPD non-specific ❖ Current system contributes little, requires change to empirically supported conceptualisation Hopwood et al., 2018 48 How helpful are categories? ➢ But aren’t categories useful in a clinical capacity? • PROS • Guide for treatment • Diagnosis can be a relief for the individual, lead to understanding re: one’s struggles • Can help clinician understand client too • Ease communication (clinical, and also useful for research) • CONS • Not much evidence re: effective tx • Can increase stigma, and viewed as stable and pervasive • Are we better off addressing on symptom-level (the specific patterns of behaviour – e.g., emotional regulation skills in BPD)? 49 ICD-11 dimensional model International Classification of Diseases (ICD) includes mental health section • ICD-11 published in 2019 moved from categorical to dimensional model Focus on impairment of self and interpersonal functioning, global assessment • Classified according to severity (Mild, Moderate, Severe) • One or more prominent trait qualifiers: ➢ Negative affectivity ➢ Detachment ➢ Dissociality ➢ Disinhibition ➢ Anankastia • Includes Borderline Patterns qualifier Bach & First, 2018 50 ICD-11 dimensional model Dimensional classification: • Encouraging clinicians to consider PDs • Impact on treatment selection and development Watts (2019) argues against inclusion of BPD qualifier • No evidence yet that this assist with treatment or reduces stigma • “Patients have regularly reported that being diagnosed with a personality disorder is the ultimate character slur, leading to realisation of every worst fear one has about themselves, and often reinforcing messages from abusers that they are inherently problematic” Watts, 2019 51 Aetiology and Cognitive Models 52 PDs: Aetiology (basic model) Genetic predisposition + Life events Personality Personality disorders associated with experience of disrupted attachment with primary carers, trauma, neglect, deprivation Cognitive models Role of maladaptive core beliefs, ‘schemas’ (Beck, Young) • e.g., abandonment, entitlement, unrelenting standards ❖ Schema as filter through which new information processed • E.g., perceive ambiguous email as rejection ❖ Each PD is characterised by specific maladaptive core beliefs/schema ❖ Core beliefs are resistant to change -> maintenance of dysfunctional beliefs, emotions and behaviours (Beck & Freeman, 1990) Cognitive models Early Maladaptive Schema in PDs: • Highly resistant to change, • Associated with high levels of affect, • Significantly impair functioning, • Individual selectively perceives and distorts information that confirms schema and filters out info that disconfirms them ❖Emotion, body sensations and behaviours are tied in with cognitions. Schema Domain Early maladaptive schema Schema Domain Early maladaptive schema Disconnection/ rejection Abandonment/ Instability Mistrust/Abuse Emotional Deprivation Defectiveness/ Unlovability Social Isolation Overvigilance/ inhibition Negativity/Pessimism Self-punitiveness Emotional inhibition Unrelenting standards Impaired autonomy Dependence/ Incompetence Vulnerability to harm or illness Enmeshment/ undeveloped self Failure to achieve Other-directedness Subjugation Self-sacrifice Approval seeking/ Recognition seeking Impaired limits Entitlement/superiority Insufficient selfcontrol/self-discipline Schema perpetuation in PDs • Schema Surrender – Individual accepts schema as true, fully experiences the associated intense emotions and behaves according to the schema • Schema avoidance – Blocks thoughts, images, feelings that are part of the schema due to distressing nature (e.g. substance use) or avoid situations that trigger schema (e.g. relationships) • Schema overcompensation – Reacts in extreme opposite to the schema- underlying schema remains intact but also creates more problems Dialectical Behaviour Therapy (DBT) model Dialectical Behaviour Therapy (Linehan), model and therapy based on the following: • Dysfunctional emotion regulation system is fundamental– part biological/ part experiential. • Temperament - high in neuroticism, heightened baseline arousal, increased intensity of responses to emotional stimuli; • Child is subjected to drastically invalidating environments, e.g., deprivation, neglect, and physical and emotional abuse. Personality disorders: Additional issues 59 Ongoing questions • What is the role of culture in the development and conceptualisation of PDs? • What is the role of gender? Do differences in prevalence represent diagnostic biases? • What is the role of the ecological niche? • i.e., when personality type rewarded by environment • Are PDs increasing in prevalence? • Or is it increasing recognition? 60 Stigma • Stigma associated with personality disorders • e.g., BPD in clinical settings • Personality disorders viewed as ‘egosyntonic’ – part of who the person ‘is’? • Understanding and empathy vital • Person doing their best to get through life best way they know how • Aetiology – emphasis on parental behaviour • Careful of blame – most parents trying their best given their personal resources 61 Treatment of personality disorders Psychosocial: o CBT or variants of CBT (Young Schema Therapy, DBT, CAT) o Group and individual o BPD – early detection and treatment valuable Pharmacological o Behaviour traits associated with personality disorders associated with neurochemical abnormalities. o Nearly all clinical trials have been with borderline personality disorder Outcomes: • Cluster A – Limited evidence-based treatments • Cluster B – Most research, increasing treatment success • Cluster C – Least severe functional impairment, best outlook Treatment of personality disorders Issues: • What are we treating? • No consensus on how to measure improvement • Co-morbidity with other disorders • Social and interpersonal function often remain impaired • Major lack of evidence-based treatments… Strengths-based approaches • Current emphasis in mental health is on categorising individuals according to pathology • Focussed on pathology • Low self-esteem, stigma, poor QoL • Considered chronic • Instead, focussing on individual’s attributes that promote health • Mental health seen as normal part of human life • Focus on individual’s abilities, assets, strengths, to function better and increase confidence to progress through recovery • Focus on living meaningful life despite mental illness • Greater autonomy in recovery ❖ Strengths-based approaches associated with better academic, social, and behavioural outcomes, and increased life satisfaction – but more research needed 64 e.g, Xie, 2013 Conclusions • PDs - significant functional challenges for the individual • Issues re DSM conceptualisation and assessment • Little treatment evidence other than for borderline personality disorder • Growing support for dimensional models – and this may facilitate improved understanding and therefore treatment outcomes

Lecture 8 Personality Disorders.pdf

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