PSY110P-Chapter-12-Personality-Disorders.pptx

Personality Disorders  Personality Disorders   Personality disorder is a common and chronic disorder.  Personality disorder is also a predisposing factor for other psychiatric disorders (e.g., substance use, suicide, affective disorders, impulse-control disorders, eating disorders, and anxiety...

Personality Disorders  Personality Disorders   Personality disorder is a common and chronic disorder.  Personality disorder is also a predisposing factor for other psychiatric disorders (e.g., substance use, suicide, affective disorders, impulse-control disorders, eating disorders, and anxiety disorders).   Persons with personality disorders are far more likely to refuse psychiatric help  Personality disorder symptoms are alloplastic (i.e., able to adapt to, and alter, the external environment) and ego-syntonic (i.e., acceptable to the ego).  Persons with personality disorders do not feel anxiety about their maladaptive behavior. Because they do not routinely acknowledge pain from what others perceive as their symptoms, they often seem disinterested in treatment and impervious to recovery.   Personality disorders  A persistent pattern of emotions, cognitions and behavior that results in enduring emotional distress for the person affected and/or for others and may cause difficulties with work and relationships   High comorbidity  Poorer prognosis  Therapist reactions  Countertransference  10 specific personality disorders  3 clusters Clusters of Personality Disorders  Cluster A includes three disorders with odd, aloof features, such as paranoid, schizoid, and schizotypal.  Cluster B includes four disorders with dramatic, impulsive, and erratic features, such as borderline, antisocial, narcissistic, and histrionic.  Cluster C includes three disorders sharing anxious and fearful features, such as avoidant, dependent, and obsessivecompulsive. Categorical and Dimensional Models   Categorical vs. dimensional models  “Kind” vs. “Degree”   Dimensions instead of categories By a dimensional model individuals would not only be given categorical diagnoses but also would be rated on a series of personality dimensions  “Emerging measures and models” Categorical and Dimensional Models   Five factor model of personality (“Big Five”)      Openness to experience Conscientiousness Extraversion Agreeableness Emotional stability  Cross-cultural research establishes the universal nature of the five dimensions Personality Disorder Clusters   Statistics and Development   Prevalence  Barlow (2015) = 6%, may be closer to 10%  Kring (2012) = 10 – 20%  Origins and course  Begin in childhood  Chronic course  Can remit but is replaced by other personality disorder  High comorbidity Gender Differences   Men diagnosed with a personality disorder tend to display traits characterized as more  Aggressive, structured, self-assertive and detached  Women tend to present with characteristics that are  More submissive, emotional and insecure Personality Disorders UnderStudy  Categories of disorders  Sadistic - includes people who receive pleasure by inflicting pain on others  Passive aggressive - includes people who are defiant and refuse to cooperate with requests— attempting to undermine authority figures Passive Aggressive Personality Disorder   Persons with passive-aggressive personality disorder are characterized by covert obstructionism, procrastination, stubbornness, and inefficiency.  Patients with passive-aggressive personality disorder characteristically procrastinate, resist demands for adequate performance, find excuses for delays, and find fault with those on whom they depend Cluster A: Paranoid   Clinical description  Mistrust and suspicion       Pervasive Unjustified Few meaningful relationships Volatile Tense Sensitive to criticism Cluster A: Paranoid   Causes  Possible relationship to schizophrenia  Possible role of early experience    Trauma Learning People are malevolent and deceptive  Cultural factors     Prisoners refugees people with hearing impairments older adults Cluster A: Paranoid Personality Disorder   The hallmarks of paranoid personality disorder are excessive suspiciousness and distrust of others expressed as a pervasive tendency to interpret actions of others as deliberately demeaning, malevolent, threatening, exploiting, or deceiving.  Persons with this disorder externalize their own emotions and use the defense of projection; they attribute to others the impulses and thoughts that they cannot accept in themselves.   A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:  suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her  is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates   is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her  reads hidden demeaning or threatening meanings into benign remarks or events  persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights  perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack  has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner Cluster A: Paranoid   Treatment  Unlikely to seek on own  Crisis  Focus on developing trust  Cognitive therapy  Assumptions  No empirically-supported treatments  Poor improvement rate Cluster A: Schizoid   Clinical description  Appear to neither enjoy nor desire relationships  Loner  Limited range of emotions  Appear cold, detached  Appear unaffected by praise, criticism  Unable or unwilling to express emotion  No thought disorder Cluster A: Schizoid Personality Disorder   Schizoid personality disorder is diagnosed in patients who display a lifelong pattern of social withdrawal. Their discomfort with human interaction, their introversion, and their bland, constricted affect are noteworthy. Persons with schizoid personality disorder are often seen by others as eccentric, isolated, or lonely.  Persons with the disorder tend to gravitate toward solitary jobs that involve little or no contact with others. Many prefer night work to day work, so that they need not deal with many persons.   Their affect may be constricted, aloof, or inappropriately serious, but underneath the aloofness, sensitive clinicians can recognize fear.  Their speech is goal-directed, but they are likely to give short answers to questions and to avoid spontaneous conversation. They may occasionally use unusual figures of speech, such as an odd metaphor, and may be fascinated with inanimate objects or metaphysical constructs.  Their mental content may reveal an unnecessary sense of intimacy with persons they do not know well or whom they have not seen for a long time. Cluster A: Schizoid   Causes  Limited research  Precursor: childhood shyness  Possibly related to:   Abuse/neglect Autism Cluster A: Schizoid   Treatment  Unlikely to seek on own  Crisis  Focus on relationships  Social skills therapy    Empathy training Role playing Social network building  Empirically-supported treatments limited Cluster A: Schizotypal   Clinical description  Psychotic-like symptoms    Magical thinking Ideas of reference Illusions  Odd and/or unusual   Behavior Appearance  Socially isolated  Suspicious Cluster A: Schizotypal Personality Disorder   Persons with schizotypal personality disorder are strikingly odd or strange, even to laypersons. Magical thinking, peculiar notions, ideas of reference, illusions, and derealization are part of a schizotypal person's everyday world.  These patients may be superstitious or claim powers of clairvoyance and may believe that they have other special powers of thought and insight. Cluster A: Schizotypal   Causes  Schizophrenia phenotype?  Lack full biological or environmental contributions  Cognitive impairments   Left hemisphere More generalized Cluster A: Schizotypal   Treatment  Treatment of comorbid depression 30 – 50%  Multidimensional approach    Social skill training Antipsychotic medications Community treatment Cluster B: Antisocial   Clinical description  Noncompliance with social norms  “Social Predators”     Violate rights of others Irresponsible Impulsive Deceitful  Lack a conscience, empathy, and remorse Cluster B: Antisocial   Nature of psychopathy       Glibness/superficial charm Grandiose sense of self-worth Pathological lying Conning/manipulative Lack of remorse Callous/lack of empathy Cluster B: Antisocial   DSM-5  More trait based approach  Overlap with ASPD, criminality  Intelligence Cluster B: Antisocial   Developmental considerations  Early histories of behavioral problems  Conduct disorder  childhood-onset type  adolescent-onset type  Families history of:     Inconsistent parental discipline Variable support Criminality Violence Causes of Antisocial Personality   Gene-environment interaction  Genetic predisposition  Environmental triggers  Arousal hypotheses  Underarousal  Fearlessness Cluster B: Antisocial Personality Disorder   Antisocial personality disorder is an inability to conform to the social norms that ordinarily govern many aspects of a person's adolescent and adult behavior.  Patients with antisocial personality disorder can fool even the most experienced clinicians. In an interview, patients can appear composed and credible, but beneath the veneer (or, to use Hervey Cleckley's term, the mask of sanity) lurks tension, hostility, irritability, and rage.   Patients with antisocial personality disorder can often seem to be normal and even charming.  Their histories, however, reveal many areas of disordered life functioning. Lying, truancy, running away from home, thefts, fights, substance abuse, and illegal activities are typical experiences that patients report as beginning in childhood. These patients often impress opposite-sex clinicians with the colorful, seductive aspects of their personalities, but same-sex clinicians may regard them as manipulative and demanding.   They are extremely manipulative and can frequently talk others into participating in schemes for easy ways to make money or to achieve fame or notoriety. These schemes may eventually lead the unwary to financial ruin or social embarrassment or both.  A notable finding is a lack of remorse for these actions; that is, they appear to lack a conscience. Antisocial Personality Disorder  Treatment      Unlikely to seek on own High recidivism Incarceration Early intervention Prevention     Parent training Rewards for pro-social behaviors Skills training Improve social competence Cluster B: Borderline Personality Disorder   Patients with borderline personality disorder stand on the border between neurosis and psychosis and they are characterized by extraordinarily unstable affect, mood, behavior, object relations, and self-image.  Persons with borderline personality disorder almost always appear to be in a state of crisis.  Patients can be argumentative at one moment, depressed the next, and later complain of having no feelings. Patients can have short-lived psychotic episodes (so-called micropsychotic episodes) rather than full-blown psychotic breaks, and the psychotic symptoms of these patients are almost always circumscribed, fleeting, or doubtful.   The behavior of patients with borderline personality disorder is highly unpredictable, and their achievements are rarely at the level of their abilities.  The painful nature of their lives is reflected in repetitive self-destructive acts. Such patients may slash their wrists and perform other selfmutilations to elicit help from others, to express anger, or to numb themselves to overwhelming affect.   Patients with borderline personality disorder cannot tolerate being alone, and they prefer a frantic search for companionship, no matter how unsatisfactory, to their own company.  They often complain about chronic feelings of emptiness and boredom and the lack of a consistent sense of identity (identity diffusion) Cluster B: Borderline  Clinical description  1 – 2% of population  Patterns of instability       Intense moods Turbulent relationships Impulsivity Very poor self-image Self-mutilation Suicidal gestures Cluster B: Borderline  Comorbid disorders  Depression – 20%  Suicide – 6%  Bipolar – 40%  Substance abuse – 67%  Eating disorders  25% of bulimics have BPD Cluster B: Borderline  Causes  Genetic/biological components   Serotonin Limbic network  Cognitive biases  Early childhood experience    Neglect Trauma Abuse Cluster B: Borderline  Treatment  Highly likely to seek treatment  Antidepressant medications  Dialectical behavior therapy  Reduce “interfering” behaviors    Self-harm Treatment Quality of life  Outcomes Cluster B: Histrionic Personality Disorder   Persons with histrionic personality disorder are excitable and emotional and behave in a colorful, dramatic, extroverted fashion.  Persons with histrionic personality disorder show a high degree of attention-seeking behavior. They tend to exaggerate their thoughts and feelings and make everything sound more important than it really is.  They display temper tantrums, tears, and accusations when they are not the center of attention or are not receiving praise or approval.   Seductive behavior is common in both sexes. Sexual fantasies about persons with whom patients are involved are common, but patients are inconsistent about verbalizing these fantasies and may be shy or flirtatious rather than sexually aggressive. Cluster B: Histrionic  Clinical description         Center of attention Sexually provocative Shallow shifting emotions Physical appearance-focused Impressionistic Overly dramatic Suggestible Misinterprets relationships Cluster B: Histrionic  Causes  Little research  Links with antisocial personality  Sex-typed alternative expression Cluster B: Histrionic  Treatment  Problematic interpersonal relationships   Attention seeking Long-term consequences of behavior  Little empirical support Cluster B: Narcissistic Personality Disorder   Persons with narcissistic personality disorder are characterized by a heightened sense of self-importance and grandiose feelings of uniqueness.  Persons with narcissistic personality disorder have a grandiose sense of self-importance; they consider themselves special and expect special treatment.  Persons with this disorder want their own way and are frequently ambitious to achieve fame and fortune.   Their relationships are fragile, and they can make others furious by their refusal to obey conventional rules of behavior. Interpersonal exploitiveness is common place.  They cannot show empathy, and they feign sympathy only to achieve their own selfish ends. Cluster B: Narcissistic  Clinical description  Exaggerated and unreasonable sense of selfimportance       Grandiosity Require attention Lack sensitivity and compassion Sensitive to criticism Envious Arrogant Cluster B: Narcissistic  Causes  Deficits in early childhood learning   Altruism Empathy  Sociological view   Increased individual focus “Me generation” Cluster B: Narcissistic  Treatment focuses on:      Grandiosity Lack of empathy Hypersensitivity to evaluation Co-occurring depression Little empirical support Cluster C: Avoidant Personality Disorder   Persons with avoidant personality disorder show extreme sensitivity to rejection and may lead a socially withdrawn life. Although shy, they are not asocial and show a great desire for companionship, but they need unusually strong guarantees of uncritical acceptance.  Such persons are commonly described as having an inferiority complex.   Hypersensitivity to rejection by others is the central clinical feature of avoidant personality disorder, and patients' main personality trait is timidity.  When talking with someone, they express uncertainty and show a lack of self-confidence.  They are apt to misinterpret other persons' comments as derogatory or ridiculing. The refusal of any request leads them to withdraw from others and to feel hurt. Cluster C: Avoidant  Clinical description     Extreme sensitivity to opinions Avoid most relationships Interpersonally anxious Fearful of rejection Cluster C: Avoidant  Causes     Schizophrenia-related disorders Difficult temperament Early parental rejection Interpersonal isolation and conflict Cluster C: Avoidant  Treatment     Similar to social phobia Increase social skills Therapeutic alliance Moderate empirical support Cluster C: Dependent Personality Disorder   Persons with dependent personality disorder subordinate their own needs to those of others, get others to assume responsibility for major areas of their lives, lack self-confidence, and may experience intense discomfort when alone for more than a brief period.  Freud described an oral-dependent personality dimension characterized by dependence, pessimism, fear of sexuality, self-doubt, passivity, suggestibility, and lack of perseverance; his description is similar to the DSM-IV-TR categorization of dependent personality disorder.   Persons with the disorder cannot make decisions without an excessive amount of advice and reassurance from others. They avoid positions of responsibility and become anxious if asked to assume a leadership role.  An abusive, unfaithful, or alcoholic spouse may be tolerated for long periods to avoid disturbing the sense of attachment. Cluster C: Dependent  Clinical description          Rely on others for major and minor decisions Unreasonable fear of abandonment Clingy Submissive Timid Passive Feelings of inadequacy Sensitivity to criticism High need for reassurance Cluster C: Dependent  Causes  Little research  Early experience     Death of a parent Rejection by caregiver Attachment Genetic influences Cluster C: Dependent  Treatment  Limited empirical support  Caution: dependence on therapist  Gradual increases in:    Independence Personal responsibility Confidence Cluster C: ObsessiveCompulsive Personality Disorder   Obsessive-compulsive personality disorder is characterized by emotional constriction, orderliness, perseverance, stubbornness, and indecisiveness.  Patients with obsessive-compulsive personality disorder may have a stiff, formal, and rigid conduct.  They lack spontaneity, and their mood is usually serious. Such patients may be anxious about not being in control of the interview.   They insist that rules be followed rigidly and cannot tolerate what they consider infractions. Accordingly, they lack flexibility and are intolerant.  Persons with obsessive-compulsive personality disorder have limited interpersonal skills. They are formal and serious and often lack a sense of humor. Cluster C: ObsessiveCompulsive  Clinical description        Fixation on doing things the “right way” Rigid Perfectionistic Orderly Preoccupation with details Poor interpersonal relationships Obsessions and compulsions are rare Cluster C: ObsessiveCompulsive  Causes  Limited research  Weak genetic contributions  Predisposed to favor structure? Cluster C: ObsessiveCompulsive  Treatment  Similar to OCD  Address fears related to the need for orderliness  Limited efficacy data Etiology of Personality Disorders 1. Biological Factors A. Genetic Factors Cluster A personality disorders are more common in the biological relatives of patients with schizophrenia than in control groups. Cluster B personality disorders apparently have a genetic base. Antisocial personality disorder is associated with alcohol use disorders. Cluster C personality disorders may also have a genetic base. Patients with avoidant personality disorder often have high anxiety levels. Obsessive-compulsive traits are more common in monozygotic twins than in dizygotic twins   B. Hormones  Persons who exhibit impulsive traits also often show high levels of testosterone  C. Neurotransmitters  High endogenous endorphin levels may be associated with persons who are phlegmatic.  Serotonin, are low in persons who attempt suicide and in patients who are impulsive and aggressive.   D. Electrophysiology  Changes in electrical conductance on the electroencephalogram (EEG) occur in some patients with personality disorders, most commonly antisocial and borderline types; these changes appear as slow-wave activity on EEGs.   B. Psychoanalytic Factors  Fixation  Sigmund Freud suggested that personality traits are related to a fixation at one psychosexual stage of development.  Those with an anal character are stubborn, parsimonious, and highly conscientious because of struggles over toilet training during the anal period.   Too much use of Defenses  Persons with paranoid personality disorder, for instance, use projection, whereas schizoid personality disorder is associated with withdrawal.  When defenses work effectively, persons with personality disorders master feelings of anxiety, depression, anger, shame, guilt, and other affects.  Personalit Defenses y Disorder Manifestation Schizoid They seek solace and satisfaction within themselves by creating imaginary lives, especially imaginary friends. Fantasy Obsessive Isolation Compulsi ve Patients may show intensified self-restraint, overly formal social behavior, and obstinacy. Paranoid Projection Persons with this disorder externalize their own emotions and use the defense of projection; they attribute to others the impulses and thoughts that they cannot accept in themselves. Histrionic Dissociati on Persons who frequently dissociate are often seen as dramatizing and emotionally shallow Antisocial Acting Out and The clinician faced with acting out, either aggressive or sexual, in an interview Treatment   Antipsychotic Drugs - These medications seem particularly helpful for reducing the unusual thinking of patients with Schizotypal Personality Disorder.  Social Skills Training - Avoidant personality disorder appears to respond to the same treatments that are effective for those with social anxiety disorder.