Personality Disorders PDF

Personality Disorders Back to Basics: Human Personality and the “Big 5” Personality Traits • Personality = relatively enduring and consistent patterns of thinking, feeling, and acting – part of what makes each of us unique Is curious about many different things? Openness to Experience Can be so...

Personality Disorders Back to Basics: Human Personality and the “Big 5” Personality Traits • Personality = relatively enduring and consistent patterns of thinking, feeling, and acting – part of what makes each of us unique Is curious about many different things? Openness to Experience Can be somewhat careless? Conscientiousness Is outgoing, sociable? Extraversion Is helpful and unselfish with others? Agreeableness • For example, are you someone who… Worries a lot? Negative Affectivity (AKA Neuroticism) An Evolutionary Perspective on the Big 5 Nettle (2006) argued there’s no single level of any of these traits that is inherently “optimal” (from an evolutionary perspective), which could partly explain why there’s a lot of diversity Can our traits be “maladaptive”? • Traits might be particularly liable to cause problems for us if they: • are at the extremes (poles) of the bell curve; e.g.: • Highly emotionally labile (very high N) • Highly unconstrained (very low C) • strongly and inflexibly influence our behavior • e.g., if we have trouble adapting our behavior to changes in our environment, goals, etc. • are a poor match (“fit”) for our environment in some way Introduction Personality Disorders in the DSM Personality Symptoms? • A car salesperson lies to people to manipulate them into buying cars – and feels no guilt about making unethical sales. • A person becomes upset when their spouse rearranges their closet, does not have dinner ready on schedule, or in any way interferes with their rigidly planned work schedule. • A person is careful to lock their car and house immediately after entering them because they fear intruders. • A person has little interest in socializing with others. They communicate with people at their job, but have little to no social contact outside of work. DSM-5 General Definition of “Personality Disorder” • Criterion A: Enduring pattern of inner experience and behavior that deviates markedly from cultural expectations and is manifested in 2+ of: cognition (thinking), emotion (feeling), relationships, impulse control (behavioral constraint) • B: Pattern is inflexible, pervasive across broad range of personal and social situations • C: Pattern leads to clinically significant distress or impairment • D: Pattern is stable and of long duration; onset can be traced back at least to early adulthood Example 1: Diagnostic Criteria for Paranoid Personality Disorder Example 2: Diagnostic Criteria for Schizoid Personality Disorder • Somewhere between 10-12% meet criteria for at least one PD in the past 2-5 years • Very high rate of comorbidity with other DSM disorders (specific comorbidities vary across PDs) Prevalence: Clinic vs. Community Are PDs “egosyntonic”? • Historically, widely thought that PDs were frequently (always?) egosyntonic = people with PDs largely unaware of and/or unbothered by PD-related traits/problems • Modern empirical findings largely do not support this claim (e.g., Sleep et al., 2020) • But, people with high levels of PD traits… • may perceive more upsides of having those traits (Hart et al., 2018) • are not necessarily highly motivated to change them (e.g., because they may not think it is possible to change them; Sleep et al., 2022) Etiology of PDs: Nature x Nurture • Moderate to high heritability • Evidence of shared genetic risk across PDs • Family and early adversity very common across most PDs (Cohen et al., 2005) • As always, not very specific • Personality traits, themselves, are shaped by interactions between nature and nurture • Genetic contributions may be mediated partly by temperament, personality traits (Kendler et al., 2008; Livesley, 2005) • Not enough prospective research overall • Surprisingly little cross-cultural research The Current DSM Approach to PDs Issues and Alternatives Issue #1: Misdiagnosis • Arguably more misdiagnoses/diagnostic unreliability than any other category of disorder in routine clinical practice • Imprecise criteria (e.g., “goes to excessive lengths to obtain nurturance and support from others”) • Structured interviews can help a lot, but questions persist re: reliability (and validity) • Creates problems for both clinical practice and research Issue #2: Diagnostic Stability • As my PSCY 375 students can hopefully tell you, personality traits are reasonably (though by no means totally) stable over time • But, personality disorders aren’t especially stable (e.g., compared to other classes of disorders; see d’Huart et al., 2023 for meta-analysis): • About half of people in remission 2 years later (McGlashan et al., 2005) • 99% remitted when assessed after 16 years (Zanari et al., 2011) • People may still have some symptoms after remission (possibility that some “underlying” traits/features may remain stable?) • Many will experience recurrences, diagnostic cross-over Issue #3: Diagnostic Overlap • > 50% meet criteria for another PD • Overlap in symptoms, concerns • Poses challenges for research Examples of Overlapping Symptoms Schizoid Schizotypal • Displays constricted affect, e.g., is aloof, cold, rarely reciprocates gestures or facial expressions, such as smiles or nods • Inappropriate or constricted affect, e.g., silly, aloof, rarely reciprocates gestures or facial expressions, such as smiles or nods Examples of Overlapping Symptoms Schizoid Avoidant • Has no close friends or confidants (or just 1) other than first degree relatives • Has no close friends or confidants (or just 1) other than first degree relatives Examples of Overlapping Symptoms Avoidant Dependent • Is easily hurt by criticism or disapproval • Is easily hurt by criticism or disapproval Issue #4: Diagnostic Heterogeneity For BPD dx, must endorse 5 of 9 criteria with no cardinal criterion Person 1 Person 2 Frantic efforts to avoid abandonment Chronic feelings of emptiness Unstable and intense interpersonal relationships Marked mood reactivity Transient stress-related paranoid ideation Difficulty controlling anger Behavioral impulsivity Behavioral impulsivity Unstable self-image Recurrent suicidal behavior Issue #5: Diagnostic Coverage • Many people report symptoms that seem to meet the broad criteria for a PD, but don’t meet criteria for any specific PD → PDNOS (DSM-IV) / Unspecified Personality Disorder (DSM-5) • The most common PD diagnosis when clinicians use unstructured diagnostic interviewing • 3rd most common even when structured interviews used (Verheul & Widiger, 2004) • PDNOS diagnosis not necessarily associated with any less functional impairment than specific diagnoses (Johnson & Levy, 2017) Issue #6: Lack of Integration w/ Modern Personality Science • PD diagnostic categories and criteria largely don’t reflect modern advances in personality theory or research • Research on PDs has often proceeded separately from basic personality research • Not at all clear that the 10 categories in the DSM accurately or adequately capture the various ways personality traits or other aspects of personality might become problematic PDs and the Big 5 • PDs do correlate with the Big 5… • but these correlations are often no larger or in some cases smaller than correlations between the Big 5 and non-PD diagnoses (see Wright et al., 2022) Alternative approaches? • DSM-5 committee on PDs recommended shifting to a more dimensional system for identifying and describing how personality traits can cause problems The Alternative Model of Personality Disorders (AMPD) • Reduced number of PDs: 6 of the 10 DSM-IV PDs, excluding: • Schizoid, histrionic, dependent, paranoid – comparatively rare, hard to diagnose reliably, less empirical research • Foreground consideration of long-standing dysfunction + how personality traits might explain these difficulties • Focus on two types of dimensional ratings • 5 broad trait domains, more or less grounded in the Big 5 (Negative Affect, Detachment, Antagonism, Disinhibition, Psychoticism), plus 25 narrower “facets” of those traits (e.g., Callousness, Risk-Taking, Perfectionism, etc.) • Overall “level of personality functioning” The Alternative Approach • Identify people with high scores on the personality traits and longstanding, pervasive functional problems • Can use clinician-, self-, and other-ratings • Describe traits that are of most concern • Can map from the trait profiles back to the traditional personality disorder categories insofar as these are useful for research or clinical practice • If none fit, diagnose as “Personality Disorder-Trait Specified” Potential Advantages of the Alternative Approach • Dimensions provide more specificity than broad categories • Dimensions provide richer index of “how much?” vs. “yes/no” • Dimensions have higher internal consistency, test-retest stability • Ties into a vast literature on the Big 5 (e.g., more opportunities for standardization and comparison across full spectrum of personality trait variability) • In surveys, many clinicians said they found the new approach helpful • AMPD dimensions are equally strong or stronger than PD categories as predictors of social, emotional, and behavioral functioning (Ringwald, Woods, & Wright, 2023) So, what happened? • The PD working group unanimously* approved its final proposal and presented it to the DSM-5 Task Force in October 2012 • The Task Force rejected the AMPD • Relegated to an obscure appendix • Pretty unprecedented Why? • The proposal generated a lot of pushback • The working group received ~8,600 (!) comments in two months of public comments • “Clinicians are accustomed to thinking in terms of syndromes, not deconstructed trait ratings. Researchers think in terms of variables, and there’s just a huge schism.” – Dr. Jonathan Shedler • “It’s draconian, and the first of its kind, I think, that half of a group of disorders are eliminated by committee.” – Dr. John Gunderson • “The obvious complexity and incoherence seriously interfere with clinical utility. “ – Dr. Allen Frances • Lots of people invested in the status quo, wary of change To be clear… • Even many people who strongly support dimensional models of PDs thought AMPD was far from perfect • e.g., Zimmerman et al. found that it would only modestly reduce the rate of comorbidity • The AMPD is not the only alternative framework or dimensional model that’s been proposed (see Morey et al., 2007) • Recall that DSM proposals are produced through consensus and compromise • Something rather similar to the AMPD was adopted for ICD-11 “Long Live the Interpersonal Disorders”? • Wright et al. (2022) point out that measures of personality functioning, Big 5 correlate with many clinical syndromes, not just PDs • Propose that we should reconceptualize the PDs as “interpersonal disorders” • Specific impairments in self/identity and interpersonal functioning may be better discriminators of PDs from non-PDs than personality traits (e.g., Beeney et al., 2019) • Ethics of conceptualizing/diagnosing a person’s “personality” as “disordered” (e.g., in relation to lay conceptualizations of personality) Stigma and the PDs • As we know, mental disorders are broadly stigmatized • But is there something uniquely stigmatizing about the idea of a “personality disorder”? • One way in which the PDs may be somewhat unusual re: stigma is how stigmatized they are among mental health professionals and researchers (e.g., Masland et al., 2023) Specific Personality Disorders Focus on the 6 with the strongest evidence base… and on some of those 6 more than others Schizotypal: PD… or Schizophrenia Spectrum? • Symptoms resemble aspects of schizophrenia • Under high stress, people with schizotypal more liable to develop (transient) psychotic symptoms • Cognitive and perceptual distortions observed in schizotypal PD not particularly well-explained by the five-factor model of personality (Watson et al., 2008) • “Psychoticism” (Krueger, Eaton, Derringer et al., 2011) • Shares many biological, cognitive correlates with schizophrenia • Higher risk in those with relatives with schizophrenia, teenagers dx with schizotypal at higher risk for schizophrenia in adulthood • Possibility that it’s essentially a less severe manifestation of the same underlying processes as schizophrenia? (Lenzenweger, 2010; Raine, 2006) • It’s actually listed in both categories in the DSM What about psychopathy? Psychopathy vs. ASPD • Clearly, there’s some overlap; in what ways are they different? • DSM focus on behavior was deliberate – effort to increase reliability – but what about validity? • Psychopathy may be a better predictor than ASPD of, e.g., aggression, recidivism (Hare et al., 2012) • ASPD may miss people who show a lot of Factor 1 features, but few Factor 2 features • Conversely, ASPD may include people who have a history of antisocial acts, but don’t show the same interpersonal/affective features • DSM-5 considered incorporating more of the features of psychopathy into the diagnostic criteria, but ultimately declined to Myths about Psychopathy • Myth #1: Most people who commit crimes or are in prison are psychopaths • People in prison more likely to meet DSM ASPD criteria than Cleckley’s criteria for psychopathy • Social factors/systems play an enormous role not only in what is considered a crime, but also in who breaks the law, attitudes toward (and punishments for) certain types of crimes, who is policed/put in prison, etc. • Most people violate some law or another at some point in their life (underage drinking, jaywalking, etc.) • Myth #2: Psychopathy explains all white-collar crime • Although rates of psychopathy may be higher in corporate samples than in the community (Babiak et al., 2010) • Myth #3: There’s a robust and straightforward association between psychopathy and leadership, promotion (Landay, Harms, & Crede, 2018) • Although there’s some evidence that having more power can make people less agreeable (Keltner, 2016) • Not a myth: A lot of the research on psychopathy has historically been done in incarcerated populations • This introduces all sorts of (societal) biases into the data Risk Factors for ASPD • Psychopathy moderately heritable • Overlap with risk for substance use problems (“externalizing”) • Environment • Lack of warmth, negativity, conflict in the family environment • Harsh or inconsistent discipline, lack of parental supervision • Neglect, abuse • Poverty • Exposure to violence • Peer effects • Social marginalization of people who interact with the criminal justice system A Developmental Perspective on ASPD • # of antisocial behaviors in childhood is the strongest predictor of adult ASPD diagnoses • The younger the age at which antisocial behaviors start, the higher the risk (Robins, 1991) • A common diagnostic trajectory: strong-willed temperament (fearless, disinhibited) → Oppositional Defiant Disorder → (Early-Onset) Conduct Disorder → ASPD (Lahey et al., 2005) • “Life-course-persistent antisocial behavior” (Moffitt et al., 2002) • But not every child diagnosed with ODD will go on to meet criteria for ASPD by any means • And this isn’t the only developmental pathways to ASPD (Fowles, 2018) • Developmental models emphasize transactions over time between the individual and their environment, including other people in the environment GxE Correlations and Transactions in ASPD • Biological parents can shape the lives of their offspring through two pathways: passing down genes and shaping (early) environments • People who inherit genetic diatheses for antisocial behavior from their parents are also at greater risk for exposure to adverse environments (e.g., witnessing domestic violence, experiencing abuse) • Another example: children with genetic vulnerability to antisocial behavior are more likely to elicit certain types of responses from the people around them (e.g., harsh parenting, peer rejection, frequent punishments from teachers) that might strengthen antisocial tendencies (Jackson & Beaver, 2015) • In other words, there’s a correlation between people’s genetic inheritances and the environments they’re raised in • And these influences may often reinforce each other GxE Interactions in ASPD • Adopted-away children of biological parents with ASPD were more likely to develop antisocial personalities if their adoptive parents also exposed them to an adverse environments (e.g., Riggins-Caspers et al., 2003) • As we’ve found elsewhere, then, diathesis + stress = highest likelihood of disorder • But one of the takeaways should be that the diathesis and the stress aren’t always independent (they can be systematically correlated!) Risk Factors & Etiological Models for Psychopathy • Environmental risk factors: parental rejection, abuse, neglect, inconsistent discipline • “Callous/unemotional temperament” in childhood? (Frick) • Fearlessness/boldness? • Reduced physiological responses to unpleasant stimuli related to Factor 1 (but not Factor 2) • Slow at learning to inhibit behavior to avoid punishment – intact understanding of response-punishment association, but subjective and some physiological components of fear diminished • Lots of interest in amygdala • Dominance motivation? (desire for power, social rank) • Aggressive responses to perceived insults, disrespect (Cale & Lilienfeld, 2006) • Single-minded goal-pursuit? (Vitale & Newman, 2017) • As with ASPD, interactions of/transactions between biological influences and environmental influences Facets (Subtypes?) of Narcissism: Grandiosity & Vulnerability • DSM criteria foreground grandiosity, but many also experience considerable vulnerability • People who experience more vulnerability more likely to end up in treatment (may skew clinicians’ perspectives, introduce bias into research) • Not a clear categorical distinction – there are individual differences between people with NPD and people with NPD can fluctuate between more grandiose and vulnerable presentations (e.g., Edershile et al., 2019) • Both dimensions associated with low agreeableness (e.g., low altruism, trust, and modesty; “antagonism”) • But also some distinct risk factors and personality correlates • Vulnerability: early adversity; intrusive, cold, controlling parenting; high negative affectivity (e.g., selfconsciousness, anger); low, highly variable, and/or highly contingent self-esteem • Grandiosity: highly indulgent parenting; low negative affectivity; high “agentic” extraversion (e.g., assertiveness, excitement-seeking); stably high (explicit) self-esteem • Ties to the pursuit of status, power, and esteem? (e.g., high reactivity to perceived criticism, status challenges) Common Spousal Descriptions (Wink, 1991) • High in grandiosity: “aggressive, hardheaded, outspoken, assertive, determined” • High in vulnerability: “worrying, emotional, defensive, anxious, bitter, tense, complaining” • Both: “bossy, intolerant, cruel, argumentative, dishonest, opportunistic, conceited, arrogant, demanding” • Emphasizes the interpersonal challenges, consequences that people with PDs frequently encounter They said she was made of fire. And she said, I am quick to anger, but it is because all of the colors inside of me turn to rage when they are silenced. They said emotional dysregulation. And she said, my mood is a temperamental ocean enormous and pulled in infinite directions. They said marked impulsivity—an inability to regulate responses to stimuli. And she said, when everything is an emergency, it is impossible to prepare for disaster. They said frequent suicide gestures, gesture as in the physicality of speech. Just as the poem demonstrates that which has no words, so do the injuries illustrate that which is unimaginable. They said a pattern of violent relationships. And she said, my ocean loves just as deep as it hates. My ocean buries its history and vomits it up on the shore, the sea glass soft as my apologies. They said difficult to treat. She said, how do you disentangle the roots from a tree? How do you uncurl a bonsai from its contortions even when it knows it will not live long this way? How do you learn to stop hurting yourself when it is the closest you’ve come to being quiet? They call me borderline like an insult, but I know how it feels to be limitless. Women who feel in extremes are taught to be quiet about our grief, are taught control, contortion, a bonsai bent into impossible positions. The contortionist curls herself into a glass box. Look how small she can become. Watch how her bones turn to cartilage. And when she disappears entirely, all around the doctors gasp as if they did not intend to make her this way. They call me borderline because I am the border between extremes. My highs are helium, my lows a skydive. The borderlines that climb my skin speak of nights I did not know how to feel this much—inhibition of my own grief. I curl myself into a glass box, but I do not fit. My ocean salt spills out around me. – Coral More on Borderline Personality Disorder Epidemiology of BPD • Approximately ¾ of those diagnosed with BPD in clinical settings are women, but epi studies suggest a more equal gender ratio—why? • By late life, most no longer meet diagnostic criteria, though some traits may still be evident in some fashion • Very high comorbidity with other disorders (e.g., mood, anxiety, SUDs, eating) • High rate of self-injurious behavior (it’s a criterion, after all) • In community samples, almost ¼ people diagnosed with BPD report at least one suicide attempt (Pagura et al., 2010) • 8-10% end their lives by suicide • High rates of NSSI… although many people who engage in NSSI do not have BPD A Dimensional Model of BPD: 3 Core Dimensions? (Tull et al., 2010) • Emotion Dysregulation • Unusually intense emotional responses to external triggers • Affective lability – drastic and rapid shifts from one emotion to another • Emotion-related impulsivity • Marsha Linehan has argued that “Emotion Dysregulation Disorder” would be more apt label • Interpersonal Problems • Fear of abandonment → rejection sensitivity • Bias toward perception of anger (skilled at accurate detection, but also misperceive neutral = angry) • Self-Identity Disturbance • Negative self-concept • Unstable sense of self DSM-5 Working Group’s BPD Proposal Criterion A: Self / Interpersonal Impairment Criterion B: Pathological Personality Traits Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in 2+ of: Four or more of the following pathological personality traits, including at least one of: Impulsivity, Risk taking, or Hostility Identity: Unstable self-image, often associated w/ excessive criticism; chronic feelings of emptiness Emotional lability Self-direction: Instability in goals, aspirations, values Anxiousness Empathy: difficulty recognizing/validating the feelings of others associated with interpersonal hypersensitivity; negativity bias Separation insecurity Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust and preoccupation with abandonment; close others often viewed in extremes of idealization and devaluation Depressivity Impulsivity Risk taking Hostility Neurobiological Factors • Genes may confer predisposition to temperament, personality traits, such as negative affectivity, impulsivity • Non-specific risk – may help to explain comorbidities • Not clear which specific genes are involved (few GWAS, small samples, heterogenous clinical phenotype) • Some evidence of diminished connectivity of brain regions involved in emotion experience, regulation Environmental Risk Factors • Two prospective community-based studies have reported high rates of childhood maltreatment, abuse • Highly correlated with other factors, such as marital discord, parental substance use, etc.; hard to tease apart what’s really driving the association • Genetically driven impulsivity, emotionality, risk-seeking in the parents could increase the risk of both experiencing abuse and BPD • Not specific to BPD, and many people who meet BPD criteria do not have any reported history of abuse or trauma (Porter et al., 2020) • Insecure attachment to early caregivers, particularly “disorganized attachment” (Steele & Siever, 2010) Linehan’s “Biopsychosocial Model” • Diathesis of biologically grounded emotion dysregulation, plus • Stress of invalidating family environment (child’s feelings are discounted, minimized) • Produces a dynamic interaction • Ironic effect: behaviors aimed at seeking validation, avoiding (the pain of) rejection often produce rejection… which increases expectations of and sensitivity to rejection “People with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.” – Marsha Linehan “It is hard to be accused of manipulation when really it’s a scream for love”- Diana McQueen “She didn’t know who would leave or stay, so she pushed them all away.” – unknown author “We are all borderline when going through a serious break up” – unknown author Avoidant PD vs. Social Anxiety Disorder • Genetic vulnerability is at least partially shared • Shared cognitive, personality traits • Negative affectivity, self-critical beliefs, overestimation of consequences of social mistakes • Avoidant PD as a more severe, chronic version of social anxiety disorder? (Chambless et al., 2008) • Very few people who meet criteria for Avoidant PD do not also meet criteria for Social Anxiety Disorder, but the reverse isn’t true • Persistently low self-esteem more strongly implicated in Avoidant PD OCD vs. OCPD • OC: recurrent, distressing obsessions; rule-bound compulsions • OCPD: emphasis on detail, precision, rules; perfectionism; focus on work; rule-bound; difficulty with compromise • You can sort of see the conceptual overlaps (e.g., desire for control, intolerance of uncertainty) • But only about 20% of those with OCD have a comorbid diagnosis of OCPD • This is lower than, e.g., the % of people with Anorexia who meet criteria for comorbid OCPD Treatment General Findings • For a long time, PDs thought to be nigh on untreatable • Providers often reluctant to even try to treat, take on clients with PDs, also reluctant to inform service users about PD diagnoses (e.g., due to stigma) • The evidence suggests, though, that people with PDs often benefit from treatment! (e.g., Katakis et al., 2023) • Early intervention associated with better outcomes (e.g., for antisocial behavior) • Presence of PD does predict slower improvement in therapy • Building rapport around personality themes can be difficult • Some therapy goals may be easier to achieve than others • Noncompletion of/withdrawal from treatment is a major problem • Not nearly enough research on treatment of some PDs (e.g., Narcissistic PD) • Some interventions designed to reduce recidivism may actually produce higher rates of reoffending in those high in psychopathy (Harris & Rice, 2006) General Findings (cont’d) • Clients often enter treatment for a condition other than PD (e.g., depression) or at someone else’s insistence (e.g., a family member or, particularly in the case of ASPD, a court) • Psychotherapy generally preferred to medication • Low doses of antipsychotics can be modestly helpful for reducing unusual thinking in schizotypal PD • Antidepressants may be helpful in Avoidant PD • Polypharmacy is the norm in BPD, but not clear how effective these are for treating BPD so much as managing comorbidities and individual symptoms (Bateman et al., 2015) Cognitive-Behavioral Therapies • e.g., treatment of Avoidant PD very similar to treatment for Social Anxiety Disorder • Challenge negative beliefs about self and others • Social skills training • Exposure to feared situations • OTOH, efforts to treat PDs has also spurred development of new approaches (e.g., dialectical behavior therapy and mentalizing therapy for BPD) Dialectical Behavior Therapy (DBT) • Linehan translated her etiological model into a treatment approach for BPD • Motivated by frustration she experienced using more traditional CBT approaches • Fusion of CBT with mindfulness-based approaches (adapted in part from Buddhist philosophy and praxis); works hard to strike a balance between client-centered acceptance/validation and change • Dialectic = two things that seem to be in opposition but can both be true at the same time • Four core skills modules: Mindfulness, Emotion Regulation, Interpersonal Effectiveness, Distress Tolerance with self-monitoring (“diary cards”), frequent “chain analyses” to identify patterns and opportunities to use skills • Not the only evidence-based therapy for BPD (e.g. mentalization therapy; Bateman & Fonagy, 2010), but definitely the most well-studied • Has since been shown to be effective for a wide range of presenting problems, including BPD (not very specific) • Adapted into a treatment for disorders of overcontrol (e.g., OCPD, anorexia): Radically Open DBT (Lynch)