Personality Disorders PDF

Personality Disorders: Focus on BPD and ASPD Dr. Nicole E. Kostiuk, R. Psych Personality Disorders as per the DSM-5 General Definition applies to all 10 A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is...

Personality Disorders: Focus on BPD and ASPD Dr. Nicole E. Kostiuk, R. Psych Personality Disorders as per the DSM-5 General Definition applies to all 10 A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas: 1. Cognition (i.e., ways of perceiving and interpreting self, others, and events) 2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response) 3. Interpersonal functioning 4. Impulse control B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning D. The pattern is stable and of long durations, 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 mental disorder F. Not attributable to physiological effects of a substance or other medical condition DSM-IV-TR vs DSM-5 DSM-5 promised to move towards a dimensional model Dimensional Model: Differs in degree, not kind Extreme versions of traits we all have How OCPD or BPD are you? Changes were not incorporated into DSM-5; continues to be categorical Not enough agreement or research Therefore virtually no changes were made from the DSM-IV-TR to the DSM-5 with respect to personality disorders Alternative model introduced for further study Many people with one diagnosed personality disorder also have signs and symptoms of at least one additional personality disorder. Often from the same cluster Suggests the diagnoses are not distinct categories Makes assessment (and treatment!) more difficult # of personality disorders may also be reduced from 10 to 6 Antisocial Avoidant Borderline Narcissistic Obsessive-compulsive Schizotypal Assessment of Personality Disorders Complicated by the overlap with other personality disorders and “Axis I” disorders No test is definitive Importance of multiple sources of information History/Interview Observation Formal Assessment Measures PAI, MMPI, SCID-II/SSPQ, PCL-R Importance of collateral information The specific types of personality disorders are grouped into three clusters based on similar characteristics and symptoms. Cluster A Appear odd or eccentric Cluster B Appear dramatic, emotional, or erratic Cluster C Appear anxious or fearful Cluster A Schizoid Personality Disorder A. A pervasive patter of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Neither desires nor enjoys close relationships, including being part of a family 2. Almost always chooses solitary activities 3. Has little, if any, interest in having sexual experiences with another person 4. Takes pleasure in few, if any, activities 5. Lacks close friends or confidants other than first-degree relatives 6. Appears indifferent to the praise or criticism of others 7. Shows emotional coldness, detachment, or flattened affectivity B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition Schizotypal Personality Disorder A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behaviour, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Ideas of reference (excluding delusions of reference) 2. Odd beliefs or magical thinking that influences behaviour and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations) 3. Unusual perceptual experiences, including bodily illusions 4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped) 5. Suspiciousness or paranoid ideation 6. Inappropriate or constricted affect 7. Behaviour or appearance that is odd, eccentric, or peculiar 8. Lack of close friends or confidants other than first-degree relatives 9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder, or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder Paranoid Personality Disorder A. 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: 1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her 2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates 3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her 4. Reads hidden demeaning or threatening meanings into benign remarks or events 5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights) 6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack 7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition Cluster B Histrionic Personality Disorder Diagnostic Criteria A. A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Is uncomfortable in situations in which he or she is not the center of attention 2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behaviour 3. Displays rapidly shifting and shallow expression of emotions 4. Consistently uses physical appearance to draw attention to self 5. Has a style of speech that is excessively impressionistic and lacking in detail 6. Shows self-dramatization, theatricality, and exaggerated expression of emotion 7. Is suggestible (i.e., easily influenced by others or circumstances) 8. Considers relationships to be more intimate than they actually are A search of “Histrionic Personality Disorder” on Psycinfo returned a total of 384 articles... In contrast to 5973 for BPD, 4518 for ASPD, and 1645 for NPD Perhaps because HPD does not have nearly the burden on society (either in terms of legal or mental health use) that the other Cluster B diagnoses have, thus has not received much research attention Maybe why it was one of the 4 personality disorders that was under consideration for removal from the DSM-5 However, when examining the diagnostic criteria, there is overlap with the other Cluster B diagnoses, particularly BPD, and Cluster B personality disorders are often comorbid with each other E.g., emotion dysregulation, identity disturbance, underlying impulsivity Therefore, perhaps it is not unreasonable to hypothesize similar findings? Narcissistic Personality Disorder Diagnostic Criteria A pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). 2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love 3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions) 4. Requires excessive admiration 5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations) 6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends) 7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others 8. Is often envious of others or believes that others are envious of him or her 9. Shows arrogant, haughty behaviour or attitudes A Tale of Two Evils Theory that narcissists actually think poorly about themselves Subtypes of Narcissism? 1) Vulnerable 2) Grandiose (or Malignant) Similar to a predatory psychopath Erich Fromm, social psychologist, coined the term “malignant narcissism”, describing it as a “severe mental sickness...the quintessence of evil”. (George & Short, 2018) Kernberg believed that this should be considered part of a spectrum of pathological narcissism, which he saw as ranging from Cleckley’s antisocial character (psychopaths) at the high end of severity, through malignant narcissism, and then to NPD at the low end (George & Short, 2018) Malignant narcissists are thus a less extreme form of narcissism than psychopathy (George & Short, 2018) Key difference is sadism A narcissist may deliberately damage other people in pursuit of their own selfish desires, but may regret or show remorse for doing so A malignant narcissist will harm others and enjoy doing so, showing little empathy or regret. They are generally incapable of forming the kinds of deep, meaningful relationships, readily trample over others to rise to the top, and think they are above the law (George & Short, 2018) Perhaps these two different types of narcissism also have different underlying psychological and neurocognitive functioning Structural Findings Not a large body of literature on the neuroscience of NPD Abnormalities in the insular cortex linked to lack of empathy fMRI study: higher narcissism = decreases activation of right anterior insula decreased activation of the right anterior insula during an empathy task Reduction of gray matter in insular cortex Associated with features of NPD (George & Short, 2018) DTI finding: Higher narcissism scores demonstrated reduced connectivity between certain brain regions, including the prefrontal cortex and ventral striatum Areas associated with the ability to think positively about oneself Low activity = seek out other’s positive opinions about self Neuropsychological Findings In an attempt to determine if neuropsychological test patterns could be used to support a personality diagnosis, using university students and controlling for Axis I psychopathology, it was found: Narcissistic characteristics were associated with poorer working memory, divided attention, and verbal associative memory, but greater cognitive flexibility Histrionic characteristics were associated with better list learning and selective auditory attention Borderline Personality Disorder Diagnostic Criteria Pervasive pattern of instability in relationships, self-image, and affect and marked impulsivity, as indicated by 5 or more of the following 1. Frantic efforts to avoid real or imagined abandonment 2. Pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 3. Identity disturbance; unstable self-image 4. Impulsivity in at least two area that are potentially self-damaging 5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour 6. Affective instability due to marked reactivity of mood 7. Chronic feelings of emptiness 8. Inappropriate, intense anger or difficulty controlling anger 9. Transient, stress-related paranoid ideation or severe dissociative symptoms BPD According to Linehan 1. Emotional dysregulation (emotional instability, anger)*** 2. Interpersonal dysregulation (unstable relationships, avoiding abandonment) 3. Behavioural dysregulation (suicide threats, parasuicide, impulsive acts) 4. Cognitive dysregulation (cognitive disturbances) 5. Self dysfunction (unstable sense of self, chronic emptiness) Biosocial Model of BPD Core disorder is Emotion Dysregulation Is the joint outcome of biological disposition, environmental context, and the transaction between the two during development Genetically predisposed to be more emotional vulnerable Very high sensitivity to emotional stimuli Intense response to emotional stimuli Slow return to baseline Inability to modulate emotion Difficulty inhibiting appropriate behaviour Difficulty acting in a way that is not mood-dependent Difficulty self-soothing physiological arousal Difficulty refocusing attention in the presence of strong emotions Emotional dysregulation is the combination of an oversensitive, overactive emotional response system, combined with an inability to modulate the resulting emotion Invalidating environment Tendency to respond erratically and inappropriately to private experience (e.g., beliefs, thoughts, feelings, sensations) Think attachment theory Particularly damaging for emotionally vulnerable child Emotionally vulnerable child elicits invalidation from environment This environment fails to teach the child to label and modulate arousal, tolerate distress, or trust own emotional responses Assessment of BPD History Semi-structured interview or questionnaire is helpful Collateral information Formal measures MMPI-2/RF PAI Specific borderline scale: correlates highly with BPD diagnosis SCID-II DIB-R PAI Borderline Scale Borderline Features (BOR): assesses a number of elements related to a severe personality disorder; indicators of poor control over emotions and anger, intense and often combative interpersonal relationships, confusion around identity and self-worth, and impulsivity Affective Instability (BOR-A): highly responsive emotionally, episodes of poorly controlled anger Negative Relationships (BOR-N): history of intense and unstable relationships; often feel resentful and betrayed Structured Clinical Interview for the DSM-IV Axis II Personality Disorders (SCID-II) One of the most widely used semi-structured interviews Assesses all PD’s or only administer relevant sections Also has a self-report personality questionnaire (SSPQ) to reduce clinician time If item is screened positively, clinician asks follow-up questions Computerized version saves even more time Borderline Personality Disorder and Neuropsychological Findings Notion that neurocognitive deficits play a role in development of BPD has received growing attention in recent years, major focus on EF (McClure, Hawes, & Dadds, 2016) Neuropsychological studies have revealed a generalized cognitive deficit in BPD affecting the domains of attention/working memory, psychomotor speed, learning and episodic memory, visuospatial abilities, and executive functions (decision making) Deficits may be a potential risk factors for the future development of BPD or worsening of symptoms. Samples with co-morbid personality disorders, major depression, eating disorders, any substance abuse disorders, performed worse than others Attentional biases may play a key role in the development and maintenance of BPD (e.g., problems ignoring emotional distractions, more difficulty disengaging attention from negative facial expressions when in a negative mood, heightened attentional processing of negative emotional stimuli might exacerbate an already negative mood Memory problems attributed to tendency to dissociate during times of stress, attentional problems associated with reduced presentmoment awareness, and interference from emotionally valenced materials. patients with BPD recall more negative stimuli that they were asked to forget Impaired EF functioning (difficulty in mental set-shifting, information updating and monitoring, inhibition of prepotent responses, and planning may be related to BPD symptoms like identity diffusion, impulsivity, self-injury emotion lability, irritability, poor selfcontrol, lack of self-direction, chronic feelings of emptiness, dissociative symptoms, rigidity and difficulty in shifting attention. Executive Functions in BPD Emotional Processing Emotion Recognition High lethality patients correctly identified fewer happy faces than low lethality (Williams, et al., 2015) Tended to misinterpret happy faces as angry Groups did not differ on recognition of neutral faces, or sad, fearful, or angry faces Emotion Discrimination High lethality patients showed greater difficulties in discerning subtle differences in intensities of facial expressions of sadness (Williams, et al., 2015) Also found to subjectively magnify subtle expressions of sadness in faces Prolonged and intense emotional experiences characteristic of BPD are likely to lead to cognitive disruptions, but these effects may not be detected because much of the research on neuropsychological functioning has used test batteries without emotionally laden content (Thomsen, et al., 2018) Hot or emotionally affective cognitive tests may be more strongly implicated in BPD than cold or emotionally neutral tasks (McClure, Hawes, & Dadds, 2016) Factors affecting test performance Psychologists use strategies to keep patients calm and get their best Core features of BPD may be underpinned by dysfunctional brain circuitry: Reduced amygdala volume and overactive amygdala even in neutral/negative line states Reduced hippocampal volume consistent with large effect size of memory Structural and functional abnormalities in the orbitofrontal cortex Decreased white matter integrity, decreased blood flow Associated with increased impulsivity Fronto-limbic dysregulation; failure of frontal system to modulate limbic activity May underlie emotion dysregulation, identity disturbance, and dissociation Need to teach executive function skills Not enough to explicitly explain the deleterious long-term consequences Need to help them develop new strategies Inhibition of immediate satisfaction Ability to switch attention from negative focus Not surprising that effective treatments include mindfulness Improves attention and decreased impulsivity on CPT Treatment of BPD Treatment of choice is Dialectical Behaviour Therapy (DBT) Combination of behavioural principles and “Eastern” philosophy of dialectics Behavioral Principles: Operant Conditioning, Classical Conditioning, Habituation, etc A dialectic is like the rope in a tug-of-war. Tension between polar opposites The central dialectical tension in DBT is between change and acceptance. Treatment of BPD DBT Treatment Hierarchy of Goals 1. 2. 3. 4. 5. 6. 7. Decrease suicidal and self harm behaviour Reduce therapy-interfering behaviours Reduce quality-of-life- interfering behaviours Increasing behavioural skills Decreasing post-traumatic stress Increasing self-respect Achieving individual goals Treatment of BPD DBT has four components Group skills training Individual therapy 24 hour on-call coaching line Consultation team Group Skills Training To Teach skills acquisition that relate to the problem areas identified using 4 modules: ž Goal: Ø Core Mindfulness – addresses cognitive dysregulation and self dysregulation Ø Interpersonal Effectiveness – addresses interpersonal dysregulation Ø Emotion Regulation Skills – addresses emotional dysregulation Ø Distress Tolerance Skills – addresses behavioral dysregulation Core Mindfulness The ability to be aware of your thoughts, emotions, physical sensations and actions – in the present moment – without judging or criticizing yourself or your experience” Jon Kabatt-Zinn Emotional Mind Wise Reasonable Mind Mind Emotion Regulation Skills Help you cope with emotions in more effective ways Can’t control how you feel; but you can control how you react to your feelings Learn to recognize emotions (Primary and Secondary) Understand your emotional vulnerabilities Learn to increase positive emotions Distress Tolerance Skills Help people cope with the inevitable distress and pain that occur in life help us cope and survive during a crisis, and helps us tolerate short term or long term pain (physical or emotional pain), without making it worse!! E.g.) Distraction Self-soothing Radical Acceptance Interpersonal Effectiveness A composite of: Ø social skills training Ø assertiveness training Ø listening training Ø negotiation Treatment of BPD Individual Therapy Treatment Hierarchy Level 1: Suicide/self-harm Level 2: Therapy Interfering Behaviour Level 3: Quality of Life Interfering Behaviour Level 4: Skill Acquisition Help to generalize skills Role-plays Review diary cards Treatment of BPD Coaching Line Skill generalization Homework Check-ins Prevent crises Treatment of BPD Consultation Team Treating and supporting the therapist – assisting the therapist in adhering to DBT principles. Uses the same principles as the therapy with the patient (i.e. Dialectics) Dialectical Agreement Consultation to the Patient Agreement Consistency Agreement Observing Limits Agreement Phenomenological Empathy Agreement Fallibility Agreement Treatment of BPD Research Support DBT initial clinical outcome research (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991) DBT Ss had fewer incidence of parasuicidal behavior less medically severe parasuicidal attempts compared to TAU Ss DBT was superior in treatment retention DBT Ss had significantly fewer inpatient psychiatric days DBT was equal to TAU with regard to: Depression Hopelessness suicidal ideation reasons for living Research Support Initial DBT outcome trial – 1-year follow-up (Linehan, Heard, Armstrong, 1993) DBT Ss compared with TAU Ss had higher Global Assessment Scale scores less parasuicidal behaviors less anger fewer psychiatric inpatient days less psychotropic medication usage better interviewer-rated social adjustment Research Support In adults with BPD, DBT has been found to significantly improve: Anger outbursts Hopelessness Suicidal ideation/behaviour Admissions to emergency and inpatient units for suicidality Self-injury Depression Substance dependence Research Support Adaptations of DBT have been found effective for: PTSD due to childhood sexual abuse Eating disorders Substance abuse Cluster B personality disorders Depression Please see Linehan, M. (2015). DBT Skills Training Manual, Second Edition. Guilford Press: New York for further details and references. Antisocial Personality Disorder A. A pervasive pattern of disregard for and violation of the rights of others, occuring since age 15, as indicated by three or more of the following: Failure to conform to social norms with respect to lawful behaviours, as indicated by repeatedly performing acts that are grounds for arrest Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure Impulsivity or failure to plan ahead Irritability and aggressiveness, as indicated by repeated physical fights or assaults Reckless disregard for the safety of self and others Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honor financial obligations Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another B. At least 18 years of age C. Evidence of conduct disorder with onset before age 15 D. Occurrence of antisocial behaviour is not exclusively during the course of schizophrenia or bipolar disorder The possibility of two types of ASPD have been postulated, with different underlying neuropsuchological patterns 1) the Impulsive or Reactive type Habitually displays antisocial behaviour, has difficulty controlling affect, similar to BPD These impulsive, reactive types tend to exhibit right orbitofrontal and limbic system deficits 2) the Predatory Psychopathic Left hemispheric dysfunction and overall lower levels of arousal, which may explain their failure to become conditioned to fear and learn to abide by rules and norms of socially sanctioned behaviour Not the same... Psychopathy Most portrayals in the movies are about psychopaths, not ASPD “Everyone diagnosed with psychopathy has ASPD, but not everyone with ASPD is a psychopath” Not entirely true...but “Most” 75-90% of offenders are diagnosed with ASPD Only 10-25% of those with Psychopathy Assessed with the PCL-R Consists of 2 factors: 1) Interpersonal and Affective, 2) Lifestyle/Antisocial ASPD tends to align with Factor 2 ASPD is really a diagnosis of behaviours, not personality Pseudopsychopathy Damage to the orbitomedial cortex can result in pseudopsychopathy; a constellation of symptoms characterized by jocular attitude, disinhibition, extreme self-indulgence, poor judgement, and inappropriate sexual humor These patients often also exhibit an inability to appreciate one’s impact on others and a tendency towards immediate gratification This syndrome has been labeled “acquired sociopathy” or “partial psychopaths”, since they don’t have the superficial charm, poise, etc. (Morgan & Lilienfeld, 2000) Different Samples Complicate Research Findings Antisocial symptoms have been significantly associated with cognitive control deficits; attentional problems; abnormalities in decision-making; deficits in aspects of flexible responding, such as reversal learning; planning impairments, abnormalities in neural regions governing inhibitory control, and composite measures of executive function, with medium to large effect size (Chamberlain et al., 2016) But “ASPD” included psychopathic personalities, criminality, delinquency, inmates, offenders, and conduct disorder. Are these all the same? Many of the samples are also confounded by substance use disorders. (Chamberlain et al., 2016) In addition to terminology confusion as a possible confound resulting in inconsistent results, poor performance across domains may have a different explanations. A number of IQ tests used in the research are reading-based paradigms and therefore sensitive to education Educational attainment is likely lower in ASPD than healthy groups, so may be reflective of developmental experience vs true neuropsychological differences Neuropsychological Test Results Intelligence: Antisocial groups score approximately 8 points lower on intelligence tests than non antisocial groups Reasons for this are unclear Memory: significantly poorer performance on memory Executive Functions: Robust and statistically significant relation between ASB and EF more pronounced in groups characterized by severe and persistent behavioural problems. Life course persistent pathways of antisocial behaviour displayed greater EF deficits It is not possible to determine whether deficits in EF are a precursor to ASPD, a sequela of ASPD, or a correlate that is associated with ASPD via unidentified third variables Facial Affect Recognition and Emotional IQ Individuals with ASPD are more likely to identify anger in ambiguous facial stimuli, Suggests a hostile attribution bias Impairments in recognition of a number of emotions including happiness, sadness, fear, and surprise The higher the score on the PCL-SV, the worse the ability to recognize sad faces Suggests that the amygdala processes facial information differently in individuals with ASPD (Dolan & Fulham, 2006) Facial Affect Recognition difficulties could result in poor understanding of social situation or the intentions of others. May also impair the detection of distress cues in others, thereby removing inhibition that such cues typically evoke against violence. Offenders with ASPD and psychopathy are significantly slower at classifying affective words than neutral words, when compared to offenders with no ASPD. Research suggests that individuals with ASPD fail to ignore emotional material when engaging in inhibitory control, which may give insight into their violent behaviours during episodes of high emotionality Neurobiology Several functional brain imaging studies suggest the possibility of hypofrontality, reduced gray matter volume, reduced whole brain volumes in ASPD and violent schizophrenics compared to controls has resulted in questions of neurodevelopmental abnormalities (Santana, 2016) Areas affected: right lentiform nucleus, left insula, left prefrontal cortex right fusiform gyrus right inferior parietal lobule right superior parietal lobule right cingulate gyrus right postcentral gyrus Orbitofrontal cortex Dorsolateral prefrontal cortex Anterior cingulate cortex Medial prefrontal cortex Some of these results converge with theories that relate antisocial behaviours to frontal lobe alterations/dysfunction E.g., decreased GM could predispose one to disinhibited and impulsive behaviours Violent psychopathy may differ even from other violent offenders with ASPD 17 psychopaths compared to 27 violent male offenders with ASPD: MRI found that psychopaths had significantly less grey matter in the anterior rostral prefrontal cortex and temporal poles than the brains of the non-psychpathic offenders (Blackwood, 2012) These parts of the brain are important for understanding other people’s emotions and intention and are activated when people think about moral behaviour...damage to these areas is linked with a lack of empathy, a poor response to fear and distress and a lack of self-conscious emotions such as guilt or embarrassment This study supports the hypothesis that psychopathy is a distinct neurodevelopmental brain disorder Implications of Neurocognitive Findings There is some evidence that suggests that poorer neurocognitive functioning is related to higher risk of violence Poor cognition could enhance the risk of violent behaviour via poorer decisions making or problem solving abilities, for example, difficulty generating pro social alternatives for emergent problems, or confer a higher risk for related problems such as unemployment, which may foster or perpetuate offending/reoffending Cluster C Obsessive-Compulsive Personality Disorder A. A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost 2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met) 3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity) 4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification) 5. Is unable to discard worn-out or worthless objects even when they have no sentimental value 6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things 7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes 8. Shows rigidity and stubbornness OCPD Dependent Personality Disorder A. A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others 2. Needs others to assume responsibility for most major areas of his or her life 3. Has difficulty expressing disagreement with others because of fear of loss of support or approval (Note: does not include realistic fears of retribution) 4. Has difficulty initiating projects or doing things on his or her own (because of a lack of selfconfidence in judgements or abilities rather than a lack of motivation or energy) 5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant 6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself 7. Urgently seeks another relationship as a source of care and support when a close relationship ends 8. Is unrealistically preoccupied with fears of being left to take care of himself or herself. Avoidant Personality Disorder A. A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection 2. Is unwilling to get involved with people unless certain of being liked 3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed 4. Is preoccupied with being criticized or rejected in social situations 5. Is inhibited in new interpersonal situations because of feelings of inadequacy 6. Views self as socially inept, personally unappealing, or inferior to others 7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing Considerations Some “Axis I” disorders can look like “Axis II” E.g., Trauma/PTSD and BPD PD’s are not as stable and chronic as once thought E.g., “Aging Out” phenomenon that occurs with APD and BPD Faking good or bad/malingering Lawyers have coached clients on how to answer PCL-R He said/she said