Chapter 12 Personality Disorders PDF

Chapter 12 Personality Disorders Psychopathology – PSG 3711 with Dr. E. N. Shino Brief Review & Overview What is Psychopathology?  History  Integrative approach  Clinical assessment & diagnosis  Research Methods  Anxiety, trauma- & stress- & OCD & related  Somatic symptom & dissoc...

Chapter 12 Personality Disorders Psychopathology – PSG 3711 with Dr. E. N. Shino Brief Review & Overview What is Psychopathology?  History  Integrative approach  Clinical assessment & diagnosis  Research Methods  Anxiety, trauma- & stress- & OCD & related  Somatic symptom & dissociative disorders  Mood disorders & suicide  Eatingdisorders  Paraphilic disorders & Gender dysphoria  Substance-related disorders & impulse control disorders  Schizophrenia spectrum & psychotic disorders Assessments Done Test 1  Test 2  Test 3 (upcoming soon) CA Marks will be available after Test 3. Please check for CA marks in last week of lectures.  Where are we?  Personality disorders  Neurodevelopmental disorders  Neurocognitive disorders  Mental health services: Legal & ethical issues  [Positive psychology & abnormal psychology]  What are Personality Disorders?  A persistent pattern of emotions, cognitions and behaviour that results in enduring emotional distress for the person affected and/or for others and may cause difficulties with work and relationships Personality Disorders: An Overview  Enduring, inflexible predispositions  Maladaptive, causing distress and/or impairment  High comorbidity with other disorders  Generally poor prognosis  Hard to treat effectively  Ego-syntonic: Unlike other disorders, often feel consistent with one’s identity; patients don’t feel that treatment is necessary = “the problem is with the world, not with me”  Ten specific personality disorders organized into three clusters  Clusters based on similarities  Personality disorders have traditionally been assigned as all-or-nothing categories DSM-5 personality disorder clusters Cluster Description Disorder Cluster A odd or eccentric Paranoid personality disorder cluster Schizoid, personality disorder Schizotypal personality disorder ◦– Cluster B dramatic, emotional, Antisocial personality disorder ◦– erratic cluster Borderline personality disorder Histrionic personality disorder ◦– Narcissistic personality disorder Cluster C fearful or anxious Avoidant personality disorder cluster Dependent personality disorder Obsessive-compulsive personality disorder DSM-5 Personality Disorders (See also Table 12.3) Personality Disorders: Statistics  Prevalence of personality disorders ◦ Affects about 6% of the general population  Origins and course of personality disorders ◦ Thought to begin in childhood ◦ Tend to run a chronic course if untreated  May transition into a different personality disorder  Personality Disorders: Statistics  Gender distribution and gender bias in diagnosis Men more often show traits such as aggression and detachment; women more often show submission, insecurity, emotional Antisocial – more often male Histrionic – more often female  Comorbidity Often have traits of other personality disorders An additional clinical disorder e.g. mood or anxiety disorder etc. DSM-5 Personality Disorders  Cluster A = Odd or Eccentric ◦ Paranoid, schizoid and schizotypal personality disorders  Cluster B = Dramatic or Erratic ◦ Antisocial, borderline, histrionic and narcissistic personality disorders  Cluster C = Anxious or Fearful ◦ Avoidant, dependent and obsessive- compulsive personality disorders Paranoid Personality Disorder  Overview and clinical features ◦ Pervasive and unjustified mistrust and suspicion of others ◦ Unfounded suspicion, perceive personal attack ◦ Few meaningful relationships, sensitive to criticism ◦ Poor quality of life  Causes ◦ Not well understood ◦ May involve early learning that people and the world are dangerous or deceptive  Cultural factors: More often found in people with experiences that lead to mistrust of others, e.g. ◦ Prisoners ◦ Refugees ◦ People with hearing impairments ◦ Older adults  Treatment & Management ◦ Few seek professional help on their own ◦ Treatment focuses on development of trust ◦ Cognitive therapy to counter negativistic thinking ◦ Lack of good outcome studies Schizoid Personality Disorder  Overview and clinical features  Pervasive pattern of detachment from social relationships  Very limited range of emotions in interpersonal situations  Seem neither to desire nor enjoy closeness with other people incl. romantic relationships  Seem aloof, cold, indifferent to other people  Don’t seem affected by praise or criticism  “Extreme loner”, observers rather than participants in the world around them  No ideas of reference  Social isolation  Poor rapport  Constricted affect (showing neither positive nor negative emotion)  Causes ◦ Aetiology is unclear due to scarcity of research ◦ Childhood shyness is usually present ◦ Some individuals experienced abuse or neglect in childhood ◦ Preference for social isolation resembles autism  Treatment & Management ◦ Few seek professional help on their own ◦ Crisis might prompt them to seek help ◦ Focus on the value of interpersonal relationships ◦ Taught emotions felt by others ◦ Building and learning empathy & social skills ◦ Lack of good outcome studies  Chapter 12 Personality Disorders……continue Psychopathology – PSG 3711 with Dr. E. N. Shino DSM-5 personality disorder clusters Cluster Description Disorder Cluster A odd or eccentric cluster Paranoid personality disorder Schizoid, personality disorder Schizotypal personality disorder ◦– Cluster C dramatic, emotional, Antisocial personality disorder ◦– erratic cluster Borderline personality disorder Histrionic personality disorder ◦– Narcissistic personality disorder Cluster C fearful or anxious Avoidant personality disorder cluster Dependent personality disorder Obsessive-compulsive personality disorder Schizotypal Personality Disorder  Overview & clinical features Pervasive pattern of social and interpersonal deficit Cognitive or perceptual distortions Eccentricities of behavior  Behaviour and dress is odd & unusual Socially isolated & highly suspicious Magical thinking Ideas of reference and illusions* Many meet criteria for major depression Some conceptualize this as resembling a milder form of schizophrenia Ideas of reference – belief that things have special personal significance (e.g. that seeing a certain licence plate means you’ll have a good day) Illusions – Unusual perceptual experiences, not as severe as hallucinations/delusions (e.g. feeling the presence of another person when you are alone)  Causes ◦ Mild expression of schizophrenia genes? ◦ May be more likely to develop after childhood maltreatment or trauma, especially in men ◦ More generalized brain deficits may be present (e.g. problems with learning or memory  Treatment & Management ◦ Address comorbid depression  30–50% meet criteria for major depressive disorder ◦ Main focus is on developing social skills ◦ Medical treatment is similar to that used for schizophrenia ◦ Incl. CBT for youth with schizotypal personality as preventative strategy- at risk for schizophrenia ◦ Treatment prognosis is generally poor DSM-5 Personality Disorders  Cluster A = Odd or Eccentric ◦ Paranoid personality disorder ◦ Schizoid personality disorder ◦ Schizotypal personality disorder  (Part B)  Cluster B Personality Disorders  Cluster C Personality Disorders  Few case studies Cluster B Personality Disorders Dramatic or Erratic Antisocial personality disorder Borderline personality disorder Histrionic personality disorder Narcissistic personality disorder Antisocial Personality Disorder  Overview and clinical features  Failure to comply with social norms  Violation of the rights of others  Irresponsible, impulsive and deceitful  Social predators & lie, cheat, steal  Lack of a conscience, empathy and remorse – no regret  'Sociopathy‘, 'psychopathy' typically refer to this disorder or very similar traits  May be very charming, interpersonally manipulative Cluster B: Antisocial  Conduct Disorder  Similar pattern to antisocial personality disorder  Behaviors that violate rights of others & social norms  On-set is earlier than antisocial personality disorder, prior to age 18  Onset can be in childhood or adolescence  Truancy from school, running away from home, Aetiology: Psychosocial  Often show early histories of behavioural problems, including conduct disorder ◦ 'Callous-unemotional' type of conduct disorder more likely to evolve into antisocial personality disorder  Families with inconsistent parental discipline and support  Families often have histories of criminal and violent behaviour Treatment/Management  Few seek treatment on their own  Might be manipulative with therapist  Antisocial behaviour is predictive of poor prognosis  Emphasis is placed on prevention and rehabilitation  Often incarceration is the only viable alternative  May need to focus on practical (or selfish) consequences (e.g. if you assault someone you’ll go to prison) Prevention  Identification of high-risk children  Involve parental training  Praise & privileges for prosocial behaviours Borderline Personality Disorder  Overview and clinical features  Unstable moods and relationships  “stably unstable”  Impulsivity, fear of abandonment  Poor self-image, feel empty  Self-mutilation/injury and suicidal gestures e.g. cutting, burning self - reduces/relieves tension - risk for suicide high  Comorbidity rates are high with other mental disorders, particularly mood disorders  Substance abuse, bipolar, eating disorders are common  Comorbid disorders ◦ 1 in 5 borderline patients is also depressed  10% of suicide attempts are successful ◦ 40% meet criteria for bipolar disorder ◦ 67% engage in substance abuse ◦ Eating disorders  25% of bulimia patients have borderline personality disorder  Causes ◦ Strong genetic component  Also linked to depression genetically ◦ High emotional reactivity may be inherited ◦ May have impaired functioning of limbic system ◦ Early trauma, sexual & physical abuse and neglect – increase the risk ◦ Many BPD patients have high levels of shame and low self-esteem  'Triple vulnerability' model of anxiety applies to borderline personality too  Results from the combination of: ◦ generalised biological vulnerability (reactivity) ◦ generalised psychological vulnerability (lash out when threatened) ◦ specific psychological vulnerability (stressors that elicit borderline behaviour)  Treatment/Management  Patient more likely to seek treatment because they feel distressed  Few good outcome studies  Antidepressant medications provide some short-term relief  Dialectical behaviour therapy is most promising treatment  Focus: to cope with stressors that trigger suicidal behaviours  Focus on dual reality of acceptance of difficulties and need for change  Focus on interpersonal effectiveness  Focus on distress tolerance to decrease reckless/self-harming behaviour Histrionic Personality Disorder  Overview and clinical features  Overly dramatic and sensational  Seem almost to be acting, theatrical in manner  Exaggerated – behaviours, emotions  Vain, flamboyant  May be sexually provocative, seductive in appearance & behaviours  Constantly seek reassurance & approval  Need/want praise and admiration from others - angers/upset  Impulsive, difficulties delaying gratification  Impressionistic  Speech is vague, lack details, exaggerations  Causes  Little research  Often co-occurs with antisocial PD  Feminine variant of antisocial traits?  Treatment  Little research on treatment success  Modify attention-seeking behaviours  Focus on problematic interpersonal relationships  Focus on long-term negative consequences of behaviours e.g. manipulation, complaining, seductions, using charm, sex for short-term gains Narcissistic Personality Disorder  Overview and clinical features  Exaggerated and unreasonable sense of self- importance  Think highly of themselves, exaggerate their abilities; Fantasies of greatness = Grandiosity  Think their deserve special treatment  Preoccupation with receiving attention  Lack sensitivity and compassion for other people  Highly sensitive to criticism  Often impulsive and need to be the centre of attention  Need admiration from others  Need to be treated special  Exploit others for their own interests  Little or no empathy for others  Envious, arrogant  May become depressed because did not live up to their own expectations  Causes  Kohut – child fixated at self-centered grandiose stage of development  Large-scale social changes incl. focus on individualism, focus on self ◦ i.e. Failure to learn empathy as a child ◦ Sociological view – product of the 'me' generation  Treatment  Focus on grandiosity, hypersensitivity to evaluation, lack of empathy for others, attention-seeking and long-term negative consequences  Emphasize realistic goals and coping skills for dealing with criticism  Cognitive therapy  Targets may also include problematic interpersonal behaviours  Treatment for depression as it often co-occur  Little evidence that treatment is effective DSM-5 Personality Disorders  ClusterC = Anxious or Fearful ◦ Avoidant personality disorder ◦ Dependent personality disorder ◦ Obsessive-compulsive personality disorder Avoidant Personality Disorder  Overview and clinical features  Extreme sensitivity to the opinions of others  Highly avoidant of most interpersonal relationships  Fearful of criticism  Interpersonally anxious and fearful of rejection – few friends, asocial  Pessimistic about future  Low self-esteem  Causes  May be linked to schizophrenia; occurs more often in relatives of people with schizophrenia  Born with difficult temperament  Experiences of early rejection  Treatment  Similar to treatment for social phobia  Focus on social skills, entering anxiety- provoking situations  Good relationship with therapist is important for therapeutic success Dependent Personality Disorder  Overview and clinical features  Reliance on others to make major and minor life decisions  Unreasonable fear of abandonment  Fear of rejection  Clingy, timid, passive, and submissive in interpersonal relationships  Feelings of inadequacy, sensitive to criticism, need for reassurance  Causes  Not well understood due to lack of research  Linked to early disruptions in learning independence; fear of abandonment – due to early death of parent, neglect, or rejection  Treatment  Research on treatment efficacy is lacking  Therapy typically progresses gradually due to lack of independence  Treatment targets include skills that foster confidence and independence, and decision making Obsessive-Compulsive Personality Disorder  Overview and clinical features  Excessive and rigid fixation on doing things the ‘right’ way  Highly perfectionistic, orderly and emotionally shallow  Unwilling to delegate tasks because others will do them wrong  Difficulty with spontaneity  Often have interpersonal problems  Obsessions and compulsions are rare  Causes are not well known  Weak genetic contribution  Parental reinforcement of neatness & conformity  Treatment  Little data on treatment  Address fears related to the need for orderliness  Target rumination, procrastination and feelings of inadequacy  Cognitive-Behavioural Therapy Summary of Personality Disorders  Long-standing patterns of behaviour  Begin early in development and run a chronic course  Disagreement exists over how to categorize personality disorders ◦ Categorical vs dimensional, or some combination of both  For most, little is known about causes or treatment