Lecture 4 Personality Disorders PDF 2024

18/07/2024 Next week: Week 5 Note: there is no face-to-face lecture in week 5 PERSONALITY & ITS DISORDERS PSYU/PSYX3336 Instead, there will be some pre-recorded modules in Echo (essay writing & critical Lecture...

18/07/2024 Next week: Week 5 Note: there is no face-to-face lecture in week 5 PERSONALITY & ITS DISORDERS PSYU/PSYX3336 Instead, there will be some pre-recorded modules in Echo (essay writing & critical Lecture 4: Personality disorders thinking; presentations) A/Prof Simon Boag email: [email protected] 1 2 Readings (non-assessable) Outline Leising et al.(2009). The undisordered 1. Introduction to Personality disorders personality. Review of General Psychology, 13, Changes from DSM-IV to DSM-5 230-241 Clusters A, B, & C Morey, et al. (2015). Personality disorders in 2. Trait approaches DSM-5: Emerging research on the alternative DSM-5 alternative model model. Current Psychiatry Reports, 17, 1-9 3. Personality disorders & culture PDs around the world PDs & person/culture clash 3 4 Learning objectives 1. Introduction Describe DSM Personality disorders & critically PDs: clinically important but perpetually evaluate the DSM categorical approach problematic “There are very few, if any, constructs in Describe & critically evaluate trait approaches psychiatry that are more conceptually to personality pathology encumbered than that of personality disorder. How so? Because personality disorder inherits Describe & critically evaluate the role of not only all the problems associated with the concept of “personality,” but also all the culture for differentiating normal & disordered problems associated with the concept personality “psychiatric disorder”” (Zachar & Krueger, 2013) 5 6 1  18/07/2024 Personality disorders in the DSM DSM-5: PDs in a nutshell “A Personality Disorder is an enduring pattern of inner experience & behaviour that deviates A) Enduring patterns of markedly from the expectations of the thinking/feeling/acting/relating individual’s culture, is pervasive & inflexible, B) Culturally deviant has an onset in adolescence or early C) Pervasive & inflexible adulthood, is stable over time, & leads to D) Lead to distress or social impairment stress or impairment” (DSM-IV-TR, 2000, p. 685; DSM-5, 2013, p. 645) 7 8 Personality disorders: Personality disorders: Highly problematic DSM-IV → DSM-5 Categorical model: distinct clinical entities Dimensional model proposal for DSM-5: maladaptive variants of personality traits Failure of the categorical model (Widiger & Trull, 2007; Schmeck et al, 2013) “… new model was too complex for clinical a) Extensive co-occurrence of PDs practice” b) Extreme heterogeneity (eg. 256 different ways to diagnose BPD) So, despite problems, “the American c) Poor inter-rater reliability Psychiatric Association Board of Trustees d) PD NOS most common diagnosis ultimately decided to retain the DSM-IV e) Arbitrary cut-offs categorical approach with the same 10 9 personality disorders” (APA Fact sheet) 10 Changes from DSM IV → 5 Changes from DSM IV → 5 DSM-III (1980): PDs on Axis II to distinguish Axes removed from DSM-5 them from ‘traditional mental disorders’ “DSM-5 moves from the multiaxial system to a Axis I: Clinical disorders new assessment that removes the arbitrary Axis II: Personality disorders & mental boundaries b/w personality disorders & other retardation mental disorders” Recognises the possible effects of enduring personality characteristics on the treatment of more transient clinical cases 11 12 2  18/07/2024 DEPARTMENT OF PSYCHOLOGY 13 DEPARTMENT OF PSYCHOLOGY 14 Cluster B: “Individuals with these Cluster A: “Individuals with these disorders often appear dramatic, disorders often appear odd or eccentric” emotional, or erratic” Paranoid: distrust, suspiciousness Antisocial (Dissocial): "...a pervasive pattern of Misinterprets others' actions, disregard for, & violation of, the rights of others motives that begins in childhood or early adolescence & Schizoid: social detachment, limited emotions continues into adulthood” More common in males (underdiagnosed in Prefers isolation; lacks close friendships/relationships females?) Schizotypal: acute discomfort in Highest prevalence (>70%) “among most close relations; perceptual severe samples of males with alcohol use distortions; eccentricities disorder & from substance abuse clinics, Schizophrenia spectrum disorder prisons, or other forensic settings” (DSM-5) 15 16 ASPD, alcohol & aggression Moeller, F. G., & Dougherty, D. M. (2001). Antisocial personality disorder, alcohol, & aggression. Alcohol Research & Health, 25, 5-11 17 Self-harm images on next slide 18 3  18/07/2024 Cluster B Borderline: instability of interpersonal relationships, self-image & emotions; behavioural dysregulation Fear of abandonment/rage Splitting Identity disturbances ‘Emptiness’ Self-harm, suicide risk c.75% female; 20% inpatients DEPARTMENT OF PSYCHOLOGY 19 20 Cluster B Histrionic: excessive emotionality & attention seeking Self-dramatisation Incessant drawing of attention to self Craving for activity & excitement Overreacting to minor events Winston, AP (2000). Recent developments in borderline personality disorder. Irrational, angry outbursts or tantrums Advances in Psychiatric Treatment, 6, 211-217 1-2% pop’n (F > M) Childhood sexual abuse: 40-71% BPD inpatients Commonly also receives borderline, narcissistic, Lieb et al (2004). Borderline personality disorder. The Lancet, 364, 453-461 antisocial diagnoses (Blagov & Westen, 2008) 21 Blagov, P. S., & Westen, D. (2008). Questioning the coherence of histrionic 22 personality disorder. The Journal of Nervous & Mental Disease, 196, 785-797 Cluster B Cluster B & childhood abuse Narcissistic: "a pervasive pattern of grandiosity, “Persons with documented need for admiration, & a lack of empathy" childhood abuse or neglect were more than 4 times as likely as Feels privileged, entitled; expects preferential those who were not abused or treatment neglected to be diagnosed with Exaggerated sense of self-importance PDs during early adulthood after 0-6% of pop’n (up to 75% male) age, parental education, & parental psychiatric disorders were controlled statistically” Johnson, et al. (1999). Childhood maltreatment increases risk for personality disorders during early adulthood. Archives of General Psychiatry, 56, 600-606 23 24 4  18/07/2024 Cluster C: “Individuals with these disorders often appear anxious or 2. Dimensional approaches to fearful” disordered personality Avoidant: social inhibition, If PDs not categorical, then can we make sense feeling inadequate, of them dimensionally? hypersensitivity to negative evaluation Dimensional model: maladaptive variants of Avoids social situations because personality traits of fear of embarrassment/humiliation Dependent: submissive & clinging; excessive need to be taken care of Obsessive-compulsive: preoccupation with orderliness, perfectionism & control 25 26 Dimensional approaches to disordered personality 27 28 Krueger, R. F., & Eaton, N. R. (2010). Personality traits & the classification of mental disorders: Toward a more complete integration in DSM–5 & an empirical model of psychopathology. Personality Disorders: Theory, Research, 29 & DEPARTMENT OF PSYCHOLOGY 30 Treatment, 1, 97-118 5  18/07/2024 Alternative Model for DSM-5 (AMPD): impairment & pathological traits PDs involve: Criterion A: impaired personality functioning Criterion B: pathological personality traits Hybrid model: using functioning & traits to identify specific PD diagnoses: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, schizotypal No Paranoid, Schizoid, Dependent, Histrionic 31 32 Criterion A: Impairment in personality Criterion B: Pathological personality traits functioning “Disturbances in self & interpersonal functioning Organised into 5 broad domains constitute the core of personality Negative affectivity (Neuroticism) psychopathology” (DSM-5, 2013) Detachment (Extraversion) Moderate or greater impairment in: Psychoticism (Openness) Antagonism (Agreeableness) Identity, Self-direction; Empathy, Intimacy Disinhibition (Conscientiousness) “… these five broad domains are maladaptive variants of the five domains of the extensively validated & replicated personality model known as the ‘Big Five,’ or the Five Factor Model of personality” (DSM-5, 2013) 33 34 Alternative Model for DSM-5 (AMPD): evaluation 3. Personality disorders & culture Follow up since DSM-5: Krueger, R. F., & Hobbs, K. A. (2020). An overview of the DSM-5 alternative Are there cultural differences in PD model of personality Krueger & Hobbs (2020): disorders. Psychopathology, 53, 126-132 prevalence? Meaningful clinical correlates (eg. self-harm; BPD, ASPD ↑ in US over past 30 years treatment dropout) ASPD: US 3%; Taiwan 0.2% Acceptable/improved inter-rater reliability 2001–2002 National Epidemiologic Survey Reasonable psychometric properties on Alcohol & Related Conditions: approx. 15% US adults have at least one personality Still unclear whether the AMPD is superior to disorder (Grant et al (2004). Prevalence, correlates, & disability of personality disorders in the United States. Journal of Clinical Psychiatry, the categorical model (Widiger & Hines, 2022) 65, 948–958) Not always easy to compare cultures 35 36 6  18/07/2024 Personality disorders & culture Personality disorders & culture https://www.abc.net.au/news/2020-10-07/people-with-poor- mental-health-shackled-higher-risk-coronavirus/12736904 Winsper et al. (2020): systematic review & meta-analysis (46 studies from 21 countries/6 continents) Global prevalence of PDs: 7.8% PDs: High income > Low income Cluster B & C less common in Low income countries Cultural protection? Individualism? 37 Winsper, et al. (2020). The prevalence of personality disorders in the community: a 38 global systematic review & meta-analysis. British Journal of Psychiatry, 216, 69-78 Personality disorder & cultural Personality disorders & culture clash? (Caldwell-Harris & Aycicegi, 2006) PDs & person-cultural value clash? Compared US vs Turkish undergrad Ss Chen et al (2009): Dependent PD not Symptoms & culture-clash? maladaptive in Confucian culture AvPD, DPD, BPD not in Chinese Classification of Mental Disorders Leising et al. (2009): Personality/culture clash can be a source of distress Niche seeking & avoiding distress Chen et al. (2009). Rethinking dependent personality disorder: Comparing different human relatedness in cultural 39 40 contexts. The Journal of Nervous & Mental Disease, 197, 793-800 Personality disorders & culture Personality disorders & culture (Caldwell-Harris & Aycicegi, 2006) Can we make sense of normal personality & disordered personality without culture? “A PD reflects difficulties in how an individual behaves & is perceived to behave by others in the social field, & this, of necessity, brings into play cultural values related to what is expected, valued, & devalued in a person” Caldwell-Harris, C. L., & Aycicegi, A. (2006). When personality & culture (Alarcón & Foulks, 1995) clash: The psychological distress of allocentrics in an individualist culture & idiocentrics in a collectivist culture. Transcultural Psychiatry, 43, 331- 361 41 42 7  18/07/2024 Questions? Thanks… 43 8