Personality Disorders PDF

11/27/23, 3:30 AM Realizeit for Student Personality Disorders Onset and Clinical Course Personality disorders are relatively common, occurring in 10% to 20% of the general population. Incidence is even higher for people in lower socioeconomic groups and unstable or disadvantaged populations. Of al...

11/27/23, 3:30 AM Realizeit for Student Personality Disorders Onset and Clinical Course Personality disorders are relatively common, occurring in 10% to 20% of the general population. Incidence is even higher for people in lower socioeconomic groups and unstable or disadvantaged populations. Of all psychiatric inpatients, 15% have a primary diagnosis of a personality disorder. Of those with a primary diagnosis of major mental illness, 40% to 45% also have a coexisting personality disorder that significantly complicates treatment. In mental health outpatient settings, the incidence of personality disorder is 30% to 50% (Cloninger & Svrakic, 2017). Clients with personality disorders have a higher death rate, especially as a result of suicide; they also have higher rates of suicide attempts, accidents, and emergency department visits, and increased rates of separation, divorce, and involvement in legal proceedings regarding child custody. Personality disorders have been highly correlated with criminal behavior, alcoholism, and drug abuse. People with personality disorders are often described as “treatment resistant.” This is not surprising, considering that personality characteristics and behavioral patterns are deeply ingrained. It is difficult to change one’s personality; if such changes occur, they evolve slowly. The slow course of treatment can be frustrating for family, friends, and health care providers. Another barrier to treatment is that many clients with personality disorders do not perceive their dysfunctional or maladaptive behaviors as a problem; indeed, these behaviors sometimes are a source of pride. For example, a belligerent or aggressive person may perceive him or herself as having a strong personality and as being someone who cannot be taken advantage of or pushed around. Clients with personality disorders frequently fail to understand the need to change their behavior and may view changes as a threat. The difficulties associated with personality disorders persist throughout young and middle adulthood, but tend to diminish in the 40s and 50s. Those with antisocial personality disorder are less likely to engage in criminal behavior, though problems with substance abuse and disregard for the feelings of others persist. Clients with borderline personality disorder (BPD) tend to demonstrate decreased impulsive behavior, increased adaptive behavior, and more stable relationships by age 50. This increased stability and improved behavior can occur even without treatment. Some personality disorders, such as schizotypal avoidant and obsessive–compulsive, tend to remain consistent throughout life. Etiology Biologic Theories Personality develops through the interaction of hereditary dispositions and environmental influences. Temperament refers to the biologic processes of sensation, association, and motivation that underlie the integration of skills and habits based on emotion. Genetic differences account for about 50% of the variances in temperament traits. The four temperament traits are harm avoidance, novelty seeking, reward dependence, and persistence. Each of these four genetically influenced traits affects a person’s automatic responses to certain situations. These response patterns are ingrained by 2 to 3 years of age. People with high harm avoidance exhibit fear of uncertainty, social inhibition, shyness with strangers, rapid fatigability, and pessimistic worry in anticipation of problems. Those with low harm avoidance are carefree, energetic, outgoing, and optimistic. High harm avoidance behaviors may result in maladaptive inhibition and excessive anxiety. Low harm avoidance behaviors may result in unwarranted optimism and unresponsiveness to potential harm or danger. DSM5-TR DIAGNOSTIC CRITERIA: Borderline Personality Disorder 301.83 (F60.3) A. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and prese indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self-image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not behavior covered in Criterion 5.) 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation or severe dissociative symptoms. Reprinted with permission from the American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: Author. A high novelty-seeking temperament results in someone who is quick-tempered, curious, easily bored, impulsive, extravagant, and disorderly. He or she may be easily bored and distracted with daily life, prone to angry outbursts, and fickle in relationships. The person low in novelty seeking is slowhttps://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVtCtaoun4KMdegul%2fePt%2bh9MMaIFoYvxFjmrRvhyUR… 1/3 11/27/23, 3:30 AM Realizeit for Student tempered, stoic, reflective, frugal, reserved, orderly, and tolerant of monotony; he or she may adhere to a routine of activities. Reward dependence defines how a person responds to social cues. People high in reward dependence are tenderhearted, sensitive, sociable, and socially dependent. They may become overly dependent on approval from others and readily assume the ideas or wishes of others without regard for their own beliefs or desires. People with low reward dependence are practical, tough-minded, cold, socially insensitive, irresolute, and indifferent to being alone. Social withdrawal, detachment, aloofness, and disinterest in others can result. Highly persistent people are hardworking and ambitious overachievers who respond to fatigue or frustration as a personal challenge. They may persevere even when a situation dictates they should change or stop. People with low persistence are inactive, indolent, unstable, and erratic. They tend to give up easily when frustrated and rarely strive for higher accomplishments. These four genetically independent temperament traits occur in all possible combinations. Some of the previous descriptions of high and low levels of traits correspond closely with the descriptions of the various personality disorders. For example, people with antisocial personality disorder are low in harm avoidance traits and high in novelty-seeking traits, while people with avoidant personality disorder are high in reward dependence traits and harm avoidance traits. Psychodynamic Theories Although temperament is largely inherited, social learning, culture, and random life events unique to each person influence character. Character consists of concepts about the self and the external world. It develops over time as a person comes into contact with people and situations and confronts challenges. Three major character traits have been distinguished: self-directedness, cooperativeness, and self-transcendence. When fully developed, these character traits define a mature personality (Cloninger & Svrakic, 2017). Self-directedness is the extent to which a person is responsible, reliable, resourceful, goal-oriented, and self-confident. Self-directed people are realistic and effective and can adapt their behavior to achieve goals. People low in self-directedness are blaming, helpless, irresponsible, and unreliable. They cannot set and pursue meaningful goals. Cooperativeness refers to the extent to which a person sees him or herself as an integral part of human society. Highly cooperative people are described as empathic, tolerant, compassionate, supportive, and principled. People with low cooperativeness are self-absorbed, intolerant, critical, unhelpful, revengeful, and opportunistic; that is, they look out for themselves without regard for the rights and feelings of others. Self-transcendence describes the extent to which a person considers him or herself to be an integral part of the universe. Self-transcendent people are spiritual, unpretentious, humble, and fulfilled. These traits are helpful when dealing with suffering, illness, or death. People low in self-transcendence are practical, self-conscious, materialistic, and controlling. They may have difficulty accepting suffering, loss of control, personal and material losses, and death. Character matures in stepwise stages from infancy through late adulthood. Each stage has an associated developmental task that the person must perform for mature personality development. Failure to complete a developmental task jeopardizes the person’s ability to achieve future developmental tasks. For example, if the task of basic trust is not achieved in infancy, mistrust results and subsequently interferes with achievement of all future tasks. Experiences with family, peers, and others can significantly influence psychosocial development. Social education in the family creates an environment that can support or oppress specific character development. For example, a family environment that does not value and demonstrate cooperation with others (compassion or tolerance) fails to support the development of that trait in its children. Likewise, the person with nonsupportive or difficult peer relationships growing up may have lifelong difficulty relating to others and forming satisfactory relationships. In summary, personality develops in response to inherited dispositions (temperament) and environmental influences (character), which are experiences unique to each person. Personality disorders result when the combination of temperament and character development produces maladaptive, inflexible ways of viewing self, coping with the world, and relating to others. Although a personality disorder is a psychiatric diagnosis, it is important to remember that it is not an illness with treatable symptoms in the way other mental disorders are. The personality traits are ingrained ways of being and thinking. Although some change may occur slowly over time, there will be no significant improvement or quick resolution of problematic behavior. CULTURAL CONSIDERATIONS Judgments about personality functioning must involve a consideration of the person’s ethnic, cultural, and social background. Members of minority groups, immigrants, political refugees, and people from different ethnic backgrounds may display guarded or defensive behavior as a result of language barriers or previous negative experiences; this should not be confused with emotional coldness or lack of concern for others. People with religious or spiritual beliefs, such as clairvoyance, speaking in tongues, or evil spirits as a cause of disease, could be misinterpreted as having schizotypal personality disorder. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVtCtaoun4KMdegul%2fePt%2bh9MMaIFoYvxFjmrRvhyUR… 2/3 11/27/23, 3:30 AM Realizeit for Student There is also a difference in how some cultural groups view avoidance or dependent behavior, particularly for women. An emphasis on deference, passivity, and politeness should not be confused with avoidant personality disorder. Cultures that value work and productivity may produce citizens with a strong emphasis in these areas; this should not be confused with obsessive–compulsive personality disorder. Certain personality disorders—for example, antisocial personality disorder—are diagnosed more often in men. BPD is diagnosed more often in women. Social stereotypes about typical gender roles and behaviors can influence diagnostic decisions if clinicians are unaware of such biases. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVtCtaoun4KMdegul%2fePt%2bh9MMaIFoYvxFjmrRvhyUR… 3/3