Personality Disorders PDF

Personality Disorders Learning Objectives 1. Define “personality disorder” (naming the primary characterisitics) 2. Identify the major traits of the 3 personallity disorder clusters, and differentiate between them. (understand differences between the PD clusters) 3. Describe the biopsychosocial mode...

Personality Disorders Learning Objectives 1. Define “personality disorder” (naming the primary characterisitics) 2. Identify the major traits of the 3 personallity disorder clusters, and differentiate between them. (understand differences between the PD clusters) 3. Describe the biopsychosocial model/theory of BPD 4. Distinguish between ASPD and Psychopathy Additional Required Material Trull and Widiger (2013) 5 factor model of personality traits and the dimensional nature of personality disorders. Try and describe each of the personality disorders using high or low levels of some of these traits: Personality Disorders 1 What are they? they are the most understudied and least understood, alongside the most difficult to treat which is why many find them interesting. Personality disorders → chronic pattern of behaviour Chronic aspects early onset (childhood or adolescence) Stable and longstanding Pervasive across life areas (social life, work, home etc.) Identity aspects Inflexible → these traits do not change deviate from cultural expectations (out of cultural/social norms) clinical distress or impaired functioning in: cognition Affect interpersonal functioning impulse control Note: not everyone with a personality disorder will feel distress about their disorder Personality Disorders Clusters Overview Note: The clusters are not empirically based, they were clumped not by research but just clumped them in the past. Cluster A Marked by odd or eccentric ideas, avoid social contact Paranoid Schizoid Personality Disorders 2 Schizotypal Cluster B Marked by tendencies to be dramatic erratic, punitive, and hostile Antisocial Histrionic Borderline Narcissistic Cluster C Characterstics include: anxious, fearfulness Avoidant Dependent Obsessive-Compulsive Cluster A Personality Disorders Moderate heritability → genes play a role in this cluster to a moderate degree Disorder Characteristics Paranoid Suspiciousness, mistrustful of others, on guard for expected attacks by others, seeing hidden meaning in remarks, tendency to see the self as blamness, barring grudges, tend to not be psychotic (not psychotic paranoia, they are not out of touch with reality) Schizoid Inability to form attachments and no interest in forming attachments/relationships. unable to express feelings, and generally apathetic (don’t experiencing strong emotions), and are often highly introverted. “the folks who would be happy being light house attendant” aka they are very content being alone. Schizotypal Personality Disorders strange and often magical thinking, perception and speech interferes with communication → often see things and say things in ways that are unusual and difficult for others to 3 understand. they are quite introverted and often very superspicious. Cluster B Personality Disorders Personality disorders in cluster B tend to be highly comorbid with each other Often someone could have multiple of these personality disorders e.g. Narcissistic and Borderline Disorder Histrionic Characteristics Dramatic, attention-seeking → which can lead to irritability or temper outbursts if they can’t achieve/recieve attention, emphasis on attractiveness/concern for their own sexual attractiveness Grandiosity, attention-seeking, lack of empathy, tendency to Narcissistic Antisocial self promote, being hypercritical and retaliatory → if they feel they’ve been wronged they will often retaliate. Disregard and violation of others rights; serious violation of social norms, are deceitful, manipulative, and had conduct disorder in childhood (before 15yrs) Borderline impulsivity, extreme emotional reactivity, drastic mood shifts, increased amount of self-injury/suicide attempts. Cluster C Personality Disorders Disorder Characterstics shy, hypersensitive to rejection (very sensitive and Avoidant concerned about rejection, and see rejection even when it’s not happening), extreme social insecurity, selfconsciousness and self critical. Often they don’t want to be alone, (some people say it’s an extreme version of social phobia). Dependent Obsessive-compulsive (OCPD) Personality Disorders Extreme discomfort to being alone, suppress their own needs to keep relationships and are highly indecisive. NOT THE SAME AS OCD (only 20% overlap of people who have both). Excessive concern with order, rules, and trivial details; rigidity, perfectionism, lack of warmth. 4 Borderline Personality Disorder It can change, with the right treatment you can change this personality disorder. Term came from conversations that depicted the personality disorder as on the borderline between neurosis & psychosis Main Characteristics of BPD 1. Impulsivity impulsive reaction to dysphoria (bad feelings → which leads to self injury, suicide attempts or substance abuse 2. Affective Instability Rapid mood changes → this is often mistaken as bipolar disorder which is quite inaccurate. Main Differences between BPD and Bipolar Disorder 1. Baseline mood: Dysthymia & emptiness (+ anger and anxiety) which is quite different from bipolar disorder 2. Mood: Highly responsive to environmental changes/input they are responding very heightened sensitivity to what is going on around them, especially in interpersonal things. In contrast, bipolar disorder is more of a force of nature of it’s own → meaning it doesn’t care what is going on around them/in outside world it just wants to go into mania or depression. It is not as responsive to environmental cues as BPD is. 3. Mood change: the pace of mood changes, hours vs. weeks-months (bipolar disorder) BPD → rapid changes within hours Bipolar → weeks to months to change. Symptoms of Dysregulation in BPD 1. Emotional dysregulation high emotional reactivity Personality Disorders 5 Unstable mood (depression, anxiety, irritability, anger) 2. Interpersonal dysregulation Intense fears of abandonment unstable & intense relationships 3. Behavioural dysregulation Extreme impulsivity NSSI, suicidal behaviour 4. Of the self dysregulation feelings of emptiness Unstable sense of self stress-related paranoia/dissociation The course of Borderline Personality Disorder In Young Adulthood has the greatest impairments and suicide risk → this is when you see a lot of patients come in for treatment and the need for treatment is much higher In 30s and 40s (adulthood) there is greater stability across areas a lot of individuals age out of the disorder (not everyone but there are those people who do), even without treatment, or they get treatment and get better. At least >50% of people diagnosed with BPD do not meet the full criteria 10 years later, which is great considering how negative of an impact the disorder can have on someone. Prevalence of Borderline Personality Disorder 1%-2% of population High among psychiatric inpatients (20% are BPD patients) Personality Disorders 6 Due to suicidality there are many of these individuals are in inpatient programs for safety, and. DBT is an outpatient treatment. Equal prevalence in both women and men Comorbidities Present with BPD Mood disorders (85%) Anxiety Disorders (83%) Substance abuse (78%) Eating disorders PTSD → often there's a great history of abuse in BPD patients Other cluster B personality disorders Etiology of BPD Genes Heritable Traits Neuroticism impulsivity 5x more common among 1st-degree relatives, however, it’s the traits that are heritable more so than BPD itself. Relatives may also have impulsive spectrum disorders (e.g. ASPD, substance abuse). Twin studies show impulsivity and affective instability Biology Brain reduced (-) volume in Orbitofrontal volume linked to impulsivity, aggression, mood instability Reduced (-) Hippocampal volume Stress overreactive and increased (+) fear responses. Personality Disorders 7 Hyperactivity in Amygdala affective lability Decreased 5-HT (serotonin) levels impulsive behaviour, disinhibition. fMRI: Amygdala Hyperactivity Study: showed individuals with BPD face of different emotions They saw a hyperactivity in the amygdala → meaning there seems to be a hypervigilance to the threat. Those with BPD are very much attending to threats, anger or something being wrong. They even perceived neutral faces as threatening. In short Amygdala hyperactivity was linked to: Hypervigilance emotional dysregulation Neutral=threatening (side note: often those with BPD are invalidated about the fact that they perceive something neutral as threatening this can lead to them pretending things aren’t negative) Psychological Etiology of BPD Emotion Perceived rejection → that quickly evolves to intense rage (anger) misperception of anger Cognition “thinking mistakes” similar/as seen in depression and anxiety lectures Dichotomous (black and white) thinking, catastrophizing, etc. The thinking mistakes seem to result from a perceived/fear of abandonment and rejection. Personality Disorders 8 thinking/schema “This is my habit (thinking mistakes) because I am terrified that if I don’t think this way, I am going to be left/rejected, and I must protect my relationship” Social Etiology in BPD The biggest etiology for BPD seems to be Invalidating environments Early Adverse Events Trauma/maltreatment 90% people with BPD have experienced childhood physical/sexual abuse, and/or neglect Early separation or loss Abnormal Parenting in childhood Abnormal bonding between parent and child Neglectful and overprotective decreased (-) family cohesion Study on Childhood Maltreatment and Cluster B Personality Disorders 7.95/8x risk for developing Cluster B PD’s (especially BPD) in adulthood if experienced childhood physical abuse, sexual abuse, and neglect. Diathesis-Stress In BPD Personality Disorders 9 Biosocial Theory for BPD: Biological diathesis for emotional reactivity (being highly emotionally reactive and having difficulty coming down from an intense emotion). + Invalidating Environment = BPD Invalidating environment efforts to communicate one's inner experience of the world are disrespected or punished. e.g. Saying “suck it up” then the child can feel that either they get punished for what their feeling, or what they feel is unacceptable. A lot of children who are “highly sensitive” experience this Childhood suppresses emotions → explosion of emotions → gets parents’ attention → attention reinforces outbursts. Child is feeling intense dysregulation and seek parents/adults for help but when their needs aren’t met or validated they react even more to get attention. leads to a cycle of behaviour. Multidimensional Diathesis-Stress Note → also in the textbook. Personality Disorders 10 BPD Treatment Biological treatment For those with comorbid mood disorders take SSRI’s Mood stabilizers Often patients may feel ‘not themselves’ on the medication as so much of their emotional reactivity and dysregulation has been identified as part of their identity. For those with psychotic/dissociative symptoms take Antipsychotics Psychological treatments Dialectical behavioural therapy (BPT) It is the most common form of outpatient treatment for BPD) Intensive → group skills training, individual, phone calls, homework etc. Expensive → highly trained clinicians focused on this therapy, can take a while for patients (a year or so) Personality Disorders 11 Mentalization Therapy Focuses on the client-therapist relationship Perspective-taking works on others perspectives and look at how others may feel is a single modality (therapy session in contrast to DBT however it is still under-researched) Transference-based psychodynamic psychotherapy Based on the Client-therapist relationship Expensive Takes years (a very long time) DBT as a form of treatment for BPD Core Principles 1. Acceptance individuals are doing the best they can and want to improve 2. Change They need to do better, try harder, be more motivated to change They may not have caused all their problems but they have to solve them anyway. Their lives are often unbearable as they are currently being lived so they must learn new behaviours in many contexts Components of DBT CBT (Change) Validation (acceptance) Dialectics (finding the “middle” path) → putting two things that may be opposite together and seeing a compromise. DBT Modes Individual therapy → 1h per week Personality Disorders 12 Skills group (like a class on emotions/practicing emotional skills) → include homework that you must complete before the next class. This mode is crucial as the skills you learn are what you put into practice, then apply them, then go over in therapy. Without this mode (skills learning) you are not doing DBT. Phone Coaching → learning how to incorporate skills into daily life and practice them. (5-10 minutes - what works what doesn't etc.) Consultation Group → this is for clinicians, they meet and discuss the cases they are working on, and if they are having troubles with a patient/client they can bring it up and have suggestions made. Shows it’s a group of clinicians helping the patient, not a single clinician. For adolescents, the skills group is a “family skills group” so they come with a guardian/parent and they both have to learn the skills and do the homework. Helpful because adolescents can’t change behaviours when parents don’t know how to help them change. Interactions with family would improve greatly and are critical. DBT Skills Training 4 modules including: 1. Mindfulness reduce confusion of the self, have awareness of triggers for the emotions that are happening, learn how to be in the moment/be aware of what’s around and within us and choose a response that is the most effective 2. Emotion regulation intense mood changes and mood-dependent behaviours. They often engage in mood-dependent behaviours → If I'm in this mood I'm not doing this → however the issue is they are often in a dysregulated mood therefore it’s important to learn how to be mood independent meaning don’t let moods dictate your life/behaviour. 3. Distress Tolerance Impulsivity and helping patients get through the initial episode without making it worse. Using crisis survival skills to shift biology when faced with stressors 4. Interpersonal effectiveness Personality Disorders 13 working on interpersonal problems → how to keep more effective ways to get their needs met in a relationship while maintaining self-respect. Helps avoid loneliness 5. Dialectics extreme thinking, acting, feeling, difficulty navigating conflicts very important module for teenagers. Skill example: Radical Acceptance accepting things wholeheartedly through a series of 4 steps. e.g. Distressing situation → 1. acknowledge 2. Endure (it will pass) 3. Don’t give up/give in 4. Can work to change when it’s effective Antisocial Personality Disorder (ASPD) Marked by: Inadequate conscience development Irresponsible and impulsive behaviour High ability to impress and exploit others ASPD Symptoms Disregard for and violation of the rights of others Deceitfulness Impulsivity Aggressiveness Reckless disregard for the safety of self or others Consistent irresponsibility Personality Disorders 14 Lack of remorse Disorders Comorbid with ASPD Substance abuse Other cluster B PD’s Prevalence of disorder 3% men 1% women In Prison 47% men 21% women Younger adults and lower SES Biological Etiology of ASPD Pre-frontal cortex (PFC) dysfunction poor executive control Genetic influence Low MAOA (X-linked gene which allows it to be more easily researched in males) resulting in low 5-HT (serotonin) Similar to BPD, it is more traits that are passed down genetically than the disorder itself including: Aggressiveness Impulsivity Low anxiety Psychosocial Etiology of ASPD Low income Low parental supervision Personality Disorders 15 Parent psychopathology Delinquent sibling/peers Neglect Abuse (physical or sexual) harsh discipline Diathesis-Stress Study on ASPD: Role of Genotype in the Cycle of Violence in Maltreated Children Study: Looked at boys and their MAOA activity and whether there was maltreatment present. Results: If you have high MAOA activity (neurotransmitters are intact as well), it takes severe maltreatment for you to increase the Antisocial behaviour you engage in. In contrast, in those with low MAOA activity, antisocial behaviour increases very fast and high with probably to severe maltreatment. Developmental Course of ASPD Strong/High Risk for ASPD: ODD (operational defiant disorder) by age 6 → conduct disorder (CD) by age 9 → then are high risk for ASPD ADHD + CD in childhood → highly likely to develop into ASPD and possible psychopathy. → shows there's a mental/neurological dysfunction that plays a large role. Psychopathy It is not the same as ASPD but has some overlap with ASPD ASPD is a broad category ASPD is more behavioural symptoms (e.g. criminality etc.) Personality Disorders 16 However, Psychopathy is narrow focuses on personality structure Prevalence of Psychopathy Prevalence is unknown → likely unlikely to report if they have psychopathy There is either Successful vs. Unsuccessful psychopathy E.g. Corporate vs. incarcerated Psychopathy is being disguised as success and leadership in successful psychopathy Dimensions of Psychopathy Core Dimensions Interpersonal superficial charm, pathological lying, super charming Affective Lack of remorse, guilt, empathy Behavioural Dimensions Lifestyle need for stimulation, impulsivity Antisocial poor behavioural control, criminality Biological Etiology Genes about 50% of the variance is genetics genetic factors are again due to heritable traits including callousness/unemotional traits Brain structure smaller amygdala volume Personality Disorders 17 Prefrontal Cortex Dysfunction → Note: issue in studying these stats, are that were looking at non-successful psychopaths not looking at successful psychopathy which is a different subset which may have very different functions/etiology. Psychological Etiology Largest is callous and unemotional traits Low levels of fear/poor conditioning of fear cognitive encoding low physiological and emotional encoding You will see these more in unsuccessful psychopaths as successful psychopaths are more likely able to encode dangerous psychological and emotional factors and not act on them to not get caught. in contrast non-successful will act on them. General emotional deficits High reward sensitivity → very tuned in to rewards making it difficult for them to resist the “reward” attentional directedness (tunnel vision) → only see what they want and go after that. Social Etiology Early parental Loss Parental loss or rejection Callous/unemotional traits evoke negative parenting responses anger frustration harsh discipline Note: think of the bi-directionality of these traits, and how the parents react to these traits, more harsh discipline = more harsh/callous behaviours. (traits + reaction to traits make it worse) Personality Disorders 18 Sociocultural Etiology Socialized aggression differs → expression of aggression differs across cultures. Individualistic vs. collectivistic → different expression as well ASPD vs. Psychopathy Developmental Risk Factors ASPD Difficulty learning to regulate emotions high emotional reactivity (aggressive, antisocial) in response to stress Psychopathy fearlessness, low anxiety poor conscience premeditated aggression → ASPD is more reactive than psychopathy which is more planned with its aggression Treatment Punishment is ineffective (laws don’t matter) treatment is very difficult Early intervention is CRITICAL specifically in adolescence decompression treatment Principles of treatment focuses on social skills → which just ends up improving the patient's ability to manipulate (rather than an underlying lack of empathy, etc.) especially true for group therapy. Better to work toward redirecting their skills toward prosocial goals would still have to be of benefit to them but not harmful to others Personality Disorders 19 Decompression Treatment Study Decompression → The name was from the concept of scuba diving as you need to come up from the water slowly so you aren’t sick Participants adolescents are violent offenders the more punishment they got the more they broke rules The key issue saw was that the kids had no relationships low to moderate psychopathy scores Intervention of participants Interpersonal bond → for this short period of time if you don’t break rules for half an hour you can do __. Shapes them to start associating good behaviour with good results. → leads to their ability to better work with rules (reduce antagonistic responses). intense (several hours/day) Daily Typically > 1 year 1:1 with therapist addresses underlying emotional responses Results: shapes compliance and affiliative mindset Confounds of study no consequences for not doing good behaviour/not being violent, there was just no reward. done in a mental health facility Decompression Treatment Study Follow-Up Outcome: Recidivism 2 years post-treatment is much less in the non-treatment group. Personality Disorders 20 the best predictor is the length of treatment With this, it shows there is the possibility for treatment/intervention in psychopathy. Though expensive/greater resources needed it is very helpful Personality Disorders 21