PSY 183 Personality Disorders Lecture Notes PDF

Personality Disorders  Introduction to Psychopathology Alan J. Fridlund, Ph.D. NOTICE: These Lecture Notes © Copyright 2014, 2020, 2023, by Alan J. Fridlund, Ph.D. All Rights Reserved. They May Be Downloaded for Private Use Only by Students Cur...

Personality Disorders  Introduction to Psychopathology Alan J. Fridlund, Ph.D. NOTICE: These Lecture Notes © Copyright 2014, 2020, 2023, by Alan J. Fridlund, Ph.D. All Rights Reserved. They May Be Downloaded for Private Use Only by Students Currently Registered in UCSB Psych 183. For-Profit Reproduction in Whole or In Part Without Written Permission of the Instructor Is a Violation of U.C. Regulations and the DMCA and Is Expressly Prohibited.  Notice All Course materials (class lectures and discussions, handouts, examinations, Web materials) and the intellectual content of the Course itself are protected by United States Federal Copyright Law, and the California Civil Code. UC Policy 102.23 expressly prohibits students (and all other persons) from recording lectures or discussions and from distributing or selling lectures notes and all other course materials without the prior written permission of the Instructor (See http://policy.ucop.edu/doc/2710530/PACAOS-100). Students are permitted to make notes solely for their own private educational use. Exceptions to accommodate students with disabilities may be granted with appropriate documentation. To be clear, in this class students are forbidden from completing study guides and selling them to any person or organization. The text has been approved by UC General Counsel. You are granted permission in Psych 183 to download and retain personal copies of these slides solely for your own use.  Personality Disorders ⚫ Possession of chronic, even lifelong, maladaptive traits outside the norms for one’s culture. Traits relate to cognition, affect, interpersonal functioning, and/or impulse control. ⚫ Often are exaggerations of normal character traits. ⚫ The traits become a “disorder” when they: – Preclude a satisfying life, and/or – Alienate others and create estrangement and loneliness, and/or – Result in moral or criminal violations. ⚫ Personality disorders occur in varying degrees of severity. ⚫ Point prevalence across several cultures is 10.5% for personality disorders as a whole. ⚫ Formerly known as “Character disorders,” once thought to respond only to long-term therapy. ⚫ The DSM-5-TR Personality Disorder diagnostic criteria overlap, some more than others, and interrater reliabilities are among the lowest of all the disorders in DSM-5-TR.  Personality Disorder Clusters ⚫ Cluster A (~ 3.6% point prevalence): “Odd, eccentric” – cognitive or perceptual distortions, emotional detachment, and/or discomfort with social relationships – Paranoid PD – Schizoid PD – Schizotypal PD ⚫ Cluster B (~ 4.5% point prevalence): “Dramatic, emotional, unstable.” – excessive emotionality, unstable and sometimes manipulative social relationships, and/or lack of empathy. – Borderline PD – Antisocial PD – Narcissistic PD – Histrionic PD ⚫ Cluster C (~ 2.8% point prevalence): “Anxious, apprehensive.” – issues relating to social adequacy and inhibition, neediness, and control. – Avoidant PD – Dependent PD – Obsessive-Compulsive PD – Passive-Aggressive PD (“Other Specified PD” in DSM-5-TR)  Cluster B (“Dramatic, Emotional, Unstable”) Personality Disorders Borderline PD Antisocial PD Narcissistic PD  Borderline Personality Disorder (~2 % prevalence, ¾ F in clinical samples, but F = M in community samples) People with Borderline BD have a pervasive pattern of instability in relationships, impulsivity, dramatic emotionality and self-damaging behavior, e.g., they have: ⚫ disproportionate intense anger and marked mood shifts, sometimes called “transient psychotic episodes” (~50% of Borderline PD people) ⚫ unstable, chaotic and intense relationships ⚫ “splitting” – idealization / devaluation (a “soulmate” rapidly becomes a “worthless pieces of sh**, just like all the rest”) ⚫ intolerance of being alone w/ deep abandonment depressions ⚫ feelings of internal emptiness and “void” which they impulsively try to fill with new relationships, identities. ⚫ self-damaging behavior (sex, ETOH / drugs, reckless driving, gambling, overeating, binge/purge cycling) ⚫ Repeated suicidal gestures, threats, self-injurious behavior – 70-75% “cut,” burn themselves, etc. or attempt suicide – 9% completed suicides ⚫ Frequently co-morbid with Major Depression, Substance Abuse and/or Dependence, ADHD, Panic Disorder, Agoraphobia, Eating Disorders; presence of multiple (3-4) co-morbidities is common. Cluster B Borderline PD in the Cinema Fatal Attraction (1987)  Borderline Personality Disorder: Etiologies, Treatments ⚫ Some cases related to early physical or sexual abuse, and there may be associated PTSD. ⚫ Psychoanalytic theory (limited evidence): failure to master separation/individuation from mother, faulty family boundaries, and/or “pervasively invalidating environment” ⚫ Common differential diagnoses (DDx’s): PTSD, Bipolar II disorder, Rapid-Cycling Bipolar Disorder ⚫ Medication for symptoms (partially effective) – As indicated: Mood stabilizers, antidepressants, and / or anxiolytics (must be prescribed with consideration of high OD potential) – Sometimes, antipsychotics for high anxiety, transient psychotic symptoms ⚫ Treatment – Long-term therapy ⚫ For children and adolescents, family-therapy interventions, and structured day programs with behavior management for severe cases ⚫ Short hospital stays for abandonment depressions, suicide attempts, self-injurious behavior ⚫ Highly structured, psychodynamic therapy or Dialectical Behavior Therapy (DBT) – only data-supported treatment for Borderline PD Cluster B  Dialectical Behavior Therapy (Marsha Linehan, 1991) ⚫ Developed for “parasuicidal” (tending toward suicide) patients, especially those with Borderline PD. ⚫ “Dialectic” refers to tension between “environment of acceptance” and therapeutic goal of change. ⚫ DBT is a “manualized” therapy that combines weekly individual and group sessions, and “diary cards” to track “therapy interfering behaviors” (e.g. suicidal thoughts, cutting, purging). ⚫ Four “modules” comprise DBT: – Mindfulness (accepting thoughts and feelings) – Distress tolerance (calmly recognizing current situations) – Emotion regulation (analyzing emotional reactions instead of becoming overwhelmed by them). – Interpersonal effectiveness (assertiveness & problem-solving) ⚫ Gives therapists a structure by which to handle difficult patients. ⚫ Only evidence-based treatment for Borderline PD.  DSM-5-TR Antisocial Personality Disorder APD is a diagnosis that may be applied to individuals who come under the auspices of the mental health system (and also possibly the judicial system) because of repeated moral offenses or criminal acts. Such individuals may be sociopaths, psychopaths or fit some other categories. Thus, APD is a heterogeneous category. MS-13 Other Serial killer/Necrophile Gang Member Ted Bundy Sociopaths Psychopaths Individuals who are Individuals who are constitutionally socialized into lifestyles deficient in empathy and interpersonal that involve repeated moral regard, are smooth, manipulative and offenses and/or criminal conscience- free. Some – but not all – acts (e.g., gangs, cartels, act in ways that involve repeated organized crime, black- moral offenses and/or criminal acts, market operators). Usually (E,g, financial scammers, some serial referred to criminal justice killers). Only antisocial psychopathic and not mental health individuals are diagnosable in a system. treatment or legal context.  DSM-5-TR Antisocial Personality Disorder (~3% of males, ~1% of females) ⚫ DSM-5-TR Conduct Disorder before age 18 (lying, cutting school, sexual/physical assault, heavy drug/ETOH use, cruelty to animals and other humans) ⚫ Continual violation of laws, social norms, and/or rights of others ⚫ Pattern of repeated lying, use of aliases, and coming of others for personal profit or pleasure; concrete morality (“What’s in it for me?”) ⚫ Impulsivity and reckless behavior ⚫ Irritability and aggressiveness, m/b repeated fights or assaults ⚫ Repeated failure to obtain consistent work or honor financial obligations ⚫ Reckless disregard for safety of self or others ⚫ Lack of remorse m/b indifference or rationalization re: harm to others. ⚫ NOTE: The diagnosis of APD is made only if and when the person enters the mental health system. Cluster B  Facts/Hypotheses About Psychopathy ⚫ Not a mental disorder diagnosis. It is a “neurodivergent” condition. ⚫ Accounts for 20% of all prisoners, 50% of all crimes ⚫ Linked to low socioeconomic levels, incompetent parenting, missing fathers (causes or effects?) – BUT many psychopaths come from perfectly normal parenting ⚫ Strong familial (genetic?) contribution (heritability ~ 0.6) ⚫ Diagnosed only at age 18 and after (Conduct Disorder “Successful psychopaths” - may evade the criminal justice and mental health systems; common and even useful in certain occupations ⚫ Only evidence-based treatment for Antisocial PD psychopaths: Incarceration Cluster B  Psychopathy (Subgroup of Antisocial PD Individuals) Pro-Social Psychopathy?  Ted Bundy, a “Charming Psychopath” ⚫ Showed childhood interest in knives, and as an adolescent he picked through garbage cans looking for books/magazines with sexual violence and pictures of dead bodies. Later got repeatedly drunk and drove through neighborhoods looking for females undressing through their drapes. ⚫ Was arrested multiple times in HS for burglary, auto theft and forgery. He still finished college with a psychology degree, followed by a law degree. ⚫ Began killing females likely at age 19, but perhaps as early as 14. He typically flirted with young, white, attractive brunettes, invited them for drives, bludgeoned them to death, often decapitating them, and removed and had sex with the dead bodies (necrophilia) in the woods of Washington State. He then went on a cross-country killing spree, culminating in the murders of three Florida State University sorority members. ⚫ Proclaimed his innocence until the end of his life, he eventually confessed to 30 murders, but probably committed over 100. and blamed “pornography” for making him a murderer. Executed by electrocution in Florida in 1989. Ted Bundy, the Night Before His Execution* https://www.youtube.com/watch?v=tfwJeHtrWNI *January 24, 1989, Age 42  Narcissistic Personality Disorder (1 % of population, ¾ are M) Individuals with Narcissistic PD have a grandiose sense of self-importance or uniqueness, need for admiration, and lack of empathy, e.g., they: ⚫ exaggerate their abilities and talents and expect automatic admiration and acknowledgement of superiority. ⚫ believe that are special and unique, can only be understood by others at their level, and expect special treatment and automatic compliance from others. ⚫ seek only “highest-caliber” partners, friends, doctors, therapists, etc. ⚫ lack empathy for others’ feelings and devalue others’ perspectives. ⚫ evaluate relationships based on likelihood of self- advancement; others are either allies or obstacles. ⚫ show “splitting”: idealization / devaluation (professing “true love” and then immediately “deleting” or waging war on the ex-partner) ⚫ react to criticism with rage, indifference, or “gaslighting” (turning blame on the critic, invalidating the criticism, or trying to make the critic believe he/she is delusional) ⚫ Rarely seek treatment, often “test” therapists or question their competence, then drop out of therapy Cluster B  Unofficial Types of Narcissism (Not in DSM-5-TR) ⚫ Grandiose narcissism – outgoing, arrogant, disdainful, shameless, and entitled. ⚫ Malignant narcissism – Vindictive, cruel, sadistic, with an extreme need to be praised and elevated above others. ⚫ Vulnerable narcissism – introverted, avoidant, defensive, distrustful, bitter, and “plays the victim.” ⚫ Communal narcissism – desires to be seen as extra-giving, selfless, and wonderful, in order to achieve power and influence.  Histrionic Personality Disorder (0.9 – 1.8% Prevalence, F > M in most surveys) People with Histrionic PD show increased emotionality and attention-seeking by early adulthood, e.g. they: ⚫ are uncomfortable when they are not the center of attention, and may make up stories or “make a scene” to steal focus. ⚫ often show inappropriately sexually seductive or provocative behavior, which may alienate friends and their partners via jealousy drama. ⚫ consistently use their physical appearance to attract attention. ⚫ initially charming, but turn off or embarrass others due to self- Vivian Leigh as dramatizing, theatrical, and exaggerated modes of expression. Blanche DuBois ⚫ are easily influenced by others and susceptible to fads. in film of Tennessee ⚫ consider relations to be more intimate than they actually are Williams’s (everyone is their “dearest friend”) Streetcar Named Desire (1951) ⚫ have frequent health complaints which become focus of attention. ⚫ show increased risk of suicidal threats / gestures. ⚫ have shallow, transient relationships characterized by self- indulgent, inconsiderate behavior, and the use of dependency and “helplessness” as tactics (e.g. Blanche DuBois in Streetcar Named Desire) Cluster B  Cluster A (“Odd, Eccentric”) Personality Disorders Paranoid PD Schizoid PD Schizotypal PD  Paranoid Personality Disorder (2-4% Prevalence, F:M ?) Those with Paranoid PD have pervasive distrust and suspiciousness of others, e.g., they: ⚫ suspect that others are being deceptive plotting to harm them. ⚫ have unjustified doubts about others’ loyalty or sexual fidelity. ⚫ are reluctant to confide in others. ⚫ read hidden negative or threatening meanings in benign remarks or events. ⚫ hold grudges and are unforgiving of insults or slights. ⚫ readily interpret others’ statements as attacks to their character or reputation and are quick to counterattack. ⚫ may be seen in members of minority ethnic backgrounds because of unfamiliarity with culture and perceived or real marginalization. Cluster A  Schizoid Personality Disorder (1-4% Prevalence, F:M ?) People with Schizoid PD have a persistent pattern of detachment from others and a restricted range of emotion (“whatever”), manifest by, e.g.: ⚫ neither desiring nor enjoying close relationships or being part of a family. ⚫ preference for solitary activities. ⚫ little interest in sexual experiences with others. ⚫ exhibiting little or no pleasure in activities. ⚫ appearing indifferent to the praise or criticism of others. ⚫ May be seen in members of minority ethnic backgrounds because of unfamiliarity with culture and perceived or real marginalization ⚫ May be weak form of “schizotype” (Schizophrenia vulnerability), and may have brief psychotic experiences lasting minutes to hours under stress. ⚫ Differential diagnoses (DDx’s): – Autistic Spectrum Disorder – People with ASD people likelier to have obsessive interests and repetitive behaviors – Avoidant Personality Disorder – Unlike Schizoid people, Avoidant PD people are motivated by lifelong social anxiety or embarrassment Cluster A  Schizotypal Personality Disorder (0/6 – 3.9 % Prevalence, M > F) People with Schizotypal PD have traits of Schizoid PD plus ongoing eccentric behaviors and cognitive/perceptual distortions: ⚫ ideas of reference (“people are thinking about me,” “the storm was a warning intended for me”) ⚫ odd beliefs, magical thinking and rituals that can control others or events, undue superstitiousness, belief in “sixth sense,” telepathy, and, in children or adolescents, bizarre fantasies and preoccupations, all of which are outside cultural norms. ⚫ perceptual distortions that include bodily illusions (“my head is getting smaller,” I’m gradually disappearing”). ⚫ odd thinking, dress, speech, and/or mannerisms. ⚫ high social anxiety and suspiciousness, even with familiarity, and social estrangement associated with paranoid fears. ⚫ high risk of death by suicide. ⚫ may be moderate form of “schizotype” (Schizophrenia vulnerability), seen more commonly in families with Schizophrenia, although most people with Schizotypal PD do not progress to schizophrenia. In DSM-5-TR, Schizotypal PD is also included among “Schizophrenia Spectrum and Other Psychotic Disorders.” Cluster A Treatments for Cluster A Personality Disorders ⚫ Rarely seen in psychotherapy or medical settings due to suspiciousness about mental health care. ⚫ Symptomatic care (“Treating what bothers the patient.”) – Antidepressants for depression and anxiety – Antipsychotics for paranoid ideation and psychosis (hallucinations, delusions) – Suicide precautions. ⚫ Treatment and medication compliance is low.  Cluster C (“Anxious, Apprehensive”) Personality Disorders Avoidant PD Dependent PD Obsessive-Compulsive PD Passive-Aggressive PD  Avoidant Personality Disorder (~1 % of population, M = F) ⚫ Hypersensitive to rejection or ridicule ⚫ Strong desire for relationships, but extreme skittishness about them ⚫ Social withdrawal, retreat to secondary social roles ⚫ Overriding desire for acceptance, affection ⚫ Low self-esteem – Devaluation of personal strengths – Overvaluation of personal shortcomings ⚫ Treatment – Medication for anxiety, depressive symptoms – Therapy ⚫ Social skills and assertiveness training ⚫ Supportive individual therapy ⚫ Group therapy ⚫ Differential dx. of Social Anxiety Disorder; Avoidant PD is lifelong whereas Social Anxiety Disorder has typical onset in puberty. Cluster C  Dependent Personality Disorder (~2 % of population, M = F) People with Dependent PD have a pervasive need to be taken care of, e.g., they: ⚫ see themselves as helpless or stupid, and require excessive advice and reassurance on almost all decisions. ⚫ ask others to assume responsibility for major areas of life. ⚫ do not disagree with or make demands on others for fear of jeopardizing relationships; feel overly thankful for friendships, and may tolerate abusive friends, partners, etc. ⚫ rarely initiate projects or do things on their own. ⚫ feel uncomfortable or helpless on their own. ⚫ urgent tries to replace a close relationship that ends. ⚫ are preoccupied with fears of having to take care of themselves Sees self as helpless, stupid ⚫ typically appears selfless and bland. ⚫ may have their dependency precipitated by chronic physical illness. Treatment: – Medication for symptoms. – Group, family or couples therapy for relationship issues. – Assertiveness training to build initiative. Cluster C  Obsessive-Compulsive Personality Disorder (~2 % of population, ¾ are M) ⚫ Not OCD, all OCPD symptoms are ego-syntonic. People w/ OCPD: ⚫ are preoccupied with small details, lists, rules, schedules to the point of neglecting the goals of the activities ⚫ show perfectionism that interferes with task completion. ⚫ are excessively devoted to work and productivity to the exclusion of leisure activities and friendships (when not dictated by economic necessity). ⚫ are overconscientious, exact, and inflexible about matters of morality, ethics or values ⚫ are reluctant to delegate tasks to others ⚫ tend to be miserly toward both themselves and others ⚫ can be indecisive – Fear of making mistakes ‒‒» procrastination – Rumination about priorities Treatment – Psychotherapy focusing on awareness of consequences of one’s behavior, stress management, compassion toward self and others – Antidepressants for depression, anxiety – Treatments have limited effectiveness due to ego-syntonic nature of disorder. Cluster C  Passive-Aggressive (Negativistic) Personality Disorder In “Other Specified Personality Disorder” category in DSM-5-TR People with Passive-Aggressive PD show: ⚫ a continuous pattern of negative attitudes (“hostile compliance,” “begrudging agreement”) that usually beings in early adulthood. ⚫ passive resistance to demands for adequate performance in social and occupational situations. Expressed as: – Procrastination – Intentional inefficiency and obstructionism – “Forgetting” obligations, always arriving late, repeated evasion and excuse-making – Sulking, arguing, or giving the “silent treatment” when challenged or confronted – Stubbornness / resentment of useful suggestions – Complaining about “unreasonable” demands, gossiping critically about authority figures or peers, manipulating others into assuming their obligations by inflicting guilt (“emotional blackmail”) – Caustic joking, unacknowledged hostility, using innuendo and playing innocent  Treatment of Passive-Aggressive PD ⚫ Supportive psychotherapy – Build self-confidence – Teach assertiveness and negotiation instead of sulking, manipulativeness, “silent treatment” ⚫ Antidepressant medication (e.g., SSRI’s) for any associated depression or anxiety End