Week 10 Personality disorders.pdf

Personality Disorders 9 May 2024 Psychopathology of Everyday Life PSYC30014 Dr. Vanja Rozenblat [email protected] 1  Overview ❖ Definitions and core features of personality disorders ❖ DSM-5 Personality Disorder diagnoses & aetiology ❖ Clus...

Personality Disorders 9 May 2024 Psychopathology of Everyday Life PSYC30014 Dr. Vanja Rozenblat [email protected] 1  Overview ❖ Definitions and core features of personality disorders ❖ DSM-5 Personality Disorder diagnoses & aetiology ❖ Cluster A Part 1 ❖ Cluster B ❖ Cluster C ❖ Alternative dimensional models ❖ Aetiology and cognitive models Part 2 ❖ Additional issues 2  Some definitions What is personality? Personality refers to individual differences in characteristic patterns of thinking, feeling and behaving What is personality disorder? An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture and is manifested in 2 or more of the following areas: Cognition (ways of thinking and interpreting self, others, events) Affectivity (range, intensity, lability and appropriateness of emotional response.) Interpersonal functioning Impulse control 3  Core features of PD 1. Functional inflexibility Failure in adaptation to changing and varied life experience; A tendency to rigidly apply a range of behavioural strategies or responses across diverse life situations - even when inappropriate 2. Self-defeating behaviour patterns Typical ways of responding or coping that worsen the current situation or are explicitly damaging for the person. Nevertheless, the person demonstrates limited capacity to intervene constructively or to learn from experience 3. Tenuous stability under stress Marked instability in mood, thinking and behaviour during difficult periods 4  PDs in the DSM First introduced in a systematic fashion by the DSM–III in 1980. Considered “Axis II” disorder until DSM-5 removed axis system Encouraging clinicians to think of PDs as co-existing with ‘Axis 1’ disorders PDs as interacting with ‘Axis 1’ disorders – impact presentation, treatment adherence, response, etc Clinical Personality Medical Psychosocial Global Axis 1 Axis 2 Axis 3 Axis 4 Axis 5 Disorders Disorders Conditions & enviro Functioning Score 5  DSM-5 General diagnostic criteria DSM-5: General diagnostic criteria A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. The pattern is manifested in two (or more) of the following Cognition (i.e., ways of perceiving and interpreting self, other people, and events) Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response) Interpersonal functioning Impulse control B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations C. Leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood E. Not better explained as a manifestation or consequence of another disorder F. Not due to physiological effects of substance or medical condition 6  DSM-5 Personality Disorders Cluster A Cluster C Paranoid PD Avoidant PD Schizoid PD Dependent PD Schizotypal PD Obsessive-compulsive PD Cluster B Other Antisocial PD Personality change due to another medical condition Borderline PD Other specified/unspecific Histrionic PD personality disorder Narcissistic PD 7  Cluster A – Paranoid PD Diagnostic criteria (abrv.) A. A pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent o Inc: Suspicious of others, questions loyalty of friends/associates, reluctant to confide as expect to be exploited, reads hidden messages onto benign remarks, bears grudges, easily slighted and quick to retaliate, suspicious of fidelity of partner B. Does not occur exclusively during schizophrenia or other disorder w psychotic features, or medical condition Begins by early adulthood Unlikely to present for treatment 2.3% - 4% of the population 8 Prevalence data for this lecture: APA, 2013; Grant et al., 2004; Volkert et al., 2018  Cluster A – Paranoid PD Aetiology Research sparse More common in relatives of those with schizophrenia – genetic loading? Low self-esteem Deficits in emotional and social processing Can find ecological niche where PD works in favour 9  Cluster A – Schizoid PD Diagnostic criteria (abrv.) A. Pervasive pattern of detachment from social relationships and restricted range of expression of emotions in interpersonal settings o Inc: No desire for close relationships, chooses solitary activities, little interest in sexual experiences, takes pleasure in few activities, lacks close friends or confidants, appears indifferent from praise/criticism, shows emotional coldness/detachment/flattened affectivity. B. Does not occur exclusively during schizophrenia or other disorder w psychotic features, or medical condition Begins by early adulthood 2.2%-4% of population 10  Cluster A – Schizoid PD Aetiology (abrv.) Very little research – some calls for it to be removed from DSM-5 pre-publication Speculation that linked to ASD Under-stimulated upbringing, underpowered limbic system Not associated with schizophrenia spectrum disorders High level of dysfunction 11  Cluster A – Schizotypal Diagnostic criteria (abrv.) A. Pervasive pattern of social and interpersonal deficits marked by acute discomfort and reduced capacity for close relationships, as well as by cognitive/perceptual distortions and eccentric behaviour o Inc: Ideas of reference, odd beliefs/magical thinking, unusual perceptual experiences, odd thinking and speech, suspiciousness/paranoid ideation, inappropriate/constrained affect, odd or eccentric behaviour or appearance, lack of close friends, social anxiety related to paranoia B. Does not occur exclusively during schizophrenia or other disorder w psychotic features, or medical condition 1.5%-4.6% of population 12  Cluster A – Schizotypal Aetiology Link with schizophrenia - milder form of schizophrenia Cognitive abnormalities - attention, memory deficits; Higher levels of dopamine neurotransmitter (Siever & Davis, 2004). Crossover to schizophrenia-spectrum disorders 13  Case example (Cluster A) Mark attends therapy at the urging of others. He sits where instructed, erect but listless. When the therapist asks him how he feels about attending therapy, he shrugs and mumbles "OK, I guess". He rarely twitches or flexes his muscles or in any way deviates from the posture he has assumed early on. He shows no feelings when discussing his uneventful childhood, his parents ("of course I love them"), and sad and happy moments he recollects at the therapist’s request. Mark veers between being bored with the encounter and being annoyed by it. When asked how he would describe his relationships with other people, he states that he has none that he can think of. In whom does he confide? He eyes the therapist quizzically: "confide?" Who are his friends? Does he have a partner? No. He shares pressing problems with his mother and sister, he finally remembers. When was the last time he spoke to them? More than two years ago, he thinks. Does this best fit with Paranoid PD, Schizoid PD, or Schizotypal PD? 14  Cluster B – Antisocial PD Diagnostic criteria (abrv.) A. Pervasive pattern of disregard for and violation of the rights of others o Inc: Failure to conform to social norms/lawful behaviour (behaviour that is grounds for arrest), deceitfulness, impulsivity or failure to plan ahead, irritability and aggressiveness (repeated fights/physical assaults), reckless disregard for safety, consistent irresponsibility, lack of remorse. B. Individual at least 18 years of age C. Evidence of conduct disorder before 15 yrs D. Does not occur exclusively during schizophrenia/bipolar Prevalence varies depending on sample. Community samples about 3%-3.5% Over-represented in prison populations 15  Cluster B – Antisocial PD Aetiology High sensation-seeking; childhood conduct disorder, low psycho-physiological arousal Elevated in family members, as is higher levels of criminality, high levels of impulsivity (genetic contribution) Low levels of serotonin; Frontal problems High levels of childhood aggression and associated with physical abuse, harsh and neglectful parenting ❖ Link with psychopathy ❖ What should be the implications for sentencing? 16  Cluster B – Borderline PD Diagnostic criteria (abrv.) A. Pervasive pattern of instability of interpersonal relationships, self-image, and affects, marked impulsivity o Inc: Frantic efforts to avoid abandonment, unstable and intense interpersonal relationships, identity disturbance, impulsivity (e.g., spending, sex, binge eating, reckless driving), recurrent suicidal behaviour/self-harm, affective instability (marked reactivity of mood), chronic feelings of emptiness, inappropriate/intense anger, transient paranoid ideation/dissociative symptoms Community samples - 1.6-5.9% 75% females Begins by early adulthood – adolescent diagnosis has diagnostic validity 17  Cluster B – Borderline PD Aetiology Torgersen et al. (2000) found genetic contribution Meta-analytic data indicating association with sexual & physical abuse, parental hostility/verbal abuse, and neglectful and invalidating environments Increased hippocampal volumes and heightened activation in amygdala Insecure attachment and fear of abandonment, desire intimacy but anxious about dependency on others Comorbidity Mood disorders Anxiety disorders Substance use disorder 18 Winsper et al. 2016  Cluster B – Borderline PD ❖ Some argument it is better defined as a mood/emotional regulation disorder or a form of PTSD Cluster analysis revealed difference between BPD and complex PTSD inc. ‘frantic efforts to avoid abandonment’, ‘unstable sense of self’, ‘unstable and intense interpersonal relationships’, and ‘impulsiveness’ BPD does not respond to mood stabilising medication as with mood disorders, and tx for BPD and complex PTSD also differ 19 Cloitre et al. 2014  Cluster B – Histrionic PD Diagnostic criteria (abrv.) A. Pervasive pattern of excessive emotionality and attention seeking o Inc: Uncomfortable when not centre of attention, interaction characterised by inappropriate sexually seductive or provocative behaviour, rapidly shifting and shallow emotional expression, uses physical appearance to draw attention to self, speech overly impressionistic and lacking in detail, is suggestible, considers relationships more intimate than they are Begins by adulthood Prevalence 0.8-1.8% More commonly diagnosed in females 20  Cluster B – Histrionic PD Aetiology Little work Family studies show higher rates of BPD, Antisocial and histrionic PD in relatives. Theoretical accounts focus on encouragement of sexualisation, attention- seeking and role of intense, inconsistent and non-empathic parenting interactions 21  Cluster B – Narcissistic PD Diagnostic criteria (abrv.) A. Pervasive pattern of grandiosity, need for admiration, and lack of empathy. o Inc: Grandiose sense of self-importance, preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love, believes they are ‘special’ and can only associated/be understood by other special/high status people or institutions, requires excessive admiration, sense of entitlement, interpersonally exploitative (to achieve own ends), lacks empathy, envious of others, shows arrogant or haughty behaviours or attitudes Begins by early adulthood Not aligned with reality/actual achievements 1.2 - 6.2% 50%-75% males 22  Cluster B – Narcissistic PD Aetiology Early childhood experiences: child’s needs for nurturing and affection were not met. Kernberg says chronically cold caregivers display either indifference or aggression towards the child. Stone (1993) adds that compensatory beliefs can arise when a child is exposed to parental indifference OR alternative theory – too much praise leading to inflated sense of ego Livelsey et al. (1993) say this PD has the highest genetic loading 23  Narcissistic PD Factor analysis suggests two underlying subtypes (Wink, 1991): ❖ Grandiosity or Overt Narcissism Associated with grandiosity, social charm, failure to respond to needs of others, invulnerability, entitlement, aggression, and dominance ❖ Vulnerability/Sensitivity or Covert Narcissism Uses grandiose behaviour to mask hypersensitivity to criticism, self-doubt, deep feelings of inadequacy, incompetence, inferiority, worthlessness and negative affect (high neuroticism) May present as more introverted 24  Case example (Cluster B) A student quickly formed a very intense relationship with another student she met in class. Immediately, the young woman wanted to spend all of her free time with the other student and spoke very highly of her new “best friend.” However, the first time the other student declined an offer to socialize, the young woman felt intensely afraid and hurt. She suddenly suspected that her new friend was abandoning her and lashed out at the other student, accusing her friend of deserting her. Understandably, the other student ended the relationship. Does this best fit with Anti-social PD, Borderline PD, Histrionic PD, or Narcissistic PD? 25  Cluster C – Avoidant PD Diagnostic criteria (abrv.) A. Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation o Inc: Avoid occupational activities with high interpersonal contact due to fear of criticism, unwilling to get involved with people unless certain of being liked, restraint in intimate relos due to fear of being shamed/ridiculed, preoccupied with social rejection/criticism, inhibited in new social settings, views self as inferior/socially inept, reluctant to take personal risks/new activities 2.4% prevalence Differences in cultural expectations 26  Cluster C – Avoidant PD Aetiology High in restraint as children, high neuroticism, low extroversion, shyness in childhood; higher incidence of avoidant PD in first-degree relatives Jovev and Jackson (2004) found schemas related to defectiveness and abandonment. 27  Cluster C – Dependent PD Diagnostic criteria (abrv.) A. Pervasive and excessive need to be taken care of, leads to submissive and clinging behaviour and fears of separation o Inc: Difficulty making daily decisions w/out reassurance, need for others to make decisions for them, difficulty expressing disagreement due to fear of rejection, difficulty starting things alone, goes to excessive lengths to obtain nurturance/support, feels uncomfortable/helpless when alone, urgently seeks another relationship if one ends, preoccupied with fears of being left to take care of themselves