11- Personality Dx 1 Flashcards
Personality and DSM
Traits and beh that characterize a person => HOW you are in the world across time and contexts
“Big Five” model of personality: Neuroticism, Extraversion, Openness to experience, Agreeableness, Conscientiousness
Personality pathology = stable, enduring, inflexible patterns
Introduced in 1980 in DSM-III: Largely ignored by researchers until 1980
- Means of distinguishing longstanding maladaptive ways of relating to the world from phasic clinical “syndromes”
- DSM-III devoted Axis II to these conditions
- Axis I: acute, transient, diathesis-stress condition
- Axis II: permanent, gradually developed, inflexible condition
- Multiaxial system removed in DSM-5
DSM-5 Def of Personality Dx
- An enduring pattern of inner experience and beh
- Deviates markedly from the expectations of the individual’s culture
- Pervasive and inflexible
- Onset in adolescence or early adulthood
- Stable over time
- Leads to distress (ego-dystonic vs ego-syntonic) and impairment
=> Recall Wakefield’s Harmful Dysfunction
- Scientific component: Dysfunction = “organ system performing contrary to its design” => Brain functions: thinking, feeling, emotion regulation
- Social component: Causes harm in its own env context => Value judgment about what is considered acceptable according to social norms
DSM Categories of Personality Dx and Epidemio
Cluster A: Odd/Eccentric
- Paranoid
- Schizoid
- Schizotypal
Cluster B: Dramatic/Emotional/Erratic
- Narcissistic
- Antisocial *
- Borderline *
- Histrionic
Cluster C: Anxious/Fearful
- Avoidant
- Dependent
- Obsessive-compulsive
Prevalence
- Varies considerably, depending on study and pop
- 4-15% in the general population (US)
- Little research in Canada
- Meta-analysis of general pop rates in Western countries = prevalence rate for any PD of 12.16%
- Much higher in inpatient settings => ex: BPD 19% inpatient (vs. 11% outpatients), ASPD 12-37% inpatient (vs. 5% outpatient)
- High rates of ASPD in prison populations (30-70%)
- Rates are inflated when using self-report measures, compared to diagnostic interviews
Global Prevalence
- Recent meta-analysis of studies from 21 different countries worldwide
- Global prevalence of any PD is 7.98%
- Rates are higher in high-income countries => Bcz socialcultural factors (ex: collectivistic usually lower income vs. individualistic cultures) ex: dependent type
Problems with Assessment, Culture, Gender
Who reports?
- Person with PD may have limited insight then informants? but who nominates informant?
- Current mood states can exacerbate PD sx
- Abstract criteria => Inferred traits, not objective standards
- Diff assessment instruments often deliver different dx
Cultural Issues
- Lots of potential for misdx based on perspective of clinician
- Few clear beh indicators, no discrete time-period
- Results in much more leeway for the clinician
=> Consider ASPD: “Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest”
Gender Bias
- Clinicians are typically reluctant to: * Dx women with ASPD, Dx men with HPD, BPD
- Diagnostic criteria reflecting stereotypical gender expectations and social roles => History of “hysteria”, Criteria for histrionic PD explicitly gendered
Temporal Stability
- Dx criteria is that personality dx is stable over time => Low test-retest reliability (r=.11 to .57)
- Many findings suggest that people fail to maintain PD dx => ex: Prospective follow-up study of 160 BPD patients and 6 months later, 18 no longer met dx criteria WITHOUT tx
- Also, evidence that PDs can be successfully treated => Supports a dimensional view
Comorbidity and Dx Overlap
Comorbidity
- VERY high rates of comorbidity => Majority of people have a personality dx will have another DSM dx
- With major disorders (Axis I): mood, anxiety, substance use, etc… => Especially BPD and mood dx, OCPD and AN-R (Usually end up seeking tx for this)
- Also, with other PDs (the norm) ex: Among BPD, 47% met criteria for ASPD and 57% met criteria for HPD
Diagnostic Overlap => Not the same as comorbidity! (But can likely explain, in part, why comorbidity exists)
- Similarity of symptoms in 2+ dx
- Huge conceptual overlap within clusters ex: ASPD and BPD share sx of aggression and irritability
- Also overlap in sx across clusters
*Dx heterogeneity
Dimensional Models - 5 Factor Model and Issues
Little to no evidence that PDs are categorical in nature
=> Personality is on a continuum, with dx on the extreme end of normal personality functioning
Five Factor Model (split into facets)=> PDs might reflect extreme levels of normal personality traits ex: Neuroticism broken into: anxiety, angry- hostility, depression, self-consciousness, impulsiveness, vulnerability
Five Factor Model
- Correlations tend to be fairly predictable and meaningful
- Some general trends ex: High Neuroticism, Low Agreeableness
- Can distinguish PD from community sample
=> Not as good at distinguishing PDs from each
other = Better at specifying some PDs than others - Breaking into facets improves predictive validity
- Not designed to capture pathology
Controversies/Issues with PD Dx
- Is there a difference between Axis I and II conditions? aka Mental dx vs. Personality dx
- Are personality dx a diff of degree or a diff of kind? => Dimensional vs. Categorical
- What does it mean to have a disordered personality? And what does it mean to be diagnosed with multiple personality dx?
Proposed Revision to DSM-5 and Alternative Trait Domains
- Hybrid categorical-dimensional model => Even dimensional component to describe traits of
non-PDs - Remove 4 PDs: Dependent, histrionic, schizoid, paranoid
*No changes accepted => Still categorical model - Benefit for clinicians?
- But includes “Alternative DSM-5 Model for Personality Disorders”
Alternative DSM-5 Personality Trait Domains
- Negative affectivity (vs. emotional stability) *N
- Detachment (vs. extraversion)
- Antagonism (vs. agreeableness)
- Disinhibition (vs. conscientiousness)
- Psychoticism (vs. lucidity) *O
Paranoid PD *Exclu
Pervasive suspiciousness and distrust => View others as threatening and critical
- Tendency to see self as blameless
- On guard for perceived attacks by others
- Seen by others as hostile, jealous, preoccupied with power and control aka Lots of relationship problems
- Occurs more commonly in families of people with schizophrenia => Viewed as a related disorder (a “cousin”) but primary difference is in the severity ex: Psychotic delusions (devil) vs. non-bizarre (neighbour) paranoid beliefs
- Significant dx overlap with avoidant PD and BPD
Schizoid PD *Exclu
Near total lack of interest in intimate involvement with others => Limited emotional responsiveness
- “Loners” => Perceived as cold, indifferent
- Lack social skills and uninterested in acquiring them
- Differentiates from avoidant PD
- Dx criteria overlap with schizotypal
- Impairment in underlying affiliative system?
- Recent data suggest it may be more related to asocial dx (ex: Autism spectrum)
Schizotypal PD
Cognitive and perceptual distortions with eccentric thought and beh:
- Odd beliefs, odd speech
- Magical thinking
- Telepathy, clairvoyance
- Ideas of reference ex: moved pen to communicate to me
=> Vicious cycle with social isolation
- Lots of overlap with schizophrenia
- Severity and quality of symptoms: Eccentric and odd, but not delusional
- Some argue a mild or prodromal (not fully developed)
schizo - Familial co-aggregation
- Similar underlying cognitive deficits (ex: memory, attention, language) as schizo
Histrionic PD *Exclu
Excessive attention-seeking beh => Highly dramatic, lively, extraverted
- Preoccupied with physical appearance
- Often sexually provocative, seductive, and flirtatious
- Difficulty with maintaining relationships
- Gender differences (re: HPD vs. ASPD)
*Craving closeness
Narcissistic PD
Grandiosity => Two types: grandiose vs. vulnerable (underlying insecurity and shame so mask that by thinking they’re awesome) *Can result in highly variable clinical presentation
- Preoccupied with receiving attention
- Self-promoting => validation
- Need for admiration
- Sense of entitlement => ok to exploit
- Arrogant, dominant, obsessed with power
- Lacking empathy (ex: perspective taking)
- Differential diagnosis
*Not looking for closeness only admiration
- May be more common in males than females => Associated with sexual aggression
- Complicates tx: Increased likelihood of dropout and Slow sx change
Etiology:
- Grandiose: parental overvaluation
- Vulnerable: emotional, physical, sexual abuse/intrusive, controlling and cold parenting styles
Narcissistic Epidemic Study
Used Narcissistic Personality Inventory (NPI) *Not clinical => Meta-analysis of 85 studies including 16,475 college students
- Found increase of 2 points on NPI from 1982 to 2006
- For both men and women but especially driven by increases among women (maybe not bad thing, just + assertive)
But why? =>
- Increase in individualism
- “Self-esteem movement”
=> Follow-up Study: Similar study design but more restricted location with N=25,849
- Found no evidence of increase in NPI scores from 1996 to 2007
- Follow-up research found no difference in other related traits (ex: self-esteem, egotism)
- Technology might just make narcissism more visible, but not more prevalent
- On-going debate
Avoidant PD
Avoiding interpersonal contact => Extreme sensitivity to criticism and disapproval and view the self as inadequate, inept, incompetent
=> Avoidant vs. Schizoid?
- APD avoid intimacy and closeness, even though they desire it
- APD are very emotionally expressive
Is this just a more extreme form of social anxiety disorder? => Substantial symptom overlap and High comorbidity
- Shared genetic vulnerability => ex: Fear of evaluation and inhibited temperament also heritable
Dependent PD *Exclu
Inability to function independently => Extreme clinginess and need to be cared for
- Adopt a submissive role in relationships
- Allow other people to assume responsibility for important life aspects and decisions
- Avoid conflict and disagreement
- Overlap with other PDs ex: fear of abandonment (BPD), need for attention (HPD)
- Comorbid with avoidant PD frequently
- Relatives of male DPD: increased depression
- Relatives of female DPD: increased panic
Culture-specific => More prevalent in individualistic cultures
Obsessive Compulsive PD
Inflexibility and desire for perfection => Preoccupation with rules and order (“Trees over the forest”)
- Often moralistic and judgmental
- Viewed by others as rigid, stubborn, cold
- Most common, stable features: rigidity, stubbornness, perfectionism, reluctance to delegate
- Very little research since 1980s
OCPD vs OCD? => Often linked, but distinct
- No true obsessions or compulsive rituals
- Not always associated with anxiety and/or extreme distress (ego-syntonic)
- Similar SX: perfectionism, preoccupation with details, hoarding
- About 20% of OCD have comorbid OCPD
- OCD more likely to be comorbid with avoidant or dependent PD
- OCPD marker of severity in OCD?
