19: DISORDERS Flashcards
Cluster A
Paranoid, Schizoid, Schizotypal
Cluster B
Antisocial, Histrionic, Narcissistic, Borderline
Personality Disorders VS Mental Disorders
Unlike symptoms, traits do not come and go.
- Traits are ego-syntonic: consistent with sense of self
- Symptoms are ego-dystonic: unwanted, inconsistent with sense of self
Criteria for Definition of PDs
- Occupational impairment
- Social impairment
- Subjective personal distress
What is Abnormal?
- Statistical: different from normal. can statistically determine through rarity
- Social: looking within individuals & subjective feelings
- Psychological: disorganized thoughts, unusual beliefs & attitudes
The DSM-5
- Change from a categorical view to a dimensional view (as a continuum) where only the extreme ends cause problems to one’s self
- Ultimately decided to make no changes to the way personality disorders were defined, maintaining a categorical model of personality disorders
Criteria for PD: Enduring pattern of behaviour deviating markedly from culture
This pattern is manifest in two or more of the following areas:
Cognition (ways of perceiving and interpreting the self, others, and events)
Affectivity (the range, intensity, ability, and appropriateness of emotional responses)
Interpersonal functioning
Impulse control
The Effect of Context in PD
- Social, cultural and ethnic backgrounds must be taken into account
Ex: Adjustment to society problems may appear as disorders - Age must be taken into account
Ex: Most adolescents experiment with various identities, therefore we try to refrain from diagnosing under 18 - Undergoing severe loss
- Gender: some disorders are diagnosed more often in one gender than the other. Can reflect underlying sex differences in how people cope
- Males exhibit more externalizing problems (fighting, vandalism) where women deal with internalized problems like depression and self harm
Statistics of PD
10-13% of the general population (Wiessman)
Some are rare (narcissistic PD <1%)
Some more common (schiotypal 3-5%)
Onset is difficult to determine; there’s gradual development in childhood
Traits of Cluster A
Traits that combine to make people socially uncomfortable, and appear to act in highly unusual ways in the presence of others. Some have no interest in others, some are very uncomfortable with others
Traits of Cluster B
Tend to have trouble with emotional control and experience difficulties getting along with others. Often appear dramatic and emotional, exhibiting unpredictable behaviour.
Neurotic Paradox
Fact that those with disorders often exhibit behaviours that exacerbate, rather than lessen, their problems. For example, those with Borderline who are concerned with abandonment throw rage in a manner that drives them away.
Paranoid PD Symptoms
> Extremely distrustful of others
Misinterpreting social events (thinks everyone is out to get them) looking for hidden meanings and motivations in others
Resentment toward others
Pathological jealousy: suspecting it with no evidence
Argumentative and hostile nature
Treatment for Paranoid PD
- Development of trust
- CBT to counter negativistic thinking
Schizoid PD symptoms
Void: Devoided of pleasure and connections
> Detached from normal social relationships
> Pleasureless life and in socializing
> Inept or socially clumsy
> Passive in the face of unpleasant events
- Preference to solitary jobs & hobbies
- Little pleasure from sensory experiences like eating or having sex
- Does not respond to social cues (inept or clumsy)
Causes of Schizoid PD
Possible link to autism: low density of dopamine receptors
People from some cultures react to stress in a way that looks like schizoid
Treatment of Schizoid PD
Therapy: model emotions, social skill training
Schizotypal PD symptoms
> Anxious in social relations and avoids people
Different and noncomforting
Eccentricity of beliefs
Disorganized thoughts and speech
- Uncomfortable in social relationships
- Anxious in social situations
- Tend to be suspicious of others
- Odd & eccentric
Schizotypal Causes
Schizoid and Schizotypal Personality Disorder both take their root from schizophrenia and are closely tied to the history of the making of this category. These PDs exhibit low-grade nonpsychotic symptoms of schizophrenia.
- Comorbid with major depression
> Schizotypal is genetically similar to schizophrenia
> 1st degree relatives are more likely to exhibit features of schizotypal than the average
Treatment for Schizotypal
- Social skill training, reduce isolation
- Antipsychotics
Antisocial PD Symptoms
Antisocial means that they have a lack of concern for social norms
> Failure for concern of social norms
> Repeated lying
- General disregard for others and care little about other’s feelings
- Deceitfulness, manipulativeness and impulsivity
- Irritability or aggressiveness
- Reckless disregard for safety
- Consistent irresponsibility
- Lack of remorse
- Assaultive
Explanations for Psychopathy
> Evidence of reduced prefrontal connectivity in psychopaths, including less activity between amygdala and the prefrontal cortex (responsible for guilt & empathy)
May explain the tendency for psychopaths to display reduced fear responses and reduced guilt/remorse.
Victims of childhood abuse have higher rates of psychopathy years later
Those displaying psychopathic traits were more likely to have experienced neglect
Is the observed fearlessness of a psychopath also the result of a desensitization process, being exposed to violence or other antisocial behaviour?
Antisocial VS Psychopathy
Antisocial personality places emphasis on observable behaviours
Psychopathy places emphasis on subjective traits like the incapacity to feel guilt
> Distinction is in the first cluster of traits. Most psychopaths would meet criteria for antisocial PD but not all with antisocial PD are psychopaths.
Causes of Antisocial PD
Like with Borderline, those with antisocial were likely abused or victimized at an early age. This leads to social learning & psychoanalytic theories digging at the cause of the disorder.
- A large chunk of antisocial PD people abuse drugs or alcohol. Are biological changes associated with drug abuse responsible for antisocial behaviour?
> There are clear links to genetics but also social learning & psychoanalytics
Triarichal Model for Psychopaths
- Boldness: under-activity of the defensive motivational system of the brain
- Lack of Inhibition: deficits in frontal cortical regions involved in self-regulation, cognitive control & moral reasoning
- Meanness: Dysfunction in brain systems important to empathy, taking perspective, lower levels of oxytocin (bonding chemical)
Antisocial & Childhood Behaviour
- Early age of violating the rights & rules of others
- Seeking age-related social norms
- Aggressive toward animals
- Threatening younger children
1. Behaviour worsens with development (strength, cognitive strength & sexual maturity) - Lying and fighting could evolve into vandalism & robbery
2. If child exhibits no signs by age 16 it’s unlikely they’ll develop it.
3. Children with behavioural problems could grow out of them by early adulthood
4. The earlier the onset, the more likely to grow into antisocial PD
Biological Aspects of Antisocial PD
Low serotonin levels
1. Slow alpha waves → cortical immaturity and low arousal
2. Low anxiety: have the physiology of it but no emotional connection
3. High fear threshold (Patrick et al): lack of response to threatening sentences
4. Zuckerman: Impulsive, unsocialized, sensation-seeking, inability to inhibit
5. Gray’s Theory: high BAS, low BIS. High dopamine, low serotonin
Features of Psychopaths (Cleckley)
- superficial charm and good intelligence
- absence of nervousness
- absence of delusions
- unreliable
- untruthful and insincere
- no remorse or shame
- poorly motivated antisocial behaviour
- failure to learn from experience
- egocentric
Kiehl
> ACC: anterior cingulate cortex, for behavior regulation and impulsivity
fMRI 100 inmates, they were 2X likely to reoffend if low ACC activity
Borderline PD Symptoms
- Border between Neurotic and Psychotic functioning
- Border between emotional extremes
- Poor interpersonal borders
- Marked by instability
- Strong fear of abandonment
- Strong emotions
Borderline PD Symptoms continued
- if they sense separation they experience changes of self-image and how they behave
> If threatened with rejection, can become aggressive or manipulative. Experience self-mutilating behaviour
> “Self-mutilating gesture” looking for comfort or attention from others - Greater impairments in emotional perception increase the risk for self-harm (big emotions)
Shifting views of self-image and their goals. Unstable opinions, values, friends and sexual orientations
Borderline PD Causes
People with borderline personality disorder, compared with those without, have a higher incidence rate of childhood physical or sexual abuse, neglect, or early parental loss, could affect capacity to form relationships
> Relatives of someone diagnosed with Borderline have a higher risk of being diagnosed with the disorder themselves
A recent twin study reports a heritability rate of 46%.
Comorbid with depression, bipolar, bulimia and substance abuse
❖ Genetic link to mood disorders
Links to PTSD
Histrionic PD symptoms
Excessive attention-seeking and emotionality.
> Overly dramatic, like to be the center of attention
> Sexually provocative behaviour can be undirected and occurs in weird settings
> Important in physical appearance and how they look to others
> Express opinions greatly, but they change over time
> Display strong emotions in public
> Highly suggestible, opinions aren’t based on facts, taking on what’s popular
Causes of Histrionic PD
Is histrionic personality a sex-typed variant of antisocial personality?
Treatment of Histrionic PD
- Attention seeking and long-term negative consequences
- Problematic interpersonal behaviour
Narcissistic PD symptoms
A strong need to be admired, strong self-importance, lack of insight into other’s feelings
> Expect adulation from others, homage is long overdue
Entitlement, superiority to others
Prefer friends who are socially weak or unpopular as to not compete for attention
Inability to recognize the needs and desires of others, lots of “me myself and i”
Envious of others’ success; attention shouldn’t go to them
Narcissistic Paradox
although they have high self-esteem, their grandiose self-esteem is actually quite fragile; they’re sensitive to criticism
Even though they appear self-confident, they rely on admiration and attention to sustain it.
Causes of Narcissistic PD
> Link with early failure to learn empathy as a child
Sociological view: Narcissism as a product of the “me” generation & culture
Treatment of Narcissistic PD
> Replace grandiose fantasies with more attainable pleasures
Relaxation training to better accept criticism
Avoidant PD
A feeling of inadequacy and sensitivity to criticism
> Go to great lengths to avoid situations in which others might have the opportunity to criticize them
> May restrict their activities to avoid embarassment, cope with anxiety by avoiding
> Create missed opportunities
> Low self-esteem and feel inadequate to life’s challenges
> Tend to avoid intimate contact out of fear of criticism
Causes & Treatment of Avoidant PD
Millon (1981): Difficult temperament and parental rejection
- Anxiety reduction, social skills training
- Training would be a similar approach to social phobias, systematic desensitization and behavioural rehearsal
Dependent PD symptoms
An excessive need to be taken care of
> Act in submissive ways to encourage others to take care of them
> Seeks out reassurance, advice for decisions. Rarely takes initiative
> Avoid disagreements
> Don’t work well independently
> May tolerate extreme circumstances to obtain reassurance and support (like tolerating abuse for eg)
Treatment
Molding patient towards more independence and responsibility
Obsessive Compulsive PD symptoms
Preoccupied with order and striving to be perfect
> Hold high standards for themselves
> Perfectionists, which can stifle productivity
> Devotion to work at the expense of leisure and relationships
> Down time involves working, cleaning etc
> Highly conscientious and need to do things their way
> Might hoard money or old things
> Stubborn
Obsessive Compulsive PD Causes and Treatment
OCD is a pattern of unwanted and intrusive thoughts and is recurrent and troubling. OCPD is a collection of traits and are at risk of developing OCD
- Comorbid with avoidant, histronic & dependent PD
- Weak genetic roots, along with parental models of order and rigidity
Treatment: Therapy for relaxation & distraction techniques
The Prevalence of Personality Disorders
Most Common: OCPD, Antisocial (3.2%, 2.76%)
Least Common: Histrionic, Dependent, Narcissistic (>1%)
Estimates are based on self-report data & clinical interviews (remember, clinical interviews are more reliable as self-report data is subject to bias)
> DSM-5 notes that prevalence for narcissistic PD ranges from 0-6%. This discrepancy is possibly because those with narcissistic PD are less likely to admit to the more disordered features of their condition
> Self-reports of narcissism correlates weakly with peer reports of the same trait, despite high correlations of other traits. Self-report data often exaggerates prevalence rates of many disorders
Antisocial PD Sex Differences
The disorder with the most disparate sex difference is antisocial personality disorder (4.5% in men, 0.8% in women)
> Antisocial women are also more likely to have suffered severe physical, emotional or sexual abuse than antisocial men
Psychopathy sex differences
> Both sexes show deficits in fear, empathy & remorse; conduct disorder in childhood; and a history of deceitfulness, impulsivity, recklessness and irresponsibility
Psychopathy may be expressed differently in women such that evaluations may lead experts to underestimate the rate of psychopathy in the female population.
Gender Issues in Diagnosis
> In Dependent PD, a few of the distinguishing traits might be viewed as traditionally feminine, like putting others’ needs in front of their own
If the criteria is based on feminine stereotypes, it might be easier for women than men to meet the criteria, even if they aren’t suffering significant impairment
With Distrionic PD, a trait is excessive attention leading to seduction. A women might pursue it by hyperfemininity, or maybe being seductive. But a man might pursue through hypermasculinity, displaying strength or accomplishments
All can issue the likelihood of one receiving a diagnosis.
Explanations for disorders
biological, learning, psychodynamic, and cultural explanations. However, it is difficult to separate biology from learning.
> A person’s early experiences (with abuse for example) may lead to neurological changes in certain brain centers
We also don’t know causal direction, like if having a high level of a chemical causes the disorder or if the disorder causes a high level of the same chemical, or whether a third unknown variable controls it
Dimensional Model of Personality Disorders
Accounts for why those in the same diagnostic category can be so different in how they express the disorder
Widiger argues that disorders are maladaptive variants and combinations of normal personality traits
Disorders as maladaptive forms of traits
- Borderline PD is extreme neuroticism
- Schizoid PD is extreme introversion & low neuroticism
- Avoidant PD is extreme introversion & extreme neuroticism
- Histrionic PD is extreme extraversion
- OCD is extreme conscientiousness
- Schizotypal PD is a combo of introversion, high neuroticism, low agreeableness and extreme openness
PD-Trait Specified evaluation
- Negative effect (negative emotions, high neuroticism)
- Detachment (social withdrawal and avoidance)
- Antagonism (being deceitful/manipulative, low agreeableness)
- Disinhibition (impulsiveness and low conscientiousness)
- Psychoticism (bizarre thoughts & experiences)
What were the results of the Dichotic Listening task with psychopaths?
❖ Psychopaths don’t process words like a majority of people do
- Typical people process words on the left side better
- Psychopaths process words on both sides equally as well
What were the results with emotion- laden words versus neutral words with psychopathy?
Psychopaths process neutral vs emotional words at a different speed
- Typical people process emotional words faster than neutral words
- Psychopaths process emotional words at the same rate they process neutral
words
Why are Personality Disorders so difficult to treat?
- Long life patterns
- Low motivation to change
- Low acceptance of responsibility
- Unable to cooperate, enter into the collaborative relationship
Problems with Personality Disorders
- PDs are not as sharply defined as other disorders
- Diagnostic categories are not mutually exclusive, there’s a problem with comorbidity
- Dimensional in Nature: exaggerations of normal personality
