4. Personality Disorders Flashcards
Outline the general elements of PDs
A) Enduring patterns of thinking / feeling / acting / relating
B) Culturally deviant
C) Pervasive and inflexible
D) Lead to distress or social impairment
Typical onset in adolescence and early adulthood
Outline the categorical model of PDs and its failures
PDs as distinct clinical entities –> this is problematic
Failures:
- does not account for extensive co-morbidity of PDs
- does not account for extreme heterogeneity (many ways you can display PDs)
- poor inter-rater reliability
- PD NOS was the most common category of PD diagnosis (does not fit into a certain PD)
- arbitrary cut-offs (you need diagnosis to get treatments, but what if you don’t meet these cutoffs?)
Outline the dimensional model proposal:
Personality disorder instead conceptualised as maladaptive variants of personality traits
but ‘too complex for clinical practice’
2 Criteria
- impaired personality functioning
- - pathological personality tratis
What were the changes from the DSM-IV to DSM-V regarding PDs
Removal of the axial system:
- Axis 1: clinical disorders (phobias, depression)
- Axis 2: Personality disorders and mental retardation (intellectual disability)
- Axis 3: physical health, etc
This gave the implicit message that personality disorders were ‘untreatable’ but evidence says that you can actually treat these disorders.
These axes were removed from DSM 5
What were the clusters?
Cluster A: “weird”, odd, eccentric
- paranoid
- schizoid
- schizotypal
Cluster B: “wild”, dramatic, emotional
- Antisocial
- Borderline
- Histrionic
- Narcissistic
Cluster C: “worried”, anxious, fearful
- Avoidant
- Dependent
- Obsessive Compulsive
Outline cluster A
Odd or eccentric
Paranoid: distrust, suspiciousness
- Misinterprets others’ actions and motives
Schizoid: social detachment, limited emotions
- Prefers isolation, lacks close friendships / relationships
Schizotypal: acute discomfort in close relations
- perceptual distortions
- eccentricities
- sometimes seen on the spectrum of schizophrenia
Outline Cluster B
Dramatic, emotional, errative
Antisocial: disregard and violation of rights of others beginning in childhood/adolescence
- more common in males
- highest prevalence in alcohol use disorder clinics, prisons, and other forensic settings
Borderline: instability of interpersonal relationships, self-image, emotions; behavioural dysregulatoin
- fear of abandonment, splitting, identity disturbances, emptiness, selfharm
- makes up to 1/5 of inpatients
- 75% of BPD patients are women
Histrionic: excessive emotionality and attention seeking
- self-dramatisation, craving for activity, overreacting to minor events, irrational, angry outburts or trantrums
- 1-2% population, F>M
Narcissistic : pervasive pattern of grandiosity, need for admiration, lack of empathy
- 6% population (75% men)
Alcohol and aggression
For individuals with APD, there’s a stark increase in aggressive responding when intoxicated - compared to non-clinical group
Criteria for Antisocial personality disorder
A. Pervasive pattern of disregard for and violation of the rights of others since 15 years, including 3 of the following:
- failure to conform to social norms (grounds for arrest)
- deceitfulness (lying)
- impulsivity
- irritability and aggressiveness (fights and assaults)
- reckless disregard for safety
- irresponsible
- lack of remorse
B: individual at least 18 years
C. evidence of conduct disorder (onset before 15)
D: not during the course of schizophrenia or bipolar epsiode
Criteria for Borderline Personality Disorder
A. instability of interpersonal relationships, self image, affects, marked impulsivity beginning by early adulthood (cross contexts) - indicated by 5+
- fear of abandonment
- unstable and intense relationships (splitting)
- identity disturbance
- impulsivity in 2 areas (self damaging)
- recurrent suicidal behaviour / self-mutilating
- affective instability
- emptiness
- inappropriate intense anger
- transient stress related paranoid ideation
BPD inpatients:
- 71% had history of childhood sexual abuse
Cluster B and childhood abuse
People with documented childhood abuse are 4x as likely than those who were not to be diagnosed with PDs
Outline cluster C
Anxious, fearful
Avoidant: social inhibition, feeling inadequate, hypersensitivity to negative evaluation
- avoid social situations for fear of embarrassment
Dependent: submissive and clinging; excessive need to be taken care of
Obsessive Compulsive: preoccupation with orderliness, perfectionism and control
Outline the dimensional model:
Usually based on 5 factor model:
- neuroticism (fearful, anxious –> other extreme, oblivious to signs of threat)
- extraversion (extreme –> intense attachments, other extreme: cold, distant)
- agreeableness (extreme: docile, meek, yielding –> other extreme: combative and aggressive)
- openness (extreme: unrealistic, lives in fantasy –> other extreme, concrete)
- conscientiousness (extreme: perfectionistic –> disincline, irresponsible)
Look at the alternative model for DSM-5 –> hybrid
PDs involve:
Criterion A - impaired personality functioning
Criterion B - pathological personality traits
Use functioning and traits to identify specific PD diagnoses for:
- antisocial, avoidant, borderline, narcissistic, obsessive compulsive, schizotypal
No paranoid, schizoid, dependent, histrionic
Outline Criterion A of the alternate model
Impairment in self and interpersonal functioning
Moderate or greater impairment in:
- identity
- self direction
- empathy
- intimacy
Outline Criterion B of the alternate model
Organised into 5 broad domains:
- Negative affectivity (neuroticism)
- Detachment (extraversion)
- Psychoticism (openness)
- Antagonism (agreeableness)
- Disinhibition / losing touch w reality (conscientiousness)
Testing the alternative model:
Kreuger and Hobbs found
- meaningful clinical correlates (self-harm, treatment drop out)
- acceptable / improved inter-rater reliability
- reasonable psychometric properties
Are there cultural differences in PD prevalence?
- BPD and ASPD has increased in US over past 30 years (genuine increase, increase in pathology, definitional or diagnostic increase)
- prevalence of ASPD in US = 3%, Taiwan = 0.2%
- 15% US adults have at least one personality disorder
Outline Winsper’s 2020 systematic review and meta-analysis
Global prevalence of PDs is 7.8%
PDs are more common in high income countries compared to low income countries.
Cluster B and C are less common in low income
Explanations for this is cultural protection factor (collectivism, community support system?)
What is person-cultural value clash?
Avoidance, Dependent, Borderline personality disorders are not observed in Chinese classification of mental disorders –> in a confucian context, these traits may not be considered as disordered.
If your personality clashes with cultural values, it may cause distress (an underlying feature of personality disorders)
Self-report of US and turkish participants - cultural clash
People in the US who rated themselves as more collectivistically oriented also rated themselves as higher in avoidant and dependant personality disorder features.
For Turkish participants who were more individualist oriented, they self-reported more narcissistic, antisocial and borderline features
How can we make sense of normal personality disordered personality without culture?
A PD reflects difficulties in how a person behaves and is perceived to behave by others in this social field - bringing into play cultural values related to what is expected, valued and devalued in a person.
