6. Personality disorders Flashcards
Personalities
Personality refers to enduring patterns of thinking and behaviour that define the person and distinguish him/her from others. A person’s characteristic manner of thinking, feeling, behaving and
relating to others that has been evident since young adulthood and
is evident throughout almost everyday of adult life
What are personalities patterns of?
– expressing emotion
– thinking about ourselves and other people – i.e. our representations
What does personality facilitate?
Personality usually facilitates interactions with others – but patterns of behavior and emotion can bring the person into conflict with others
Abnormal/dysfunctional personality
• Dysfunctional personality marked by rigidity/inflexibility, narrow range of responses
• Impacting on identity and self direction and interpersonal relationships (empathy and intimacy)
– May bring a person into conflict with others; exacerbate conflict
– Impede connectedness
– Undermine problem resolution
Healthy or adaptive personality
Healthy or adaptive personality marked by flexibility, variety in responses & capacity to adapt
Reliability of personality disorders
The personality disorders as diagnostic categories tend to lack reliability
– Limited evidence that they are discrete conditions
– Substantial overlap/comorbidity
– Gender bias
Descriptive categories of personality disorders
Categories are descriptive – they do not provide any insight into the aetiology of disorder
Criticisms of personality disorders
- categories are descriptive• Considerable heterogeneity within categories
- Many are ego-syntonic
General criteria for PD
• An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture.
• Manifested in two (or more) of the following areas:
1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response).
3. Interpersonal functioning.
4. Impulse control.
Three clsuters of personality disorders
– Cluster A – social detachment, eccentric/odd
– Cluster B – emotional, erratic, dramatic
– Cluster C – anxious, fearful
Also included are:
– Personality change due to another medical condition
– Other specified personality disorder
– Unspecified personality disorder
The 10 PDS organised by cluster
• Cluster A – Schizoid Personality Disorder – Schizotypal Personality Disorder – Paranoid Personality Disorder • Cluster B – Borderline Personality Disorder – Histrionic Personality Disorder – Narcissistic Personality Disorder – Antisocial Personality Disorder • Cluster C – Avoidant Personality Disorder – Obsessive Compulsive Personality Disorder – Dependent Personality Disorder
Paranoid Personality Disorder: Diagnostic Criteria
A A pervasive distrust and suspiciousness of others such that their motives are interpreted as
malevolent
- Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or
her. - Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or
associates. - Is reluctant to confide in others because of unwarranted fear that the information will be
used maliciously against him or her. - Reads hidden demeaning or threatening meanings into benign remarks or events.
- Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
- Perceives attacks on his or her character or reputation that are not apparent to others and
is quick to react angrily or to counterattack. - Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual
partner.
B Does not occur exclusively during the course of schizophrenia, a bipolar disorder or
depressive disorder with psychotic features, or another psychotic disorder and is not
attributable to the physiological effects of another medical condition.
Schizoid Personality Disorder: Diagnostic Criteria
A A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings
- Neither desires nor enjoys close relationships, including being part of a
family. - Almost always chooses solitary activities.
- Has little, if any, interest in having sexual experiences with another
person. - Takes pleasure in few, if any, activities.
- Lacks close friends or confidants other than first-degree relatives.
- Appears indifferent to the praise or criticism of others.
- Shows emotional coldness, detachment, or flattened affectivity.
B Does not occur exclusively during the course of schizophrenia, a bipolar
disorder or depressive disorder with psychotic features, another psychotic
disorder, or autism spectrum disorder and is not attributable to the physiological
effects of another medical condition.
Schizotypal Personality Disorder: Diagnostic Criteria
A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior
- ideas of reference (excluding delusions of reference)
- odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms
(e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense“ - unusual perceptual experiences, including bodily illusions
- odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or
stereotyped) - suspiciousness or paranoid ideation
- inappropriate or constricted affect
- behavior or appearance that is odd, eccentric, or peculiar
- lack of close friends or confidants other than first-degree relatives
- excessive social anxiety that does not diminish with familiarity and tends to be associated with
paranoid fears rather than negative judgments about self
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or
depressive disorder with psychotic features, another psychotic disorder, or autism spectrum
disorder.
PD distinguished from psychosis
Psychosis (i.e. Schizophrenia) is characterised by a number of other symptoms which may include paranoia, ideas of reference, social withdrawal
– Positive symptoms: hallucinations and delusions
– Negative symptoms of reduced affectivity, poverty of thought, avolition, amotivation, anhedonia
– Disorganised thinking, speech and behaviour
Antisocial Personality Disorder:
Diagnostic Criteria
A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years
- failure to conform to social norms with respect to lawful behaviors as indicated by
repeatedly performing acts that are grounds for arrest - deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal
profit or pleasure - impulsivity or failure to plan ahead
- irritability and aggressiveness, as indicated by repeated physical fights or assaults
- reckless disregard for safety of self or others
- consistent irresponsibility, as indicated by repeated failure to sustain consistent work
behavior or honor financial obligations - lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated,
or stolen from another
B. The individual is at least age 18 years.
C. There is evidence of Conduct Disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of
Schizophrenia or a Manic Episode.
Psychopathy distinguished from antisocial behaviour
• Cleckley (1976) distinguished between 2 groups of symptoms, which Hare (1998) argues differentiate between psychopathy and
antisocial behaviour
• Psychopathy is argued to consist of both emotional/interpersonal traits and social deviance – see below
• The diagnostic criteria for ASPD capture mainly the “Social Deviance” factor
Borderline Personality Disorder
A. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts
- frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or selfmutilating
behavior covered in Criterion 5. - a pattern of unstable and intense interpersonal relationships characterized by alternating
between extremes of idealization and devaluation - identity disturbance: markedly and persistently unstable self-image or sense of self
- impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,
substance abuse, reckless driving, binge eating). Note: Do not include suicidal or selfmutilating
behavior covered in Criterion 5. - recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
- affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
irritability, or anxiety usually lasting a few hours and only rarely more than a few days) - chronic feelings of emptiness
- inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of
temper, constant anger, recurrent physical fights) - transient, stress-related paranoid ideation or severe dissociative symptoms
Histrionic Personality Disorder
A. A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts,
- is uncomfortable in situations in which he or she is not the center of
attention - interaction with others is often characterized by inappropriate sexually
seductive or provocative behavior - displays rapidly shifting and shallow expression of emotions
- consistently uses physical appearance to draw attention to self
- has a style of speech that is excessively impressionistic and lacking in
detail - shows self-dramatization, theatricality, and exaggerated expression of
emotion - is suggestible, i.e., easily influenced by others or circumstances
- considers relationships to be more intimate than they actually are
Narcissistic Personality Disorder
A. A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts
- has a grandiose sense of self-importance (e.g., exaggerates achievements and
talents, expects to be recognized as superior without commensurate achievements) - is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal
love - believes that he or she is “special” and unique and can only be understood by, or
should associate with, other special or high-status people (or institutions) - requires excessive admiration
- has a sense of entitlement, i.e., unreasonable expectations of especially favorable
treatment or automatic compliance with his or her expectations - is interpersonally exploitative, i.e., takes advantage of others to achieve his or her
own ends - lacks empathy: is unwilling to recognize or identify with the feelings and needs of
others - is often envious of others or believes that others are envious of him or her
- shows arrogant, haughty behaviors or attitudes
Avoidant Personality Disorder
A. A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation,
beginning by early adulthood and present in a variety of contexts
- avoids occupational activities that involve significant interpersonal contact,
because of fears of criticism, disapproval, or rejection - is unwilling to get involved with people unless certain of being liked
- shows restraint within intimate relationships because of the fear of being
shamed or ridiculed - is preoccupied with being criticized or rejected in social situations
- is inhibited in new interpersonal situations because of feelings of
inadequacy - views self as socially inept, personally unappealing, or inferior to others
- is unusually reluctant to take personal risks or to engage in any new
activities because they may prove embarrassing
Avoidant personality disorder distinguished from social anxiety
- Some argue there is no difference between Social Anxiety and AvPD
- Others argue that AvPD is characterised by more pervasive and diffuse avoidance
Why is AvPD characterised by more pervasive and diffuse avoidance?
– Persons with SAD tend to avoid particular situations/activities that may involve scrutiny – may have friends/close relationships but avoid ‘performance’ situations
– Tend to be comfortable with persons whom they are close to/familiar
– Persons with AvPD tend to be concerned about intimate/close relationships more generally
– Closeness/intimacy and relationships may be avoided
Dependent Personality Disorder
A. A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts
- has difficulty making everyday decisions without an excessive amount of advice and
reassurance from others - needs others to assume responsibility for most major areas of his or her life
- has difficulty expressing disagreement with others because of fear of loss of support
or approval. Note: Do not include realistic fears of retribution. - has difficulty initiating projects or doing things on his or her own (because of a lack
of self-confidence in judgment or abilities rather than a lack of motivation or energy) - goes to excessive lengths to obtain nurturance and support from others, to the point
of volunteering to do things that are unpleasant - feels uncomfortable or helpless when alone because of exaggerated fears of being
unable to care for himself or herself - urgently seeks another relationship as a source of care and support when a close
relationship ends - is unrealistically preoccupied with fears of being left to take care of himself or herself
Obsessive Compulsive PD
A. A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency
- is preoccupied with details, rules, lists, order, organization, or schedules to the extent that
the major point of the activity is lost - shows perfectionism that interferes with task completion (e.g., is unable to complete a
project because his or her own overly strict standards are not met) - is excessively devoted to work and productivity to the exclusion of leisure activities and
friendships (not accounted for by obvious economic necessity) - is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values
(not accounted for by cultural or religious identification) - is unable to discard worn-out or worthless objects even when they have no sentimental
value - is reluctant to delegate tasks or to work with others unless they submit to exactly his or her
way of doing things - adopts a miserly spending style toward both self and others; money is viewed as
something to be hoarded for future catastrophes - shows rigidity and stubbornness
Obsessive Compulsive PD comarpred to OCD
- Rigidity/rule bound behaviours are prescribed to because of the belief that they are the best person to control things
- Often do not describe subjective feelings of anxiety
- Having control does not relieve distress/anxiety as in OCD
- OCPD is typically ego-syntonic, whereas OCD is usually ego-dystonic
Other Specified Personality Disorder
– General criteria are met but criteria for a single diagnostic class are not met – Clinician specifies a particular reason that person does not meet criteria for a specific PD (e.g. mixed personality features)
Unspecified Personality Disorder
– General criteria for a PD are met but do not fully meet criteria for a specific PD
– Insufficient specific information available to make a definitive diagnosis OR
– Clinician does not specify the reason criteria are met for a specific PD
Personality Change
Due to Another Medical Condition
A. A persistent personality disturbance that represents a change from the individual’s
previous characteristic personality pattern.
B. There is evidence from the history, physical examination, or laboratory findings that
the disturbance is the direct pathophysiological consequence of another medical
condition.
Specify whether:
– Labile type: If the predominant feature is affective lability.
– Disinhibited type: If the predominant feature is poor impulse control as evidenced by sexual
indiscretions, etc.
– Aggressive type: If the predominant feature is aggressive behavior.
– Apathetic type: If the predominant feature is marked apathy and indifference.
– Paranoid type: If the predominant feature is suspiciousness or paranoid ideation.
– Other type/combined/unspecified
prevalence of PD
• Lifetime prevalence of PD ~ 10%
• Harder to identify the rates for specific PD due to reliability issues
and comorbidity
• Best prevalence data is for antisocial PD – overall lifetime
prevalence (men and women combined) = 3%
• OCPD and AvPD seem to affect 3-4%
• The prevalence rates for other PDs tends to be lower (about 1-2%), except for NPD which affects >1%
• BUT comorbidity is a significant issue
Heterogeneity of PD
Extreme heterogeneity among patients considered to have the same disorder -there are many different ways to exhibit each disorder
Comorbidity of PD
- People may exhibit characteristics from across disorders
- People many meet criteria for multiple PDs, as well as other disorders - excessive cooccurrence among disorders - at least 50% of people with PD, meet the criteria for some other PD – similar symptoms are used to describe more than one disorder
- 75% of people with a PD will also meet criteria for other mental disorders (e.g. depression, anxiety etc)
- Arbitrary diagnostic thresholds between normal and pathologic personality functions
- Inadequate coverage of personality psychopathology, evident in the common diagnosis of other Specified or Unspecified PDs (Previously PD Not Otherwise Specified)
Cloninger (2000) criticism of PD
“Our current official classification of personality
disorders is fundamentally flawed by its
assumption that personality disorder is composed
of multiple discrete categorical disorders. The
current list of clusters and categories are highly
redundant and overlapping. Systematic
diagnosis of so many categories is not feasible in
clinical practice and unjustifiable in psychometric
research. The predictive power of categorical
diagnosis is weak and inconsistent”
Gender differences in PD generally
Overall prevalence of PD about equal in men and women
Gender differences for other PD are more contentious
Gender differences in antisocial PD
Antisocial PD is unquestionably much more common in men with rates of approx. 5% reported for men and 2% for women
gender differences in BPD and DPD
BPD and DPD may be more prevalent in women than in men – but evidence is not strong
Gender differences in paranoid and OCPD
Some speculation that paranoid and OCPDs are more common among men
Gender Bias in PD diagnosis?
The definitions of some PDs are based on sex role stereotypes and are therefore are inherently sexist
– The dependent type might be viewed as a reflection of typically feminine traits – unassertive, putting needs of others first – Is DSM “arbitrarily” labeling these traits as maladaptive?
• Potentially, also clinicians may be biased in the way they diagnose their clients - more likely to diagnose a woman with borderline than a man, even if they display the same symptoms
Course of PD
- Long term course by definition
* Present from adolescence/early adulthood and persistent
Outcome of PD
Disruptive to relationships, work, sense of self
Cause of PD
- No single cause/pathway – multifactorial aetiology
- Recall equifinality and multifinality
- Theoretical models can help to understand the motivations for particular behaviours
Development and Childhood maltreatment as a cause of PD
Childhood maltreatment increases the risk for the development of any of the personality disorders
• This link is particularly strong for Cluster B
• A number of theories attempt to explain this link – attachment theory, mentalisation, object relations, cognitive, schema based, affect regulation
• All suggest developmental capacities are affected in some way (probably multiple ways) leading to impairments see in PDs
Adolescent girls and BPD
Adolescent girls with BPD report
– a lack of supervision
– frequent witness of domestic violence
– being subjected to inappropriate behavior by their parents and other adults
– verbal, physical, and sexual abuse (Helgeland & Torgersen, 2004; Pally,
2002).
Childhood trauma and BPD
– Disrupts the attachment relationship – basic security,
expectation that others are reliable and available
– Impacts the developing self and process of
separation-individuation
– Undermines the development of affect regulation –
experiences of co-regulation are necessary for
development of self-regulation
– Undermines capacity for mentalisation
Linehan’s Diathesis-Stress
Theory
– Individuals with BPD have difficulty regulating their emotions (Possible biological diathesis)
– Family invalidates or discounts emotional experiences and expression
– Leads to further difficulty organising and regulating affect
– Corresponds to the symptoms of BPD
Treatment of BPD
- Psychotherapy is the main treatment
* Often long term
Types of psychotherapy treatment
– Dialectical Behaviour Therapy – Schema Therapy – Interpersonal Therapy – Psychodynamic psychotherapies – Mentalisation Based Therapy
Dialectical Behaviour therapy
- Emphasis on increasing tolerance of strong affective states – building resources to soothe intensity and,
- Therapist’s stable presence, acceptance of the patient and challenging behaviours
Medications used to treat BPD
– antidepressants (to treat depressive symptoms, anxiety)
– Antipsychotics (work as a sedative to regulate lability in moods/transient psychotic thinking)
– Lithium/mood stabilisers (to target emotional lability
The relationship between Schizophrenia and PD - Schizotypal PD
- First degree relatives of patients diagnosed with Schizophrenia are more likely to meet criteria for Schizotypal PD
- Has lead to the postulate that Schizotypal PD is genetically related to Schizophrenia
Treatment of Schizotupal PD
- Limited treatment seeking and high rates of premature termination
- Low doses of antipsychotic medications have been shown to be effective in some instances
- Limited evidence for psychotherapy
- Treatment often focuses on other comorbid issues – e.g. depression or substance abuse/dependence
Kohut’s Self-Psychology Model to explain the aetiology of NPD
– Characteristics mask low self-esteem, feelings of worthlessness
– The presentational self
– In childhood, narcissism valued as a means to increase parent’s own self-esteem
– People with high levels of narcissism often report cold parents who overemphasized child’s achievement/performane
– May have been dismissing or mocking/devaluing of vulnerability, emotion and distress
Social cognitive model to explain the aetiology of NPD
– Narcissist has low self esteem
– Sense of self depends on achieving
– Interpersonal relationships are a way to bolster self esteem rather than increase closeness to others
– Cognitive biases that maintain narcissism
Treatment of NPD
• Psychotherapy is main treatment
• Low rates of treatment seeking due to difficulty
acknowledging weakness/vulnerability
• Treatment complicated by difficulty with interpersonal
relationships
• Often short term – present during a depressive
episode/crisis, cease treatment following crisis
• May be cyclical engagement
• Psychodynamic psychotherapies focus on increasing
willingness to acknowledge vulnerability and
understanding the impact of defenses on relationships
Genetics and ASPD
• offspring of convicted criminals raised by adoptive families show higher rates of arrests and antisocial personality disorder than controls
• concordance rates for criminality are 55% for MZ twins and 13% for DZ twins
– The genetic risk for APD, conduct disorder, and substance abuse are related
– BUT, genetics interact with environment
Family environment as a cause of ASPD
– Lack of warmth, negativity, and parental inconsistency – Poverty – Inconsistent discipline and poor parental monitoring – Exposure to violence – Marital conflict – Drug abuse – Criminal activity Argued to predict increased risk of ASPD
Underarousal hypotheses as a cause of ASPD
– Low levels of anxiety and fear
– Lower physiological response to frightening or
disgusting stimuli
– longitudinal study found that future criminals had lower skin conductance activity, lower heart rate, and more slow-frequency brain wave activity
– Higher levels of impulsivity
– Lower responsiveness to conditioning/punishment
Treatment of ASPD
• Rarely seek treatment
• May be referred via the legal system
• Treatment tends to be time limited and focused
on reducing recidivism OR targeting substance abuse/dependence
• Some evidence that targeted interventions are effective in changing specific behaviours, but general character/personality remains unchanged
The DSM 5 dimensional model of PD
personality disorders are characterized by impairments in personality functioning and presence of pathological personality traits.
Impairment in personality functioning evaluated on a continuum in terms of disturbance in both self and interpersonal functioning
Self functioning in DSM5 dimensional model
Self functioning involves identity and self-direction
Interpersonal functioning in DSM 5 dimensional model
Interpersonal functioning involves empathy and intimacy
General criteria fro PD
A. Moderate or greater impairment in personality (self/interpersonal)
functioning.
B. One or more pathological personality traits.
C. The impairments in personality functioning and the individual’s
personality trait expression are relatively inflexible and pervasive
across a broad range of personal and social situations.
D. The impairments in personality functioning and the individual’s
personality trait expression are relatively stable across time, with
onsets that can be traced back to at least adolescence or early
adulthood.
Identity in self functioning in DSM 5 criterion A
- Identity: Experience of oneself as unique, with clear boundaries between self and others; stability of
self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a range of emotional
experience.
self-direction in self functioning in DSM 5 criterion A
- Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of
constructive and prosocial internal standards of behavior; ability to self-reflect productively.
Empathy in interpersonal functioning in DSM 5
- Empathy: Comprehension and appreciation of others’ experiences and motivations; tolerance of
differing perspectives; understanding the effects of own behavior on others.
Intimacy in interpersional function in DSM 5
- Intimacy: Depth and duration of connection with others; desire and capacity for closeness; mutuality
of regard reflected in interpersonal behavior.
Pathological Personality Traits in criterion B if DSM 5
• One or more pathological personality traits
• Pathological personality traits are organized into five broad domains
(similar to the Five factor Model, but trait labels emphasise
maladaptive nature):
– Negative Affectivity
– Detachment
– Antagonism
– Disinhibition
– Psychoticism
• Within the five broad trait domains are 25 specific trait facets and
how they may be associated with current categories of PD
