Ch. 10, Personality Disorders Flashcards
when is a personality disorder diagnosed?
A personality disorder is diagnosed when there is an enduring pattern of behavior or inner experience that is pervasive and inflexible, stable across time, and of long duration. It must also cause either clinically significant distress or impairment in functioning and be manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control. The features of personality disorder are typically recognizable by adolescence or early adulthood.
How do personality disorders develop?
disorders come largely from the gradual development of inflexible and distorted personality and behavioral patterns that result in persistently maladaptive ways of perceiving, thinking about, and relating to the world. Nonetheless, stressful events early in life may help set the stage for the development of these inflexible and distorted personality patterns.
Cluster A, cluster b, Cluster C
Cluster A: Includes paranoid, schizoid, and schizotypal personality disorders. People with these disorders often seem odd or eccentric, with unusual behavior ranging from distrust and suspiciousness to social detachment.
Cluster B: Includes histrionic, narcissistic, antisocial, and borderline personality disorders. Individuals with these disorders share a tendency to be dramatic, emotional, and erratic.
Cluster C: Includes avoidant, dependent, and obsessive-compulsive personality disorders. In contrast to the other two clusters, people with these disorders often show anxiety and fearfulness.
personality disorder prevalence
ar. Somewhere between 10 and 12 percent of people meet criteria for at least one personality disorder when the time period being asked about is the person’s behavior over the last 2 to 5 years/ Cluster C disorders are most common, with a prevalence of around 7 percent. Cluster A disorders are next, with a prevalence of approximately 4 percent. Finally, the prevalence of Cluster B disorders is slightly lower, in the range of 3.5 to 4 percent
Difficulties in Diagnosing Personality Disorders
-diagnostic criteria for personality disorders are not as sharply defined as they are for most other diagnostic categories, so they are often not very precise or easy to follow in practice.
-Because the criteria for personality disorders are defined by inferred traits or consistent patterns of behavior rather than by more objective behavioral standards (such as having a panic attack or a prolonged and persistent depressed mood), the clinician must exercise more judgment in making the diagnosis than is the case for many other disorders.
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best way to reliably diagnose personality disorders
The development of semi-structured interviews and self-report inventories for the diagnosis of personality disorders has improved diagnostic reliability substantially. However, because agreement between the diagnoses made on the basis of different interviews or self-report inventories is often rather low, problems still remain with the reliability and validity of these diagnoses
dimensional vs categorical personality diagnostics
categorical approach (where disorders are considered to be distinct and separate) by adopting a dimensional approach (see Ofrat et al., 2015 for a more detailed discussion of the problems associated with a categorical system). This assumes that personality (and personality disorder) is on a continuum. Accordingly, researchers have tried to develop dimensional systems of assessment for the symptoms and traits involved in personality disorders
five factor model of personality
This builds on the five-factor model of normal personality mentioned earlier to help researchers understand the commonalities and distinctions among the different personality disorders by assessing how these individuals score on the five basic personality traits (e.g., Clark, 2007; Widiger & Trull, 2007; Widiger et al., 2009, 2012). To fully account for the many ways in which people differ, each of these five basic personality traits also has subcomponents or facets.
6 facets of neuroticism
anxiety, angry-hostility, depression, self-consciousness, impulsiveness, and vulnerability
6 facets of extroversion
warmth, gregariousness, assertiveness, activity, excitement seeking, and positive emotions
dimensional approach to personality traits (5 dimensions)
negative affectivity (neuroticism); detachment (extreme introversion); antagonism (extremely low agreeableness); and disinhibition (extremely low conscientiousness). A fifth dimension, psychoticism, does not appear to be a pathological extreme of the final dimension of normal personality (openness)—rather, as we will discuss later in the chapter in the section on schizotypal personality disorder, it reflects traits similar to the symptoms of psychotic disorders
Why Were No Changes Made to the Way Personality Disorders Are Diagnosed in DSM-5?
DSM-5 task force proposed revisions that reflected a hybrid dimensional–categorical model. This consisted of both categorical components and dimensional components and includes a set of general criteria for all personality disorders, an overall dimensional measure of the severity of personality dysfunction, a limited set of personality disorder types, and a set of pathological personality traits that could be specified in the absence of one of the personality disorder types. The proposed categorical component also retained six of the original ten specific personality disorder types (antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal).
- intended to describe personality characteristics of all patients, even those without a specific personality disorder.
- allowed clinicians to rate the level of impairment in personality functioning, reflecting aspects of both identity (having a stable and coherent sense of self and the ability to pursue meaningful life goals) and interpersonal functioning (the capacity for empathy and intimacy).
-diagnosticians could indicate the degree to which the patient showed substantial abnormality on five trait domains (negative affectivity, detachment, antagonism, disinhibition, and psychoticism), which are based primarily on the five-factor trait model discussed earlier.
REJECTED BY DSM 5 TASK FORCE = rejected because it was quite cumbersome and judged too time consuming for overworked clinicians to learn and use. Moreover clinicians probably would not have found the proposed system to be user-friendly in part because the idea of rating people on dimensions is foreign to the way clinicians have been taught to think.
Difficulties in Studying the Causes of Personality Disorders
-We do not know as much as we would like about the causal factors involved in the development of most personality disorders. One reason for this is the high level of comorbidity among them: 85 percent of patients who qualified for one personality disorder diagnosis also qualified for at least one more, and many qualified for several more
-One of the problems with the diagnostic categories of personality disorders is that the exact same observable behaviors may be associated with different personality disorders and yet have different meanings with each disorder.: difficult to attribute the symptoms to one disorder when it could be representative of many
-Another problem in drawing conclusions about causes occurs because researchers have more confidence in prospective studies. In prospective studies groups of people are observed before a disorder appears and are followed over a period of time to see which individuals develop problems and what causal factors have been present. =relatively little prospective research has been conducted with most of the personality disorders.vast majority of research has been conducted on people who already have the disorders; some of it relies on retrospective recall of prior events, and some of it relies on observing current biological, cognitive, emotional, and interpersonal functioning. Thus, any conclusions about causes that are suggested must be considered tentative.
Biological factors personality diosrdoers
Of possible biological factors, it has been suggested that infants’ temperament (an inborn disposition to react affectively to environmental stimuli; see Chapter 3) may predispose them to the development of particular personality traits and disorders
-important dimensions of temperament are negative emotionality, sociability versus social inhibition or shyness, and activity level. One way of thinking about temperament is that it lays the early foundation for the development of the adult personality, but it is not the sole determinant of adult personality.
=, the genetic contribution appears to be mediated by the genetic contributions to the primary trait dimensions most implicated in each disorder rather than to the disorders themselves= In other words, the disorder itself is not inherited but its component features may show high heritability.
psycodynamic theories and psychological factors in personality disorders vs NOW
psychodynamic theorists originally attributed great importance in the development of character disorders to an infant’s getting excessive versus insufficient gratification of his or her impulses in the first few years of life
-More recently, learning-based habit patterns and maladaptive cognitive styles have received more attention as possible causal factors= Many of these maladaptive habits and cognitive styles that have been hypothesized to play important roles for certain disorders may originate in disturbed parent–child attachment relationships rather than derive simply from differences in temperament
=Parental psychopathology and ineffective parenting practices have also been implicated in certain disorders
Paranoid Personality Disorder
Individuals with paranoid personality disorder are suspicious and distrustful of others, often reading hidden meanings into ordinary remarks. They tend to see themselves as blameless, instead blaming others for their own mistakes and failures—even to the point of ascribing evil motives to others. Such people are chronically tense and “on guard,” constantly expecting trickery and looking for clues to validate their expectations while disregarding all evidence to the contrary.
EQUAL IN MEN AND WOMEN
PPD and psychotocism
-people with paranoid personalities are not usually psychotic. Most of the time they are in clear contact with reality. During periods of high stress, however, they may experience transient psychotic symptoms that last from a few minutes to a few hours
- individuals with paranoid personality disorder do appear to be at elevated liability for schizophrenia
why is PPD not well studied/ causal factors
- One reason for this is that people who are highly suspicious and lacking in trust tend not to want to participate in research studies.
-there is evidence of modest genetic liability to paranoid personality disorder itself = This may occur through the heritability of high levels of antagonism (low agreeableness) and neuroticism (angry-hostility), which are among the primary traits in paranoid personality disorder
= Psychosocial causal factors that are suspected to play a role include parental neglect or abuse and exposure to violent adults, although any links between early adverse experiences and adult paranoid personality disorder are clearly not specific to this one personality disorder and may play a role in other disorders as well
=Symptoms of paranoid personality disorder also seem to increase after traumatic brain injury and are often found in chronic cocaine users
schizoid personality disorder
-have difficulties forming social relationships and usually lack much interest in doing so.
-t. They often lack social skills and can be classified as loners or introverts, with solitary interests and occupations, although not all loners or introverts have schizoid personality disorder
-People with this disorder tend not to take pleasure in many activities, including sexual activity, and rarely marry. More generally, they are not very emotionally reactive, rarely experiencing strong positive or negative emotions, but rather show a generally apathetic mood.
= more common in males
=, people with schizoid personality disorder show extremely high levels of introversion (especially low on warmth, gregariousness, and positive emotions). They are also low on openness to feelings (one facet of openness to experience) and on achievement striving
causes of schizoid
Schizoid personality traits have been shown to have fairly high heritability of around 55 percent
-, there is also evidence that symptoms of schizoid personality disorder do precede psychotic illness in some cases
-there is some link between schizoid personality and autism spectrum disorders. This is interesting in light of recent research suggesting that schizophrenia and autism may have some common genetic basis
Schizotypal Personality Disorder
-Like people with schizoid personality disorder, individuals with schizotypal personality disorder are also excessively introverted and have pervasive social and interpersonal deficits. But in addition they have cognitive and perceptual distortions, as well as oddities and eccentricities in their communication and behavior
-Although contact with reality is usually maintained, highly personalized and superstitious thinking is characteristic of people with schizotypal personality, and under extreme stress they may experience transient psychotic symptoms
- they often believe that they have magical powers and may engage in magical rituals. Other cognitive–perceptual problems include ideas of reference (the belief that conversations or gestures of others have special meaning or personal significance), odd speech, and paranoid beliefs.
-Oddities in thinking, speech, and other behaviors are the most stable characteristics of schizotypal personality disorder
- many researchers conceptualize schizotypal personality disorder as an attenuated form of schizophrenia
five factor model and schizotypal
although some aspects of schizotypy appear related to the five-factor model of normal personality (specifically facets of introversion and neuroticism), the other aspects related to cognitive and perceptual distortions are not adequately explained by the five-factor model of normal personality
-hese core symptoms of schizotypy form the basis of the only proposed trait that does not map neatly onto the five factors of normal personality. This pathological trait is psychoticism, which consists of three facets: unusual beliefs and experiences, eccentricity, and cognitive and perceptual dysregulation
causes of schizotypal/ similarities to schizophrenia/ cognitive deficits
-Schizotypal personality disorder has moderate heritability (Kwapil & Barrantes-Vidal, 2012; Lin et al., 2006, 2007; Raine, 2006). A genetic relationship to schizophrenia has also long been suspected. In fact, this disorder appears to be part of a spectrum of liability for schizophrenia and often occurs in some of the first-degree relatives of people with schizophrenia
-The biological associations of schizotypal personality disorder with schizophrenia are remarkable
-shown the same deficit in the ability to track a moving target visually that is found in schizophrenia
-numerous other mild impairments in cognitive functioning (Voglmaier et al., 2005), including deficits in their ability to sustain attention and deficits in working memory (e.g., being able to remember a span of digits), both of which are common in schizophrenia.
-In addition, individuals with schizotypal personality disorder, like patients with schizophrenia, show deficits in their ability to inhibit attention to a second stimulus that rapidly follows presentation of a first stimulus.
-people with schizotypal personality disorder also show language abnormalities that may be related to abnormalities in their auditory processing
second subtype of schizotypal
it has also been proposed that there is a second subtype of schizotypal personality disorder that is not genetically linked to schizophrenia. This subtype is characterized by cognitive and perceptual deficits and is instead linked to a history of childhood abuse and early trauma
environmental factors and schizotypal
Schizotypal personality disorder in adolescence has been associated with elevated exposure to stressful life events (Anglin et al., 2008; Tessner et al., 2011) and low family socioeconomic status
Histrionic personality disorder
-Excessive attention-seeking behavior and emotionality are the key characteristics
-, these individuals tend to feel unappreciated if they are not the center of attention; their lively, dramatic, and excessively extraverted styles often ensure that they can charm others into attending to them.
-Their speech is often vague and impressionistic, and they are usually considered self-centered, vain, and excessively concerned about the approval of others, who see them as overly reactive, shallow, and insincere.
sex bias and histrionic personality disorder
-given the number of traits that occur more often in females that are involved in the diagnostic criteria. For example, many of the criteria for histrionic personality disorder (as well as for several other personality disorders such as dependent) involve maladaptive variants of female-related traits
-other personality traits prominent in histrionic personality disorder are actually more common in men than in women (e.g., high excitement seeking and low self-consciousness)
-Histrionic personality disorder is highly comorbid with borderline, antisocial, narcissistic, and dependent personality disorder diagnoses
causal factors histrionic
-The suggestion of some genetic propensity to develop this disorder is also supported by findings that histrionic personality disorder may be characterized as involving extreme versions of two common, normal personality traits: extraversion and, to a lesser extent, neuroticism—two normal personality traits known to have a partial genetic basis
- In terms of the five-factor model (refer back to Table 10.2), the very high levels of extraversion of patients with histrionic personality disorder include high levels of gregariousness, excitement seeking, and positive emotions. Their high levels of neuroticism particularly involve the depression and self-consciousness facets; they are also high on openness to fantasies
-Cognitive theorists emphasize the importance of maladaptive schemas revolving around the need for attention to validate self-worth.
NPD clinical presentation/ two subtypes
- show an exaggerated sense of self-importance, a preoccupation with being admired, and a lack of empathy for the feelings of others
- two subtypes of narcissism: grandiose and vulnerable narcissism (Cain et al., 2008; Ronningstam, 2012). The grandiose presentation of narcissism, highlighted in the DSM-5 criteria, is manifested by traits related to extreme grandiosity, aggression, and dominance. These are reflected in a strong tendency to overestimate one’s own abilities and accomplishments while underestimating the abilities and accomplishments of others. This sense of entitlement is frequently a source of astonishment to others, although people with grandiose narcissism seem to regard their lavish expectations as merely what they deserve.
-Because they believe they are so special, they often think they can be understood only by other high-status people or that they should associate only with such people
-The vulnerable presentation of narcissism is not as clearly reflected in the DSM criteria but nevertheless represents a subtype long observed by researchers and clinicians. Vulnerable narcissists have a very fragile and unstable sense of self-esteem, and for these individuals, arrogance and condescension is merely a façade for intense shame and hypersensitivity to rejection and criticism
five factor model and both subtypes of narcissism
In terms of the five-factor model, both subtypes are associated with high levels of interpersonal antagonism/low agreeableness (which includes traits of low modesty, arrogance, grandiosity, and superiority), low altruism (expecting favorable treatment and exploiting others), and tough-mindedness (lack of empathy). However, the person with a more grandiose form of narcissism is exceptionally low in certain facets of neuroticism and high in extraversion. When the narcissism involves more grandiosity, close friends and relatives may be more distressed about his or her behavior than is the narcissist
vulnerable narcissist, who has very high levels of negative affectivity/neuroticism
-some individuals with narcissistic personality disorder may fluctuate between grandiosity and vulnerability
empathy and NPD
-People with narcissistic personalities also share another central trait—they are unwilling or unable to take the perspective of others, to see things other than “through their own eyes.” Moreover, if they do not receive the validation or assistance they desire, they are inclined to be hypercritical and retaliatory
-one study of male students with high levels of narcissistic traits showed that they had greater tendencies toward sexual coercion when they were rejected by the target of their sexual desires than did men with lower levels of narcissistic traits.
-disorder probably being more common in men than women (Torgersen, 2012). This gender difference is to be expected, based on known sex differences in the personality traits most prominent in narcissistic personality disorder
environmental causal factors NPD
Grandiose narcissism has not generally been associated with childhood abuse, neglect, or poor parenting. Indeed, there is some evidence that grandiose narcissism is associated with parental overvaluation. By contrast, vulnerable narcissism has been associated with emotional, physical, and sexual abuse, as well as parenting styles characterized as intrusive, controlling, and cold
antisocial personality disorder
-endency to persistently disregard and violate the rights of others. They do this through a combination of deceitful, aggressive, and antisocial behaviors. Such people have a lifelong pattern of unsocialized and irresponsible behavior with little regard for safety—either their own or that of others. These characteristics bring them into repeated conflict with society, and a high proportion end up in trouble with the law. Only individuals ages 18 or over can be diagnosed with ASPD. For the diagnosis to be made, the person must have shown symptoms of conduct disorder before age 15
-. After age 15, there must also be evidence of such things as repeated unlawful behavior, deceitfulness, impulsivity, aggressiveness, or consistent irresponsibility in work or financial matters
gender differences iN ASPD
The disorder is more common in men (approximately 3 percent) than in women (approximately 1 percent), although some studies suggest that the preponderance of men is even greater and closer to 5 to 1
difference between ASPD and psycopathy
The term antisocial personality disorder is often used interchangeably with psychopathy. But this is a mistake. Although there is some overlap between ASPD and psychopathy, they are not the same thing. The current DSM criteria for antisocial personality disorder place a heavy emphasis on observable behaviors such as lying, getting into fights, or failing to honor financial obligations. In contrast, in the construct of psychopathy, more attention is paid to personality characteristics such as superficial charm, lack of empathy, and manipulativeness.
causal factors of ASPD
-results from adoption studies and concordance rates = he results of both kinds of studies show a moderate heritability for antisocial or criminal behavior
-Many environmental factors have also been implicated in the development of antisocial personality disorder = These include low family income, inner-city living, poor supervision by parents, having a young mother, being raised in a single-parent family, conflict between parents, having a delinquent sibling, neglect, large family size, and also harsh discipline from parents
nonshared experiences in twin studies that seem to be important: . Other nonshared environmental factors (nonshared because they are not necessarily experienced by all children in the family) that are important are having delinquent peers, physical or sexual abuse, and various academic or social experiences.
monamine oxidase A gene and ASPD MAOA
-This gene, known as the monoamine oxidase A gene (MAOA gene), is involved in the breakdown of neurotransmitters like norepinephrine, dopamine, and serotonin—all neurotransmitters affected by the stress of maltreatment that can lead to aggressive behavior (see Figure 10.1). In this study, over a thousand children from New Zealand were followed from birth to age 26. Researchers found that individuals with low MAOA activity were far more likely to develop ASPD if they had experienced early maltreatment than were individuals with high MAOA activity and early maltreatment and individuals with low levels of MAOA activity without early maltreatment.
substance abuse and ASPD
-The relationship between antisocial behavior and substance abuse is sufficiently strong that some have questioned whether there may be a common factor leading to both alcoholism and antisocial personality
-ASPD and other externalizing disorders (like alcohol and drug use and conduct disorder) all share a strong common genetic vulnerability; environmental factors were more important in determining which disorder a particular person developed
why is it difficult to determine family vs genetic influences ASPD
Antisocial individuals may receive their genes from antisocial parents. In such cases, these parents will likely also expose the child to a home environment that may provide a model for criminality, or contain risk factors such as abuse, neglect, parental separations, violence, and a host of other factors. A child with a genetic liability to antisocial behavior may also elicit problems in others because of his or her behavior (this is known as evocative gene–environment correlation). Such child-driven environmental factors here might include marital conflict, increased mental health problems in parents, or harsh discipline from parents (Jackson & Beaver, 2015). In other words, the links between the family environment and antisocial behavior are complex
developmental perspective ASPD
-ASPD has its roots in childhood, especially for boys. The number of antisocial behaviors exhibited in childhood is the single best predictor of who will develop an adult diagnosis of ASPD, and the younger the age at which problems start, the higher the risk
-Prospective studies have shown that it is children with an early history of oppositional defiant disorder—characterized by a pattern of hostile and defiant behavior toward authority figures that usually begins by the age of 6 years, followed by early-onset conduct disorder around age 9—who are most likely to develop ASPD as adults
-The second early diagnosis that is often a precursor to adult ASPD is attention-deficit/hyperactivity disorder (ADHD). ADHD is characterized by restless, inattentive, and impulsive behavior, a short attention span, and high distractibility (see Chapter 15). When ADHD co-occurs with conduct disorder (which happens in at least 30 to 50 percent of cases), this leads to a high likelihood that the person will develop a severely aggressive form of ASPD and possibly psychopathy,
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life course persistent antisocial behavior
originates early in life, when the difficult behavior of a high-risk young child is exacerbated by a high-risk social environment. According to the theory, the child’s risk emerges from inherited or acquired neuropsychological variation, initially manifested as subtle cognitive deficits, difficult temperament, or hyperactivity. The environment’s risk comprises factors such as inadequate parenting, disrupted family bonds, and poverty. The environmental risk domain expands beyond the family as the child ages, to include poor relations with people such as peers and teachers, then later with partners and employers. Over the first 2 decades of development, transactions between individual and environment gradually construct a disordered personality with hallmark features of physical aggression, and antisocial behavior persisting to midlife
PFC and ASPD
- ## It is also known that antisocial individuals show abnormalities in both the structure and function of the prefrontal cortex
BPD and historical uses of the term
The term borderline personality has a long and rather confusing history (Hooley et al., 2012). Originally it was used to refer to patients who were very challenging to deal with and who were thought to have a condition that was on the “border” between neurosis and psychosis. Later, the word was used to describe patients who had some features of schizophrenia (as in borderline schizophrenia)
most well researched personality disorder/its clinical presentation
BPD
-a pattern of behavior characterized by impulsivity and instability in their interpersonal relationships, their self-image, and their moods. A central characteristic is affective instability. This shows itself in unusually intense emotional responses to environmental triggers, and a slow return to a baseline emotional state. Affective instability is also characterized by drastic and rapid shifts from one emotion to another
-highly unstable self-image or sense of self. People with BPD often have chronic feelings of emptiness and have difficulty forming a sense of who they really are. They also struggle to cope with a highly negative self-concept and find it hard to tolerate being alone.
- highly unstable interpersonal relationships. These relationships tend to be intense but stormy, typically involving overidealizations of friends or lovers (or even therapists) that later end in bitter disillusionment, disappointment, and anger
rejection and BPD
people with BPD are very skilled at (accurately) detecting signs of anger in people’s faces. However, they also tend to misperceive anger when they are presented with neutral faces (Veague & Hooley, 2014). Perhaps because of their fear of rejection, individuals with BPD often “test” their close relationships. Any failure on the part of the other person then becomes evidence of rejection or imminent abandonment. Research supports a causal link between the perception of rejection and intense, uncontrollable rage in BPD
IMPulsivity and BPD/ gender difference
-Another important feature of BPD is impulsivity. This is not carefree spontaneity. Rather it is characterized by rapid responding to environmental triggers without thinking (or caring) about long-term consequences (Paris, 2007). These individuals’ high levels of impulsivity combined with their extreme affective instability often lead to erratic, self-destructive behaviors such as risky sexual behavior or reckless driving. Suicide attempts are also common. In community samples, almost one-quarter of people diagnosed with BPD report that they have made at least one suicide attempt
-most people who seek treatment are women = gender imbalance, in reality probably split
NSSI and BPD
Nonsuicidal self-injury (NSSI) involves deliberate damage to body tissue such as might occur with skin cutting or burning (Nock, 2009). This behavior (which is sometimes called self-mutilation) occurs in the absence of an intent to die (hence the term nonsuicidal). Self-mutilating behavior has long been listed in the DSM as a symptom of BPD. However, many people who engage in self-injury do not have BPD, although they do report high levels of depressive symptoms, anxiety, suicidality, and generally low levels of functioning
-NSSI is found in males and females, as well as in people of all ethnicities and economic backgrounds. The risk for NSSI seems to be greatest in the adolescent years, with lifetime prevalence rates around 17 percent
-? NSSI is often used to regulate negative emotions.
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BPD and comorbidity/ comorbidity with other personality disorders
- tends to be comorbid with both internalizing disorders (such as mood and anxiety disorders), as well as externalizing disorders (such as substance use disorders
- comorbidity with schizotypal, narcissistic, and dependent disorder is particularly high
how is BPD different from depressive disorders?
Although it was once suggested that BPD be regarded as a variant of mood disorder because of the high comorbidity between BPD and depression, the broad scope of other disorders that are comorbid with BPD suggests otherwise. Moreover, neuroimaging data indicate that BPD individuals show different neural responses to emotional stimuli than do individuals with chronic depression
causal factors BPD
-. In the most methodologically rigorous study to date, the risk of having a BPD diagnosis was found to be four times higher in the biological relatives of patients with BPD than it was in the relatives of people who did not have a diagnosis of BPD
-genes are important. Indeed, they may account for 40 percent of the variance in the disorder
-what is most likely inherited are genes that confer susceptibility to certain personality traits—traits such as neuroticism or impulsivity that are prominent aspects of BPD
- child maltreatment and other extreme early life experiences have long been linked to BPD. Importantly, two prospective community-based studies have shown that childhood adversity and maltreatment increases the risk of developing BPD in adulthood
- reasonable to suggest that some people, by virtue of their genetic predispositions, may be highly sensitive to the effects of negative early life experiences. These stressful early experiences may create long-term dysregulation of the HPA axis (which you learned about in Chapter 5) and shape brain development, perhaps compromising key brain circuits that are involved in emotion regulation
avoidant personality disorder
-show extreme social inhibition and introversion, leading to lifelong patterns of limited social relationships and reluctance to enter into social interactions.
-, they do not seek out other people. Yet they desire affection and are often lonely and bored. Unlike schizoid personalities, people with avoidant personality disorder do not enjoy their aloneness. Avoidant individuals want contact with other people. However, their inability to relate comfortably to other people causes them acute anxiety. They are painfully self-conscious in social settings and highly critical of themselves. Not surprisingly, avoidant personality disorder is often associated with depression
-Feeling inept and socially inadequate are the two most prevalent and stable features of avoidant personality disorder
difference between avoidant personality disorder and social anxiety
-Numerous studies have found substantial overlap between these two disorders, leading some investigators to conclude that avoidant personality disorder may simply be a somewhat more severe manifestation of generalized social anxiety disorder
-his is consistent with the finding that there are cases of social anxiety disorder without avoidant personality disorder but very few cases of avoidant personality disorder without social anxiety disorder. Somewhat higher levels of dysfunction and distress are also found in the individuals with avoidant personality disorder, including more consistent feelings of low self-esteem
Causes of avoidant
avoidant personality may have its origins in an innate “inhibited” temperament that leaves the infant and child shy and inhibited in novel and ambiguous situations. A large twin study in Norway has shown that traits prominent in avoidant personality disorder show a modest genetic influence, and that the genetic vulnerability for avoidant personality disorder is at least partially shared with that for social anxiety disorder
- fear of being negatively evaluated, which is prominent in avoidant personality disorder, is moderately heritable
-introversion and neuroticism are also both elevated (refer back to Table 10.2), and they too are moderately heritable. This genetically and biologically based inhibited temperament may often serve as the diathesis that leads to avoidant personality disorder in some children who experience emotional abuse, rejection, or humiliation from parents who are not particularly affectionate
dependent personality disorder clinical presentaton i
-show an extreme need to be taken care of, which leads to clinging and submissive behavior. They also show acute fear at the possibility of separation or sometimes of simply having to be alone because they see themselves as inept
-Such individuals usually build their lives around other people and subordinate their own needs and views to keep these people involved with them. Accordingly, they may be indiscriminate in their selection of mates. They often fail to get appropriately angry with others because of a fear of losing their support, which means that people with dependent personalities may remain in psychologically or physically abusive relationships.
MORE COMMENT IN WOMAN IN MEN: This gender difference is not due to a sex bias in making the diagnosis but rather to the higher prevalence in women of certain personality traits such as neuroticism and agreeableness, which are prominent in dependent personality disorder (
comorbidity of dependent with other personality diosorders
Comorbidity is also high between dependent personality disorder and other personality disorders, especially schizoid, avoidant, borderline, and histrionic personality disorder
difference between BPD and dependent’s fear of abandonment/ as well as histrionic
borderline personalities and dependent personalities fear abandonment. However, the borderline personality, who usually has intense and stormy relationships, reacts with feelings of emptiness or rage if abandonment occurs, whereas the dependent personality reacts initially with submissiveness and appeasement and then finally with an urgent seeking of a new relationship.
. Histrionic and dependent personalities both have strong needs for reassurance and approval, but the histrionic personality is much more gregarious, flamboyant, and actively demanding of attention, whereas the dependent personality is more docile and self-effacing.
difference between dependent and avoidant
-dependent personalities have great difficulty separating in relationships because they feel incompetent on their own and have a need to be taken care of, whereas avoidant personalities have trouble initiating relationships because they fear the humiliation they will experience if they are criticized or rejected
causes dependent
-variance in dependent personality disorder symptoms might be attributable to genetic factors
-It is possible that people with these partially genetically based predispositions to dependence and anxiousness may be especially prone to the adverse effects of parents who are authoritarian and overprotective (not promoting autonomy and individuation in their child but instead reinforcing dependent behavior). This might lead children to believe that they must rely on others for their own well-being and are incompetent on their own
- Cognitive theorists describe the underlying maladaptive schemas for these individuals as involving core beliefs about weakness and competence and needing others to survive, such as “I am completely helpless” and “I can function only if I have access to somebody competent”
Obsessive-Compulsive Personality Disorder clinical presentation
Perfectionism and an excessive concern with orderliness and control characterize individuals with obsessive-compulsive personality disorder (OCPD)
- preoccupation with maintaining mental and interpersonal control occurs in part through careful attention to rules, order, and schedules. They are very careful in what they do so as not to make mistakes, but because the details they are preoccupied with are often trivial they use their time poorly and have a difficult time seeing the larger picture
- rigidity, stubbornness, and perfectionism, as well as reluctance to delegate, are the most prevalent and stable features of OCPD
-Although the name sounds similar, people with OCPD do not have true obsessions or compulsive rituals as is the case with obsessive-compulsive disorder (OCD; see Chapter 6). Indeed, only about 20 percent of patients with OCD have a comorbid diagnosis of OCPD. This is not significantly different from the rate of OCPD in patients with panic disorder
OCPD asnd gender diofferences/ five factor model
-slightly more common in men than women
-Theorists who take a five-factor dimensional approach to understanding OCPD note that these individuals have excessively high levels of conscientiousness (Samuel & Widiger, 2011). This leads to extreme devotion to work, perfectionism, and excessive controlling behavior
=nother influential biological dimensional approach—that of Cloninger (1987)—posits three primary dimensions of personality: novelty seeking, reward dependence, and harm avoidance. Individuals with obsessive-compulsive personalities have low levels of novelty seeking (i.e., they avoid change) and reward dependence (i.e., they work excessively at the expense of pleasurable pursuits) but high levels of harm avoidance (i.e., they respond strongly to aversive stimuli and try to avoid them). Research has also demonstrated that the OCPD traits show a modest genetic influence
personality variance across vs within cultures
less variance across cultures than within cultures.
may be related to findings that all cultures (both Western and non-Western, including Africa and Asia) share the same five basic personality traits discussed earlier, and their patterns of covariation also seem universal
histrionic and asian vs hispanics
histrionic personality might be expected to be (and is) less common in Asian cultures, where sexual seductiveness and drawing attention to oneself are frowned on; by contrast, it may be higher in Hispanic cultures, where such tendencies are common and well tolerated
- higher rates of histrionic personality disorder in African American women relative to Caucasian women
NPD and western culture
more common in Western cultures, where personal ambition and success are encouraged and reinforced
therapist responses to various personality disorders
Research suggests that therapists tend to feel nurturing and protective toward patients with avoidant and dependent personality disorders. However, patients with obsessive personality disorder create feelings of annoyance and boredom in their therapists
cognitive therapy for personality disorders
Cognitive therapy for personality disorders assumes that the dysfunctional feelings and behaviors associated with the personality disorders are largely the result of schemas (styles of thinking) that tend to produce consistently biased judgments, as well as tendencies to make cognitive errors
Changing these underlying dysfunctional schemas is difficult but is at the heart of cognitive therapy for personality disorders. Cognitive approaches use techniques such as monitoring automatic thoughts, challenging faulty logic, and assigning behavioral tasks in an effort to challenge the patient’s dysfunctional beliefs. Table 10.3 provides examples of some of the central beliefs associated with different personality disorders.
BPD TREATMENT with DBT
Dialectical behavior therapy (DBT) developed by Marsha Linehan, is a unique kind of cognitive and behavioral therapy specifically adapted for BPD (Linehan, 1993; Lynch & Cuper, 2012; Neacsiu & Linehan, 2014). Linehan (who, as described in The World Around Us box, once struggled with BPD herself) believes that patients’ inability to tolerate strong states of negative affect is central to this disorder. One of the primary goals of treatment is to encourage patients to accept this negative affect without engaging in self-destructive or other maladaptive behaviors. Accordingly, Linehan has developed a problem-focused treatment based on a clear hierarchy of goals, which prioritizes decreasing suicidal and self-injurious behavior and increasing coping skills. The therapy combines individual and group components as well as phone coaching. In the group setting, patients learn interpersonal effectiveness, emotion regulation, and distress tolerance skills. The individual therapist, in turn, uses therapy sessions and phone coaching to help the patient identify and change problematic behavior patterns and apply newly learned skills effectively.
Marsha Linehan
the developer of dialectical behavior therapy, has acknowledged her own experiences with mental illness ( Because of her courageous disclosure, Linehan has become a real-life example of how BPD can be overcome. In revealing her own fight with mental illness, she has given all people with BPD a new reason to have hope.
DBT and longeterm benefits for BPD vs other forms of treatment
Dialectical behavior therapy (DBT) appears to be an efficacious treatment for BPD. However, a recent meta-analysis suggests that the treatment gains are smaller than one might hope compared to routine treatment (Cristea et al., 2017). This may be because routine treatment for BPD has improved over time, making the differences between treatment as usual and DBT less marked. There are still not enough randomized controlled trials to say whether DBT works as well in men as in women, and whether it works well with minority patients
psycodynamic psycotherapy and BPD treatment/ transference-focused psycotherapy
The primary goal is seen as strengthening the weak egos of individuals, with a particular focus on their primary primitive defense mechanism of splitting. This leads them to black-and-white, all-or-none thinking, as well as to rapid shifts in their reactions to themselves and to other people (including the therapist) as “all good” or “all bad.” One major goal is to help patients see the shades of gray between these extremes and integrate positive and negative views of themselves and others into more nuanced views. Although this treatment is often expensive and time consuming (often lasting a number of years), it has been shown in at least one study to be as effective as DBT, which is regarded as the most established, effective treatment
mentalization and BPD
. This uses the therapeutic relationship to help patients develop the skills they need to accurately understand their own feelings and emotions, as well as the feelings and emotions of others
biological treatment BPD
Drugs are often used in the treatment of BPD. Indeed, many patients with BPD are taking multiple medications. Yet there is little evidence to support their use (Bateman et al., 2015). Antidepressant medications (most often from the selective serotonin reuptake inhibitors [SSRI] category) are widely used, although there is no compelling evidence that they are effective. They are most appropriate only when patients have a comorbid mood disorder (Silk & Feurino, 2012). Some second-generation antipsychotic medications (such as aripiprazole and olanzapine) and mood stabilizers (such as topiramate, valproate, and lamotrigine) may slightly reduce symptoms over the short term
pharmeceutical treatments for schizotypal personality disorder
low doses of antipsychotic drugs (including the newer, atypical antipsychotics; e.g., Keshavan et al., 2004; Koenigsberg et al., 2007; Raine, 2006) may result in modest improvements. Antidepressants from the SSRI category may also be useful. However, no treatment has yet produced anything approaching a cure for most people with this disorder
short term inpatient therapy for cluster c
hort-term inpatient treatment for Cluster C personality disorders is even more effective than long-term inpatient or outpatient therapy
avoidant personality disoreder and meds
Antidepressants from the monoamine oxidase inhibitor (MAOI) and SSRI categories may also sometimes help in the treatment of avoidant personality disorder, just as they do in closely related social anxiety disorder
psychopathy and its 4 dimensions
-This syndrome was first identified in the nineteenth century when terms such as manie sans delire (insanity without delirium), moral weakness, or moral insanity were used to describe it
-much less common in women; men = 2%, women under 1%
. The interpersonal dimension reflects a personality style that is characterized by glibness/superficial charm, a grandiose sense of self-worth, pathological lying, and the conning manipulation of others.
1b. The affective dimension reflects traits such as lack of remorse or guilt, callousness/lack of empathy, shallow affect, and a failure to accept responsibility for one’s behavior.
2a. The lifestyle dimension reflects a need for stimulation, a tendency to be easily bored, impulsivity, irresponsibility, a lack of reasonable long-term goals, as well as a parasitic lifestyle.
2b. Finally, the antisocial dimension reflects the aspects of psychopathy that involve poor behavior controls, early behavior problems, delinquency, and criminality.
PCL-R checklist
This provides a way for clinicians and researchers to diagnose psychopathy on the basis of the Cleckley criteria following a detailed interview and careful checking of past school, police, and prison records. The measure is widely used in forensic assessments.
diagnosis of ASPD VS PSYCOAPTHY
a significant number of inmates show the antisocial and aggressive behaviors necessary for a diagnosis of ASPD but do not show enough selfish, callous, and exploitative behaviors to qualify for a diagnosis of psychopathy.; ASPD much more common
psycopathy diagnosis as a predictor of criminal behavior
many researchers continue to use the Cleckley/Hare psychopathy diagnosis rather than the DSM ASPD diagnosis, not only because of the long and rich research tradition on psychopathy but also because the psychopathy diagnosis has been shown to be a better predictor of a variety of important facets of criminal behavior than the ASPD diagnosis
= diagnosis of psychopathy appears to be the single best predictor of violence and recidivism (offending again after imprisonment;
what about psycopaths wh don’t get caught?/ successful vs unsuccessful psycopaths
- Cleckley did not believe that aggressive behavior was central to the concept of psychopathy: doesn’t have to be
The results indicated that successful psychopaths (who had committed approximately the same number and type of crimes as the unsuccessful psychopaths, although they had never been convicted) showed greater heart rate reactivity under stress than the controls or the unsuccessful psychopaths did. One possibility raised by these findings is that the increased cardiac reactivity of the successful psychopaths may serve them well in processing what is going on in risky situations and perhaps facilitate them making decisions that may prevent their being caught. In another study using the same recruitment strategy, Raine and his colleagues found evidence to support the idea that successful psychopaths may have more intact information processing than unsuccessful psychopaths
psycopathy and brain structure
-Deficits in the prefrontal cortex (which is involved in behavioral control and decision making) as well as the amygdala (which is a key brain area for emotion and fear conditioning) are thought to play a role in some of the behavioral and emotional disturbances linked to psychopathy
-Unsuccessful psychopaths, however, seem to have more pronounced defects in these areas than successful psychopaths or healthy controls ^^
-. Deficits in the amygdala may be linked to problems with fear conditioning (which, as you will soon learn, is impaired in psychopaths), as well as disruptions in moral development and socialization.
corporate samples psycopathy
Taken together, the results of this study suggest that rates of psychopathy may be higher in corporate samples (4 percent) than they are in community samples (1 percent) although not as high as they are in male offenders (15 percent). They further suggest that some psychopathic individuals are able to rise high in the corporate world even in the face of negative performance reviews and poor management skills.
-t psychopathic traits such as charm and grandiosity might be mistaken for leadership skills and vision. Similarly, lack of empathy or remorse could be viewed as being cool under fire or able to make tough and unpopular decisions
major charachetristics of psycopaths
-Inadequate Conscience Development: Psychopaths appear unable to understand and accept ethical values except on a verbal level. They may glibly claim to adhere to high moral standards that have no apparent connection with their behavior. In short, their conscience development is severely retarded or nonexistent, and they behave as though social regulations and laws do not apply to them
-Irresponsible and Impulsive Behavior: Psychopaths learn to take rather than earn what they want. Prone to thrill seeking and deviant and unconventional behavior, they often break the law impulsively and without regard for the consequences. They seldom forgo immediate pleasure for future gains and long-range goals. These aspects of psychopathy are most closely related to the lifestyle and antisocial dimensions of psychopathy: Many studies have shown that antisocial personalities and some psychopaths have high rates of alcohol abuse and dependence and other substance abuse/dependence disorders
-Ability to Impress and Exploit Others: some psychopaths are superficially charming and likable, with a disarming manner that easily wins them new friends; Not surprisingly, then, psychopaths are seldom able to keep close friends. They seemingly cannot understand love in others or give it in return. Manipulative, exploitative, and sometimes coercive in sexual relationships, psychopaths are irresponsible and unfaithful partners.
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causal factors in psycopathy
-Until fairly recently, most behavior genetic research focused on genetic and environmental influences on antisocial behavior or criminality rather than on psychopathy itself. However, several strong studies have now demonstrated that psychopathy and some of its important features also show considerable heritability
-arly signs of callous/unemotional traits in these children were highly heritable (Viding et al., 2005). Moreover, children with these disturbing traits also receive high levels of negative parenting (such as parental anger and frustration). This suggests the possibility that callous and emotional traits in young children may provoke the kind of reactions in parents that may further increase risk for future antisocial behavior
- 43 and 56 percent of the variance in the dimensions of psychopathy is attributable to genetic factors, with the remaining variance being explained more by nonshared environmental influences rather than by shared environmental factors
fearlessness and impaired fear conditioning psycopaths
-Research indicates that psychopaths who are high on the dimensions of the first factor and who are egocentric, callous, and exploitative have low trait anxiety and show poor conditioning of fear
-psychopaths showed deficient conditioning of skin conductance responses (reflecting activation of the sympathetic nervous system) when anticipating an unpleasant or painful event and that they were slow at learning to stop responding in order to avoid punishment. As a result, psychopaths presumably fail to acquire many of the conditioned reactions essential to normal passive avoidance of punishment, to conscience development, and to socialization
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fear potentiated startle and psycopaths
Other interesting work concerns the startle response. Both humans and animals show a larger startle response if a startle probe stimulus (such as a loud noise) is presented when the subject is already in an anxious state. This is known as fear-potentiated startle. Comparing psychopathic and nonpsychopathic prisoners, Patrick and colleagues (1993) found that the psychopaths did not show this effect, although nonpsychopathic prisoners did.
selective attention and psycopathy
-people with psychopathy have abnormalities in their selective attention. These attention processing deficits make them unable to consider the kind of contextual information that would provide a broader perspective and allow them to modulate their behavior. In other words, when they are engaged in goal-directed behavior, there is an attention bottleneck and multiple channels of information (including affective information such as fear, or other cues that might be relevant) are not processed. All that matters is the single-minded pursuit of the goal.
General Emotional Deficits and psycopathy
pain of others and reward psycopaths
When they imagined pain in themselves, the inmates who scored high on psychopathy showed a typical response in brain areas involved in empathy for pain processing including the anterior insula and the amygdala. In contrast, when they imagined the pain of another person, activation in these areas was diminished. What was also interesting (and rather chilling) was that the psychopaths who scored highest on Factor 1 of the PCL (interpersonal and affective dimensions) actually showed an increase in activation in the ventral striatum when they were asked to take the imagine-other (as opposed to the imagine-self) perspective. This is a brain area involved in the anticipation of reward. One interpretation of these findings is that psychopaths are not only less affected by distress in others but that they find the idea of others experiencing pain to be pleasing in some way.
two different dfimensions of child temperment that may be implicated in ASPD
Some children have great difficulty learning to regulate their emotions and show high levels of emotional reactivity, including aggressive and antisocial behaviors when responding to stressful demands and negative emotions like frustration and anger. Such children are at increased risk for developing ASPD and high scores on the antisocial dimension of psychopathy. But other children may have few problems regulating negative emotions, instead showing fearlessness and low anxiety as well as callous/unemotional traits and reduced amygdala activation while responding to fearful facial expressions (e.g., Marsh et al., 2008). These are the children most likely to show poor development of conscience, and their aggressive behaviors are more instrumental and premeditated rather than reactive as seen with those children who have emotional regulation difficulties. These latter children are likely to develop high scores on the first, interpersonal affective core of psychopathy, leading to the cold, remorseless psychopaths who show low fear and lack of empathy.
differences in cross cultural manifestations of psycopathy
-They are found in all socioeconomic groups, races, ethnicities, and cultures
-Regarding different cross-cultural manifestations of the disorder, one of the primary symptoms where cultural variations occur is the frequency of aggressive and violent behavior. Socialization forces have an enormous impact on the expression of aggressive impulses. Thus, it is not surprising that in some cultures, such as China, psychopaths may be much less likely to engage in aggressive, especially violent, behavior than they are in most Western cultures (Cooke, 1996). By contrast, cross-cultural studies have indicated that the affective-interpersonal dimension of psychopathy is the most consistent across cultures
individualist culture and psycopathy
Competitiveness, self-confidence, and independence from others are emphasized in relatively individualistic societies, whereas contributions and subservience to the social group, acceptance of authority, and stability of relationships are encouraged in relatively collectivist societies (Cooke, 1996; Cooke & Michie, 1999). Thus, we would expect individualistic societies (such as in the United States) to be more likely to promote some of the behavioral characteristics that, carried to the extreme, result in psychopathy. These characteristics include “grandiosity, glibness and superficiality, promiscuity … as well as a lack of responsibility for others. … The competitiveness … not only produces higher rates of criminal behavior but also leads to an increased use of … deceptive, manipulative, and parasitic behavior” (Cooke & Michie, 1999, p. 65). Although the evidence bearing on this is minimal, it is interesting to note that estimates of the prevalence of ASPD are much lower in Taiwan, a relatively collectivist society, than they are in the United States
psycopaths and treatment programs
- few studies have found that treatments that work for other criminal offenders can actually be harmful for psychopaths in that rates of reoffending increase rather than decrease (Harris & Rice, 2006). This may be especially likely to occur if the treatment program emphasizes training in social skills or empathy because such skills may simply make them better at charming or conning future victims
CBT and psycopaths
Common targets of these interventions include the following: (1) increasing self-control, self-critical thinking, and social perspective taking; (2) increasing victim awareness; (3) teaching anger management; (4) changing antisocial attitudes; and (5) curing drug addiction.
-Even the best of these multifaceted, cognitive-behaviorally oriented treatment programs generally produce only modest changes, although they are somewhat more effective in treating young offenders (teenagers) than older offenders, who are often hard-core, lifelong psychopaths
cognitive remediation and psycopathy
-In the active treatment condition, inmates practiced attending to non-salient or peripheral cues and were taught to notice changes in contextual information such as rule changes.
-At the end of the study, inmates who had received the attentional training showed clear improvement on tasks that assessed response modulation. This suggests that such approaches might work. Of course, we have no way of knowing from this study whether this will have any impact on psychopathic behavior. Nonetheless, cognitive remediation methods offer a much needed novel treatment direction.
“burned out psycopaths”
Also, fortunately, the criminal activities of many psychopathic and antisocial personalities seem to decline after the age of 40 even without treatment, possibly because of weaker biological drives, better insight into self-defeating behaviors, and the cumulative effects of social conditioning. Such individuals are often referred to as “burned-out psychopaths.” Although there is not a great deal of evidence on this issue (Douglas et al., 2006), one important study that followed a group of male psychopaths over many years found a clear and dramatic reduction in levels of criminal behavior after age 40.
