Chap 13: Personality Disorders

Question 1

How were PDs listed in early DSMs?

How did this change in DSM-V?

Answer 1

In DSM-III, reliability for PDs was improved. They were placed on Axis II. This axis was removed in DSM-V.

Question 2

What are Millon’s 3 criteria for distinguishing disordered personality?

Answer 2

Millon identifies 3 key criteria that help distinguish normal vs. disordered personality. 1. Disordered personality is rigid and inflexible behaviour. They have difficulty altering their behaviour. 2. They engage in self-defeating behavior that fosters vicious cycles. Behaviours and cognitions perpetuate and exacerbate existing conditions. 3. Structural instability - fragility to self that cracks under stress.
- criteria that distinguish normal versus disordered personality: rigid and flexible, self defeating, vicious cycle that perpetuate troubled ways of thinking and behaving, structural instability, fragility, cracking under stress.

Question 3

What are the 3 life tasks that the personality is supposed to perform according to Livesley et al?

Answer 3

Livesley et identified 3 life tasks that the personality should be able to perform regardless of personality type our ego needs to . 1. To form stable, integrated and coherent representations of self and others. 2. Develop capacity for intimacy and positive affiliations with others. 3. To function adaptively in society by engaging in prosocial and cooperative behaviors. PDs form when there is a failure in these traits.

Question 4

What is the DSM-V Criteria for General Personality Disorder?

Answer 4

DSM-V categorical approach for diagnosing general PDs remains. A. Pattern of inner experience and behaviour deviating from cultural expectations. Manifests in 2+ areas: 1. Cognition, 2. Affectivity, 3. Interpersonal functioning. 4. Impulse control. B. The pattern is inflexible and varied. C. The pattern causes clinically significant distress or impairment D. The pattern is stable and of long duration with onset traced back to adolescence or early adulthood. E. The pattern is not better explained as a manifestation of another mental disorder. F. The pattern is not attributable to drugs or another medical condition.

Question 5

What is the Alternative Model for PDs (AMPD) in the DSM-5?

Answer 5

The Alternative Model for PDs in DSM-5 (AMPD): Criteria A assesses levels of personality functioning according to two themes: 1) self and 2) interpersonal. B involves rating person across 5 board trait dimensions: negative affectivity, detachment, antagonism, disinhibition and psychoticism

Question 6

What personality dimensions do McCrae and Costa have?

Answer 6

McCrae and Costa note 5 factors of personality: neuroticism, extroversion/introversion, openness to experience, agreeableness/antagonism and conscientiousness.

Question 7

What is Livesley and Jackson’s self report scale?

Answer 7

Livesley and Jacksons self-report scale - Dimensional Assessment of Personality Pathology Basic Questionnaire = 22 scales that assess 18 personality trait dimensions and response types.

Question 8

What is a problem of the categorical approach?

Answer 8

The categorical approach is problematic because of low stability of PD diagnosis, test-retest reliability. And it is difficult to diagnose a single specific PD.

Question 9

What does ‘PDs are egosyntonic’ mean for assessing them? What is a solution to this?

Answer 9

Many PDs are egosyntonic - person is unaware there is a problem - may not have personal distress. Assessment and diagnosis of PDs are better with significant others become informants.

Question 10

Do most clients have general PDs and don’t fit into specific PD diagnoses?

Answer 10

Most clients also have a general PD but do not fit into specific PD categories.

Question 11

What is MMPI-2 used for in terms of PDs?

Answer 11

The MMPI-2 assesses 5 dimensional personality constructs. This is the PSY-5 consisting of dimensions assessing negative emotionality/neuroticism, lack of positive emotionality, aggressiveness, lack of constraint and psychoticism.

Question 12

What is the Millon Clinical Multiaxial Inventory?

How does the MCMI-II facilitate Millon and Grossmans treatment approach?

Answer 12

The most widely used measure is Millon Clinical Multiaxial Inventory - 4th edition - 195 item T/F inventory at a 5th grade reading level revised to parallel DSM-V. The MCMI-IV has subscale measures of 15 PD scales including 12 clinical personality patterns (schizoid, avoidant, melancholic, dependent, histrionic, turbulent, narcissistic, anti-social sadistic, compulsive, negativistic and masochistic and 3 severe personality pathology scales (schizotypal, borderline and paranoid). Has 10 clinical syndrome scales and 5 validity scales - 2 detect random responses. Updated version was modified to include therapy guiding facet scales - Grossman Facet Scales. These scales facilitate Millon and Grossman’s treatment personalized therapy - recognizing each persons unique needs and personality styles.

Question 13

What are two issues with self-report measures for PDs?

Answer 13

Two issues involving self-report measures of PD: 1. Various measures differ in content and are not equivalent. 2. General concern involving self-report measures, including PD measures is the cut-off points used with self-report responses to determine presence of PD often overestimate number of people who meet diagnostic criteria.

Question 14

What PDs are common among university/college students?

Answer 14

Most common PDs in university/college students: obsessive-compulsive PD and paranoid PD + epidemic of narcissism.

Question 15

What are the 3 clusters PDs are grouped into?

Answer 15

Three general clusters of PDs: Odd (Cluster A): paranoid, schizoid, schizotypal. Dramatic (Cluster B): narcissistic, antisocial, borderline, histrionic. Anxious (cluster C): avoidant, dependant, obsessive-compulsive.

Question 16

Briefly describe the odd type PDs

Answer 16

Paranoid - excessive suspicion/distrust
Schizoid - social avoidance, aloof/introverted
Schizotypal - social avoidance, strange cognitive/perceptions.

Question 17

Briefly describe the dramatic type PDs

Answer 17

Narcissistic - self-absorbed, overconfident
Antisocial - deceitful, controlling
Borderline - relationship difficulties, neuroticism (emotional instability)
Histrionic - egocentric/dramatic, excessively strong emotions,

Question 18

Briefly describe the anxious type PDs

Answer 18

Avoidant - relationship difficulties, affect is highly reactive.
Dependent - clingy in relationships, self-critical, high anxiety.
Obsessive/Compulsive - controlling, little desire to resist compulsions.

Question 19

How to determine if a person has an abnormal personality using the 3 D’s

Answer 19

Deviant: extreme end of personality metric, counter-culture, instability. Distress - I dont like me, they don’t like me. Dysfunction - its not working for me. Danger - risk taking.

Question 20

What are 3 ways of clinically assessing PDs?

Answer 20

1. Clinical Interview - many personality disorders are egosyntonic, person lacks insight.
2. MMPI - good prediction of paranoid, schizotypal, narcissistic and anti-social PD symptoms.
3. Millon Clinical Multiaxial Inventory (MCMI)-IV - measures 15 clinical personality scales (schizoid, avoidant, melancholic, dependent, histrionic, turbulent, narcissistic, antisocial, sadistic, compulsive, negativistic and masochistic). And 3 severe personality pathology scales (schizotypal, borderline and paranoid).

Question 21

What is the Meyer-Briggs Types Indicator? Enneagrams? Costa-McRae big five? Horn Catell?

Answer 21

Meyers-Briggs Types Indicator (MBTI) - 4 continuums: I/E, S/N, T/F, J/P. Riso-Hudson (Enneagram): 9 types, based on Sufi mysticism. Costa-McRae (Big Five) - O C E A N. Horn-Cattell (16PF) - 16 factors, some clinical applications.

Question 22

Describe paranoid PD

Answer 22

Characteristics: suspicious of others, expect to be mistreated or exploited by others, reluctant to confide in others, tend to blame others, can be extremely jealous. Prevalence: most frequently in men. Differential diagnosis and comorbidity: hallucinations and full-blown delusions not present, less impairment in social and occupational functioning than paranoid schizophrenia, comorbid with other odd types + avoidant PD.

Question 23

Describe Schizoid PD

Answer 23

Characteristics: no desire for enjoyment of social relationships, appear dull bland and aloof, rarely report strong emotions, no interest in sex or pleasure, indifferent to praise and criticism, loners with solitary interests. Prevalence and Comorbidity: Prevalence < 1%, slightly more common in men, comorbid with other odd types + avoidant PD.

Question 24

Describe schizotypal PD

Answer 24

Characteristics: similar interpersonal difficulties (social detachment and restricted affect) of schizoid. Eccentric thinking (identical to prodromal and residual phases of schizophrenia), odd beliefs or magical thinking, recurrent illusions, odd speech, ideas of reference (misinterpret event as having particular personal meaning), suspiciousness, paranoid ideation, eccentric behaviour and appearance. Prevalence and Comorbidity: 3%, slightly more frequent among men, comorbidity higher than any other personality disorder, comorbid with borderline, avoidant and paranoid personality disorder.

Question 25

What is the etiology of the odd/eccentric cluster?

Answer 25

Based on family study research, possible genetic links to schizophrenia, could be linked to a history of PTSD and childhood maltreatment.

Question 26

Describe narcissistic PD

Answer 26

Characteristics: Grandiose view of own uniqueness and abilities, preoccupied with fantasies of great success, require almost constant attention and excessive admiration, lack empathy, envious of others, arrogant exploitive and entitled. Prevalence and Comorbidity: <1%, comorbid with BPD. Etiology: Khut view of emerging self: immature grandiosity and dependent over-idealization of others - failure to develop healthy self-esteem, product of our times and system of values?

Question 27

What is pathological narcissism? Dark Triad of Narcissism?

Answer 27

Pathological Narcissism (Pincus et al.): Seven components of pathological narcissism: 4 factors assess narcissistic grandiosity (entitlement rage, exploitativeness, grandiose fantasy and self-entitlement). 3 factors assess narcissistic vulnerability (contingent self-esteem, hiding the self and devaluing). 
Dark Triad of Narcissism (Paulhus and Williams): The dark triad consists of combination of narcissism, psychopathy and Machiavellianism, additional dimension added - sadism.

Question 28

Describe antisocial PD

Answer 28

Two main components in DSM-V; Conduct disorder present before age 15 and pattern of antisocial behaviour continues into adulthood (irresponsible and antisocial behaviour, work only inconsistently, break laws, physically aggressive. Comorbid with substance use, 1-4% prevalence.

Question 29

Describe psychopathy?

Answer 29

Psychopathy is related to APD but emphasizes psychological not just behavioural aspects - lack of remorse, no sense of shame, superficially charming, manipulates others for own personal gain, exploits people, thrill seeking. All psychopaths are diagnosed with APD but many with APD do not have psychopathy. Hare (1996) - kills who were not simply persistently antisocial, they were remoresless predators, used charm, intimidation and cold-blooded violence to achieve their ends. 20% of people with APD score high on Hare Psychopathy Checklist. 75-80% of convicted felons meet criteria for APD but only 15-25% meet criteria for psychopathy.
See notes for Hare psychopathology checklist

Question 30

Describe BPD

Answer 30

Characteristics: Term - borderline between neurosis and schizophrenia but DSM no longer has this. Core features of BPD: impulsivity and instability in relationships, mood and self-image, attitudes and feelings toward others vary dramatically, emotions are erratic and can shift abruptly, argumentative, irritable,sarcastic and quick to take offence. Prevalence and Comorbidity: 1-2%, more common in woman, comorbid with mood disorder, substance abuse, PTSD, eating disorders and Cluster A PDs.
Etiology of BPD: Object-relations theory - inconsistent parental love causes insecure ego development. Biological factors - runs in families, dysfunction in dorsolateral prefrontal and limbic brain regions. Linehan’s diathesis-stress theory: See notes

Question 31

Describe histrionic PD

Answer 31

Characteristics: overly dramatic and attention-seeking, use physical appearance to draw attention, display emotion extravagantly, self-centered, overly concerned with their attractiveness, inappropriately sexually provocative and seductive, speech may be impressionistic and lacking in detail. Prevalence and Comorbidity: 2-3%, more common among women, comorbid with depression and BPD. Etiology: psychoanalytic theory: seductiveness encouraged by parental upbringing. Family environment - talked about sex as dirty bbut behaved as if exciting.

Question 32

Describe avoidant PD

Answer 32

Characteristics: fearful in social situations, sensitive to possibility of criticism, rejection or disapproval, reluctant to enter relationships unless sure will be liked, associated with higher levels of life impairment compared with other personality disorders, one of most prevalent personality disorders. Prevalence and comorbidity: 2%, comorbid with dependent personality disorder, depression and generalized social phobia.

Question 33

Describe dependent PD

Answer 33

Characteristics: lack self-reliance, overly dependent on others, intense need to be taken care of, uncomfortable when alone, subordinate own needs. Comorbid with bipolar disorder, depression, anxiety disorders and bulimia. Culture-laden? Connecting with others is more valued in collectivistic cultures (East Asia) compared with North American individualism.

Question 34

Describe obsessive compulsive PD

Answer 34

Characteristics: perfectionistic approach to life, preoccupied with details, rules, schedules etc, serious , rigid, formal and inflexible, unable to discard worn out and useless objects. Differential diagnosis - OCPD does not have obsessions and compulsions that define OCD. Comorbidity: Comorbid with OCD (20%), panic disorder, depression and avoidant personality disorder.

Question 35

What is the etiology of the anxious type cluster?

Answer 35

Not much known about causes, speculation about causes focuses on parent-child attachment relationships, psychoanalytic theories: OCPD traits due to fixation at anal stage.

Question 36

What is a general therapy for PDs?

Answer 36

schema therapy for PD uses CBT to examine logical errors and dysfunctional attitudes.

Question 37

What are some therapies for BPD? (2 main)

Answer 37

individuals with BPD have trouble establishing trust, alternatively idealize then vilify therapist.
Two main therapy approaches are used for BPD: 1. Object relations therapy for BPD - strengthening clients weak ego, reducing splitting, combines client-centred acceptance with a cognitive-behavioral focus. 2. Dialectical behavior therapy (DBT) for BPD - challenge dichotomous (black and white) thinking, teach assertiveness and emotion regulation.

Question 38

What is therapy for psychopathy?

Answer 38

Psychopathy is virtually impossible to treat, they do not benefit from psychotherapy, unable to form trusting honest relationships with therapists, biological treatments are also mainly ineffective - large doses of anti-anxiety medication are used to reduce hostility.

Question 39

What are some challenges in treating PDs?

Answer 39

Challenges for treating PDs: person has long-standing vulnerabilities related to their self-concept and sense of personal identity, characteristic interpersonal tendencies that likely transfer to therapy context, along with interpersonal expectations and preconceptions, they often have 1+ disorders of a more episodic nature and these are often why people with PDs enter into treatment. People who have a PD along with other disorders tend not to show as much improvement after various forms of psychotherapy as they are more serious disturbed. As a result, may require therapy that is more intensive and extensive (focusing on broad range of disorders).

Question 40

How do psychodynamic therapies treat PDs?

Answer 40

Psychodynamic therapists aim to alter PD persons present-day views of childhood problems assumed to underlie personality disorder.

Question 41

How do behavioral and cognitive therapists treat PDs?

Answer 41

Behavioural and cognitive therapists tend to analyze the individual problems that taken together reflect a PD. Cognitive therapy for PDs: Beck, Freeman et al. - each disorder can be analyzed in terms of logical errors and dysfunctional schemata. Persuade client to accept that feelings and behaviours are primarily function of thoughts. Errors in logic are then explored. The therapist may look for dysfunctional assumptions or schemata that may underlie persons thoughts and feelings. Young - schema therapy for PDs. - identified a range of cognitive schemas measured by Young Schema Questionnaire (YSQ) believed to underlie various forms of dysfunction, including PD. The YSQ taps 3 broad themes 1) disconnection and rejection. 2)impaired autonomy and performance and 3) impaired limits. Each theme is tapped by several subscale factors ie. disconnection and rejection theme is assessed by abandonment/instability etc. Schema therapy can be adapted to main themes inherent in particular PD. Schema therapy for BPS involves 3 phases of treatment 1) bonding between client and therapist and emotional regulation 2) schema mode change and 3) development of autonomy. It takes place across 50 sessions. It is effective.

Question 42

What is hard about treating BPD?

Answer 42

With BPD client, trust is difficult - handicapping therapeutic relationship. The person alternately idealizes and vilifies therapist, imploring for understanding and support but insisting certain topics are off-limits. A number of drugs have been tried in pharmacotherapy of BPD, most notably antidepressants and antipsychotic medication. There is little to recommend antidepressants but antipsychotics show some modest effects on anxiety, suicidality and psychotic symptoms. Drugs are often abused and suicide is a risk, extreme caution must be used and drug treatmetns for BPD are not very effective.
Specific psychotherapy approaches applied to BPD - establishing the effectiveness of psychotherapeutic interventions was a game changer. It was noted people with BPD find it difficult to access treatment due to limited availability of therapists trained in treatment of BPD and long-standing negative beliefs about the difficultness of people with BPD and fact interventions are lengthy and resource intensive.

Question 43

What is object relations psychotherapy for BPD?

Answer 43

Object-Relations Psychotherapy - focuses on how children identify with people to whom they have strong emotional attachments.

Question 44

What is Kernberg’s modified analytical treatment for BPD?

Answer 44

Kernberg operates from assumption that borderline personalities have weak egos and therefore have inordinate difficulty tolerating the probing that occurs in psychoanalytic treatment. Kernberg’s modified analytic treatment has the overall goal of strengthening the persons weak ego so they do not fall prey to splitting or dichotomizing. Splitting is result of inability to form complex ideas that do not fit a simple good-bad dichotomy. The therapist employs interpretive techniques, pointing out how emotions and behaviours are being regulated by such defences as splitting. His approach is more directive than most. In addition to interpreting defensive behaviour, he gives concrete suggestions for behaving more adaptively and will hospitalize people whose behaviour becomes dangerous to themselves or others. He believes such people are unsuitable for classical psychoanalysis because of their weak egos.

Question 45

What is dialectical Behaviour therapy?

Answer 45

Linehan’s personal account focused on developing a sense of personal acceptance - approach combines client-centred empathy and acceptance with cognitive behavioural problem solving and social skills training. Dialectical behaviour therapy (DBT) has 3 overall goals for BPD - that they learn to 1. Modulate and control their extreme emotionality and behaviours, 2. Tolerate feeling distressed and 3. Trust their own thoughts and emotions. The concept of dialectics comes from Hegel - worldview that holds that reality is an outcome of constant tension between opposites. Any event - thesis - tends to generate a force in opposition to it - antithesis. The tension between opposites is resolved by creation of new event, the synthesis. She uses it to describe the paradoxical stance that the therapist must take with people with BPD - accepting each as they are and helping them change. Uses the term to refer to the borderline persons realization that they need not split the world into black and white but can achieve a synthesis of apparent opposites. DBT centres on therapists full acceptance of borderline personalities with all their contradictions and acting out, empathetically validating their beliefs with a matter-of-fact attitude toward their suicidal and other dysfunctional behaviour. The cognitive-behavioural aspect of the treatment, conducted individually and in groups involves helping clients learn to solve problems, acquire more effective and socially acceptable ways of handling daily living problems and control their emotions. Work is done on improving interpersonal skills and controlling their anger and anxieties. After many months of intensive treatment, limits are set on their behaviour, consistent with what Kernberg advocates. DBT is CBT within paradoxical context of validating and accepting the person for who they are.