Chapter 12

Question 1

Personality Disorders (PD)

Answer 1

represents patterns of behaviour
- individuals with PD consistently show maladaptive, inflexible, and restricted ways of behaving, feeling and thinking

Personality disorders = Egosyntonic (comes naturally to them) (vs egodystonic)
* Individuals often do not view their behaviour as problematic

Question 2

personality

Answer 2

All people display some consistency in their behaviour and thinking, and
this consistency is the basis for describing people as having a particular “personality.”

Question 3

Traits

Answer 3

Traits are characteristic features of a person that are displayed persistently over time and in various situations

Question 4

Cluster A: Odd and Eccentric Disorders

Answer 4

Paranoid personality disorder:
* Pervasive suspiciousness
* Non-bizarre

Schizoid personality disorder:
* Lack of emotional responsiveness
* Loners

Schizotypal personality disorder:
* Eccentricity
* Socially isolated

Question 5

Cluster A:
Paranoid Personality Disorder

Answer 5

A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as
malevolent, beginning by early adulthood and present in a variety of contexts. To qualify for a diagnosis, the patient must meet at least four out of the following criteria: - fear comes back again and again - they can be slightly convinced, but the fear still comes back

1) Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them.

2) Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends…

3) Is reluctant to confide in others because of unwarranted fear that the information will be
used maliciously against them.

4) Reads hidden demeaning or threatening meanings into benign remarks or events.

5) Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).

6) Perceives attacks on their character or reputation that are not apparent to others and is
quick to react angrily or to counterattack.

7) Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

Criteria B: should not be
diagnosed if the pattern of
behavior occurs exclusively
during the course of:
* Schizophrenia
* Bipolar disorder
* Depressive disorder with
psychotic features (or
another psychotic disorder)
* Autism spectrum disorder

Question 6

Cluster A: Schizoid Personality Disorder

Answer 6

A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and
present in a variety of contexts, as indicated by at least four of the following: - negative symptoms of schizophrenia

1) Neither desires nor enjoys close relationships, including being part of a family. - not a lot of social responsiveness

2) Almost always chooses solitary activities. - likes not having closeness with others

3) Has little, if any, interest in having sexual experiences with another person.

4) Takes pleasure in few, if any, activities.

5) Lacks close friends or confidants other than first-degree relatives.

6) Appears indifferent to the praise or criticism of others.

7) Shows emotional coldness, detachment, or flattened affectivity

Criteria B: should not be
diagnosed if the pattern of
behavior occurs exclusively
during the course of:
* Schizophrenia
* Bipolar disorder
* Depressive disorder with
psychotic features (or
another psychotic disorder)
* Autism spectrum disorder

Question 7

Cluster A:
Schizotypal Personality Disorder

Answer 7

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, beginning by early adulthood and present in a variety of contexts. At least five of the following symptoms must be present: part of schizophrenia spectrum disorder
1) ideas of reference

2) strange beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”, bizarre fantasies or preoccupations)

3) abnormal perceptual experiences, including bodily illusions

4) strange thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped)

5) suspiciousness or paranoid ideation

6) inappropriate or constricted affect

7) strange behavior or appearance

8) lack of close friends

9) excessive social anxiety that does
not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self - anxiety is still there even when you’re close to someone

Criteria B: should not be
diagnosed if the pattern of
behavior occurs exclusively
during the course of:
* Schizophrenia
* Bipolar disorder
* Depressive disorder with
psychotic features (or
another psychotic disorder)
* Autism spectrum disorder

Question 8

Cluster B:
Dramatic, Emotional, or Erratic Disorders

Answer 8

Antisocial:
- Disregard for, and violation of, the rights of others

Narcissistic:
- Grandiosity, need for admiration, and lack of empathy

Borderline:
- Instability in interpersonal
relationships, self- image, and affects,
and marked impulsivity

Histrionic:
- Excessive emotionality and
attention seeking

Psychopathy:
- (not listed in the DSM-5)

Question 9

Cluster B:
Antisocial Personality Disorder

Answer 9

A. A pervasive pattern of disregard for and violation of the rights of others, occurring
since age 15 years, as indicated by three (or more) of the following :

1) Failure to conform to social norms with respect to lawful behaviors, as
indicated by repeatedly performing acts that are grounds for arrest.

2) Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.

3) Impulsivity or failure to plan ahead.

4) Irritability and aggressiveness, as indicated by repeated physical fights or assaults.

5) Reckless disregard for safety of self or others.

6) Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.

7) 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 bipolar disorder.

• peak at 20 years old
• burn out factor - actions are not as fulfilling

Question 10

Etiology: Antisocial Personality Disorder

Answer 10

genetic factors
- autonomic
- neurocognitive
- social information processing
- temperament
- personality traits

environment factors:
- harsh and inconsistent discipline
- parent-child conflict
- maltreatment
- negative parental emotions
- disorganised parent-child attachment
- disrupted family functioning
- low parental warmth and responsivity

COMORBID: ADHD or CD

Question 11

Fearlessness hypothesis (antisocial personality disorder)

Answer 11

• a higher threshold for feeling fear
• indifferent to punishment, or
  oppositional to others’ attempts to
  control them

Question 12

Antisocial personality disorder vs Psychopathy

Answer 12

Antisocial Personality Disorder
* Diagnosis based on behavioural features
* Pervasive pattern of disregard for and violation of the rights of others that begins in childhood or early adolescence and continues into adulthood

Psychopathy
* Incorporates a richer set of emotional, interpersonal, and behavioural features
* Egocentric, deceptive, callous, manipulative individuals who lack remorse and emotional
depth – “users” of others
* Commit disproportionate amount of antisocial and violent behaviour

Question 13

Psychopathy

Answer 13

• Psychopathy and aggression – strong link
• Etiology – evolutionary, neurobiological, environmental
• Amygdala
• Serotonergic hypofunctioning in combination with a high dopamine activity
• Genes involved in oxytocinergic systems

Callous-unemotional traits

Question 14

Antisocial Personality Disorder
Differential Diagnosis

Answer 14

• Narcissistic personality disorder (cluster B personality disorder with
  overlap; exploitive and uncompassionate, but not aggressive or deceitful)
• Borderline personality disorder (cluster B personality disorder with
  overlap; manipulative, but for reassurance and nurture)
• Substance use disorder (Impulsivity and irresponsibility due to substance
  influence must be ruled out before diagnosing ASPD).
• ASPD can be diagnosed if substance use is co-occurring

Question 15

Cluster B:
Borderline Personality Disorder

Answer 15

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, as indicated by 5 (or more) :

1. Frantic efforts to avoid real or imagined abandonment
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
3. Identity disturbance: markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6. Affective instability due to a marked reactivity of mood (e.g.s intense episodic dysphoria, irritability, or anxiety usually lasting
   a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent
   physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms

Question 16

Borderline Personality Disorder
Prevalence & Presentation

Answer 16

• Prevalence of approximately 2% in the general population
• More common in women
• After about 10 years of mental services, about half of individuals do no longer have a pattern of behavior that meets full criteria for BPD.
• Nonsuicidal self-injury (NSSI) (e.g., cutting) can be used to regulate their
  emotions.
• not a necessary feature/symptom
• 10% lifetime rate of completed suicide
• Lots of comorbidities - PTSD, Depression, Bipolar disorder, substance use disorder, eating disorder, AHDH or other personality disorders

Question 17

Borderline personality disorder: Etiology

Answer 17

Disruptions in the family (childhood abuse – sexual abuse; neglect)
* Attachment disorder: anxious ambivalent
* Family transmission
- superfeelers - more intense emotional reactions

Brain dysfunctions?
* Reduced right hippocampal volumes
* Reduced volumes of grey matter in the dorsolateral prefrontal cortex
* Both are involved in sustaining and controlling impulsive and aggressive behavior
* Impact of childhood traumas - attachment security is reflected in neurological activity
measured in attachment-evoking contexts

Linehan’s biosocial theory: dysfunction of the emotion regulation system
* Vulnerability X pervasively invalidating environment

Question 18

Borderline personality disorder:
Etiology
Cognitive-Behavioural Perspectives

Answer 18

Focus on:
* Disordered schemas developed early in life
* Rigid and inflexible
* Family: invalidate emotional experiences + oversimplify the ease with which life’s problems can be solved = attention with intense emotional outbursts
* Parents as inappropriate models

Question 19

Histrionic Personality Disorder

Answer 19

A pervasive and ubiquitous pattern of consistent attention-seeking behaviors and emotional dysregulation as outlined by specific manifestations.
Diagnosis requires meeting five (or more) of the following criteria:

1) Uncomfortable when not the center of attention

2) Seductive or provocative behavior

3) Shifting and shallow emotions

4) Uses appearance to draw attention

5) Impressionistic and vague speech

6) Dramatic or exaggerated emotions

7) Suggestible (easily influenced by others)

8) Considers relationships more intimate than they are

Question 20

Narcissistic personality disorder

Answer 20

A pervasive pattern of grandiosity (fantasy or behavior), need for admiration, and with lack
of empathy, beginning by early adulthood, as indicated by at least five of the following:

1) Has a grandiose sense of self-importance (e.g., exaggerates achievements, expects to be
recognized as superior without actually completing the achievements)

2) Is preoccupied with fantasies of success, power, brilliance, beauty, or perfect love.

3) Believes that they are “special” and can only be understood by or should associate with, other special people (or institutions).

4) Requires excessive admiration.

5) Has a sense of entitlement, such as an unreasonable expectation of favorable treatment or
compliance with his or her expectations).

6) Is exploitative and takes advantage of others to achieve their own ends.

7) Lacks empathy and is unwilling to identify with the needs of others.

8) Is often envious of others or believes that others are envious of them.

9) Shows arrogant, haughty behaviors and attitudes

Question 21

Cluster C:
Anxious and Fearful Disorders

Answer 21

Avoidant:
- Social inhibition
- Feelings of inadequacy
- Hypersensitivity
to negative evaluation

Dependent:
- Submissive and clinging behavior
related to an excessive need to
be taken care of

Obsessive-Compulsive:
- Preoccupation with orderliness,
perfectionism, and control

Question 22

Avoidant Personality Disorder

Answer 22

A. Feelings of inadequacy, a pervasive pattern of social inhibition, and
hypersensitivity to negative evaluation are present in a variety of contexts, beginning by early adulthood as indicated by 4 (or more) of the following:

1) Avoidance of activities related to an occupation that involve significant interpersonal contact due to fears of such issues as disapproval, criticism, or rejection.

2) Do not want to get involved with people unless they are sure of being liked.

3) Displays restraint within intimate relationships because of the fear of being ridiculed or shamed.

4) Is preoccupied with being rejected or criticized or in normal social situations.

5) Shows inhibition in new interpersonal situations because of feelings of inadequacy.

6) Views self as socially inept, personally unappealing, and inferior to other people.

7) Is unusually reluctant to take personal risks or engage in new activities because they may prove embarrassing.

Question 23

Dependent Personality Disorder

Answer 23

The disorder is indicated by at least five of the following factors:

1) Has difficulty making everyday decisions without an excessive amount of advice and
reassurance from others.

2) Needs others to assume responsibility for most major areas of their life.

3) Has difficulty expressing disagreement with others because of fear of loss of support or approval.

4) Has difficulty initiating projects or doing things on their own (because of a lack of self confidence in judgment or abilities rather than a lack of motivation or energy).

5) Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.

6) Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to
care for themselves.

7) Urgently seeks another relationship as a source of care and support when a close relationship
ends.

8) Is unrealistically preoccupied with fears of being left to take care of themselves.

Question 24

Obsessive-Compulsive Personality Disorder

Answer 24

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: (no compulsions or obsession)

1) Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost - control freaks

2) 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)

3) Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not
accounted for bu obvious economic necessity)

4) Is overconscientious, scupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)

5) Is unable to discard worn-out or worthless objects even when they have no sentimental value

6) Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things

7) Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes

8) Shows rigidity and stubborness - everyday relationships are a bit more formal

Question 25

OCD vs OCPD

Answer 25

• People with OCD have insight - they know what they’re doing is not right or rational (not OCPD)
• The thoughts, behaviors and feared consequences common to OCD are typically not relevant to real-life
  concerns (OCPD fixates with little daily tasks)
• Often OCD interferes in several areas in the person’s life including work, social and/or family life (OCPD not on the list - interpersonal relationships are effected, but they don’t care)
• People with OCD who feel tortured by their unwanted thoughts and rituals, and are more aware of the
  unreasonable demands that the symptoms place on others, often feeling guilty because of this - OCPD don’t believe they require treatment
• Both hard on their family members

Question 26

Cluster C – Etiology: Attachment Styles

Answer 26

Psychodynamic theory - personality disorder is based on mother child relationship

Infants need sensitive &
responsive caregiving from their
parents - dev of sense of self &
interpersonal skills

Infants are sufferring from:
intrusive + irritable caregiving.
Insecure-avoidant
unaffectionate + inconsistent
caregiving.
insecure–ambivalent
neglectful + abusive caregiving.
insecure–disorganized
attachments

Question 27

different types of attachment styles

Answer 27

Secure - consistent, secure parenting - sad when mother goes, happy when mother is back

Insecure resistent (anxious ambivelent) - unaffectionate + inconsistent caregiving - baby is not sure what is going on

Insecure avoidant - intrusive+irritable caregiving - child will be sad when parent leaves and avoid parent when they are back

Insecure-disorganised attachments - neglectful+abusive caregiving - child will be disorganised and try to soothe themselves - afraid of parent abuse

Question 28

Diagnostic Issues
Are Prevalence Rates Showing True Differences?

Answer 28

Gender and Cultural Issues
* Gender biases (ex. Histrionic & Antisocial Personality Disorders)
Reliability of Diagnosis - agression in ASPD - women may be misdiagnosed, because they are normally seen as less agressive

• Zanarini and colleagues (2000): fair to good inter-rater reliability for all PD
• Fair to good test-retest reliability (except for Narcissistic & Paranoid PD)

Ethnic variations?
* Lower prevalence reported among black compared with white patients in UK studies
(see McGilloway et al. (2010). BMC psychiatry)

Comorbidity and Diagnostic Overlap
* Co-occurrence & similarity of symptoms