Chapter 6 - Personality Disorders (Midterm 2 material) Flashcards
1
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Personality Disorder (text)
A
Types of enduring patterns of inner experiences that deviate markedly from the expectations of the individual’s culture, are pervasive and inflexible, and lead to distress or impairment
2
Q
Ego syntonic
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Behavior feelings that are perceived as natural or compatible parts of the self
3
Q
Ego dystonic
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Behaviour or feelings that are perceived to be foreign or alien to ones self-identity
4
Q
What might be diagnosed as a personality disorder?
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when these behaviour patterns become so inflexible or maladaptive that they cause significant personal distress or impair functioning in the social or occupational realms
5
Q
General DSM-5 Diagnostic Criteria - personality disorder
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• A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
– (1) cognition (i.e., ways of perceiving and interpreting self, other people, and events)
– (2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
– (3) interpersonal functioning
– (4) impulse control
• B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
• C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood.
• E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
• F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma)
6
Q
The Three Clusters
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- Odd eccentric behaviour “mad”
a. Paranoid
b. Schizoid
c. Schizotypal - Dramatic, emotional, impulsive “Bad”
a. Borderline
b. Antisocial
c. Narcissistic
d. Histrionic - Anxious, fearful, avoidant “Sad”
a. Avoidant
b. Dependent
c. Observe-compulsive
7
Q
- Odd eccentric behaviour “mad”
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a. Paranoid
b. Schozoid
c. Schizotypal
8
Q
- Dramatic, emotional, impulsive “Bad”
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a. Borderline
b. Antisocial
c. Narcissistic
d. Histrionic
9
Q
- Anxious, fearful, avoidant “Sad”
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a. Avoidant
b. Dependent
c. Obsessive-compulsive
10
Q
-Important to keep in mind
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-Many (if not most) PD Dx are “PDNOS” - Personality Disorder Not Otherwise Specified
They may fluctuate in their intensity
-Make no mistake about it, these can be highly debilitating disorders. they’re not just somebody choosing to be nasty (with the possible expectation of AsPD)
11
Q
-Cluster A
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- personality Disorder characterized by odd or eccentric behaviour (“mad”)
- people who are perceived as odd or eccentric.
12
Q
People with personality disorders tend to view their traits as
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Ego syntonic
13
Q
People with anxiety disorders / depressive view themselves as
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Ego dystonic
14
Q
Cluster B
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- personality disorders characterized by dramatic, emotional or erratic behavior
- behavior which is overly dramatic, emotional, or erratic
15
Q
Cluster C
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- personality disorder characterized by anxious or fearful behaviours (“Sad”)
- often appear anxious or fearful
16
Q
-Paranoid Personality Disorder
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-type of personality disorder characterized by persistent suspiciousness by the motives of others, but not the points of holding clear-cut delusions
17
Q
Core features of Paranoid Personality Disorder
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- suspiciousness without due cause
- preoccupations with founded concerns over lack of loyalty of friends, spouse, and family
- Emotionally closed – reluctant to confide or ‘open up’
- Interpretive basis that promotes perception of innocuous content as threatening
- grudging
- defining trait is pervasive suspiciousness
-unlikely to seek treatment since they believe that others are causing their problems and not themselves
18
Q
Schizoid Personality Disorder
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- personality disorder characterized by a personal lack of interest in social relationships, flattened affects and social withdrawal
- rarely express emotions and are distant and aloof
- but emotions of people with schizoid personalities are not as shallow or blunted as they are in people with schizophrenia
-characterized by detachment from social relationships and a restricted range of emotional expression
19
Q
Core features of schizoid personality disorder
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– No interest in, or enjoyment of, close relationships
– Chronic loner
– No interest in sex
- Seldom participates in recreational activities
– Unaffected by praise or criticism
– Emotionally cold, detached, flat
-Social Isolation is the key feature
20
Q
Schizotypal Personality Disorder
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- personality disorder characterized by eccentricities or oddities of thought and behaviour but throughout clearly psychotic features. Like Sz in many respects but without the profound impairment in reality testing
- personality disorder characterized by acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior
21
Q
Core features of schizotypal disorder
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– Ideas of reference – Odd beliefs / magical thinking (not just superstitions) – Odd perceptual experiences – Peculiar thinking and speech – Suspicious/paranoid - Social isolation (other than family) – Persistent social anxiety
22
Q
There is a misunderstanding that
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you cannot diagnose before the age 18, antisocial personality disorder is the only one you cannot
23
Q
Ideas of reference
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Form of delusional thinking in which a persons reads personal meaning into the behavior of others or external events that are completely independent of the person
24
Q
Antisocial Personality Disorder (and psychopathy) (APD)
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- type of personality disorder characterized by chronic pattern of antisocial and irresponsible behaviour and lack of remorse
- personality disorder characterized by a chronic pattern or disregard for, and violation of, the rights of others
25
Core features of APD
- failure to conform to social and legal norms
- lying / conning
- impulsivity and short sightedness in planning
- irritability / aggressiveness, fighting
- recklessness with self and others
- irresponsibility
- lack of remorse
- note: MUST be 18 and have shown signs of Conduct Disorder before 15 years of age
- most striking feature about them are their low levels of anxiety in threatening situations and their lack of guilt or remorse following wrongdoing
- lack of employment
- history of alcoholism
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Psychopathy
V-Not a separate DSM PD
- an extreme case of ASPD
- type of personality pattern characterized by affective and interpersonal traits, such as shallow emotions, selfishness, arrogance, superficial charm, deceitfulness, manipulativeness, irresponsibility, sensation-seeking, and a lack of empathy, anxiety, and remorse, combined with persistent, violations of social norms, a socially deviant and nomadic lifestyle and impulsiveness
27
Facts about APD and psychopathy
- Not all criminals show sings of psychopathy
- not all ASPD patients are psychopaths either!
-Some controversial around the notion of a successful psychopath
-must distinguish between Factor I and Factor II PCL-R features
-Appreciate that one can have strong (Factor I) features without being a psychopath
(Factor 1: Interpersonal/Affective; Factor 2: Lifestyle/Antisocial),
-may be nominally law-abiding and successful in their chosen occupations, but still show callous disregard for the interests and feeling of others
- Antisocial personality disorder cuts across all racial and ethnic groups
- Researchers find no evidence of ethnic or racial differences in the rates of the disorder
- however it is more common in people with lower SES
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-There are several psycho-physiological and biological factors that are related to antisocial personality and psychopathy
-lack of emotional responsiveness
- the craving-for-stimulation model
- lack of emotional response in order to maintain a optimum level of arousal
- exaggerated levels of cravings for stimulation
-lack of restraint on impulsivity
- limbic abnormalities
- less activity in the brain that regulates emotions / emotional responses
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Optimum level of arousal
Level of arousal associated with peak performance and maximum feelings of well-being
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Borderline Personality Disorder
-primarily characterized by a pervasive pattern of instability in relationships, self-image and mood and a lack of control over impulses. People with BPD tend to be uncertain about their values, goals, loyalties, careers, choice of friends and perhaps even sexual orientations
31
-Three dialectical dilemma (Lineman)
- emotional vulnerability vs self-invalidation
- active passivity vs apparent competence
- unrelenting crisis vs inhibited grieving
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Core features of BPD
– Intense and unstable relationships. View of others fluctuates between extremes – “splitting”
– Unstable self-image / self-concept
– Marked impulsivity
– Recurrent para-suicidal / self-harming behaviour / threats
– Affective instability
– Feeling constantly empty
– Intense, frequently unwarranted, anger and difficulty controlling it
– May show dissociative or paranoid symptoms
- primarily characterized by a pervasive pattern of instability in relationships, self image and mood and a lack of control over impulses
- instability of moods
-reported that emotional abuse, not physical is at the the root of this disorder, early abuse prevents regulation of emotions (one study)
33
What is splitting ?
presenting themselves differently to different members of the treatment team, Friends, coworkers
The inability of some people (especially those with BPD) to reconcile the positive and negative aspects of themselves and other into a cohesive integration, resulting in a sudden and radical shifts between strongly negative and strongly positive feelings - separate definition
34
Histrionic Personality Disorder
-type of personality disorder characterized by excessive need to be centre of attention and to receive reassurance, praise, and approval from others, Such persons often appear overly dramatic and emotional in their behaviour
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Core features of histrionic disorder
– Resents attention being directed to others
– Often seductive or provocative
– Emotionally shallow / variable
– Uses physical appearance (including mode of dress) to attract attention
– Rehearsed way of speaking with limited substance
– Dramatic, theatrical, emotionally flamboyant
– Highly suggestible
– Considers self to be ‘close friends’ of mere acquaintances
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Histrio
Means actor
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Narcissistic Personality Disorder
-type of personality disorder characterized by the adoption of an inflated self-image and demands for constant attention and admiration, among other features
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Core features of Narcissistic Personality disorder
– Fantasizes about great power, wealth, desirability, success, etc.
– Feels special, entitled, above others, complex
– Demands admiration
– Exploitative of others
– Insensitive to the needs and feelings of others
– Arrogant, haughty
– Envious of others and resentful of their achievements, but may also think others envy them
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Primary narcissistic
believes they are all that
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Secondary narcissistic
Looks and feels the same interpersonally, but are driven by inferiority
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Avoidant Personality Disorder
-type of personality disorder characterized by avoidance of social relationships due to fears of rejection
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Core features of avoidant Personality disorder
– Looks in some respects like schizoid PD, but the person really wants to have close relationships
• Hindered by strong fear of rejection or social inadequacy
– Avoids activities (including jobs) that require social contact
– Reluctant to take chances socially. Deep sense of inadequacy
– ‘Up tight’ (inhibited), even in established relationships
– Chronically fearful of criticism
– Sees self as socially inept and inferior
– Mortified by the prospect of embarrassment
-lots of overlap between avoidant personality disorder and social anxiety disorder
43
Dependent Personality Disorder
-Type of personality disorder characterized by difficulties making independent decisions and by overly dependent behaviour
44
Core features of dependent personality disorder
– Can’t make decisions for themselves without seeking advice and reassurance
– Wants others to be responsible for them
– Avoids expressing dissent
– Lacks confidence in planning and initiating projects and activities
– Craves nurturance and support
– Feels vulnerable when alone
– Quickly finds a new relationship when another one ends
– Pre-occupied by fears of being alone
45
Obsessive-Compulsive Personality Disorder
-type of personality disorder characterized by rigid ways of relating to others, perfectionistic tendencies, lack of spontaneity and excessive attention to details
46
Core features of Obsessive compulsive personality disorder
– Highly concerned with rules, lists, details, procedures, etc.
• Interferes with completion of tasks
– Cannot complete task for fear that work is imperfect
– Neglects leisure and personal life to spend more time on work – Inflexibly conscientious, moral, ethical
– Prone to hoarding as they hate to throw things outs
– Doesn’t delegate well
– Miserly
– Stubborn and rigid with others
– Sometimes referred to as ‘anal retentive’
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People with Type A personality
Typically end up suffering from health problems due to stress and are not high producers
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Problem with classification of personality disorders
- Undetermined realistic and validity
- Problems distinguishing from other types of disorders
- Difficulty in distinguishing between variations in normal and abnormal behaviour
- Sexist biases
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Problem with classification of personality disorders
| -overlap among disorders
- not only is there a broad category but there is a lot of overlap between disorders
- undermines the DSM’s conceptual clarity or purity
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Problems in distinguishing between variations in normal behavior and abnormal
-sometimes describes normal behavior in other individuals, in lesser degrees
51
Sexist biases
- stereotypes may play into the diagnoses like either feminine or masculine
- unfairly stigmatize women who are socialized into dependent roles
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Proposed Changes Addresses:
- reduction in diagnostic overlap
- less arbitrary diagnostic threshold
- movement from categorical to dimensional conceptual action
- Recognition that symptom severity can fluctuate (trait) model:
- A. Moderate or greater impairment in personality functioning as manifested by difficulties in two or more of the following areas:
- Identity
- Self-direction
- Empathy
- Intimacy
- B. One or more pathological personality trait domains OR specific trait facets within domains, considering ALL of the following domains:
1. Negative Affectivity (vs Emotional Stability)
- intense, unstable emotions
2. Detachment (vs Extraversion)
- Withdrawal, restricted affect, social avoidance
3. Antagonism (vs agreeableness)
- behaving in a way that invites/produced conflict, including criminality
4. Disinhibition (vs conscientiousness)
- seeking immediate gratification
5. Psychoticism (vs lucidity)
- unusually, culturally-inappropriate behaviour
- severity of each is rated on a scale form 0 to 4 on the basis of impairment
53
-Probably 6 PDs will survive into the next version of DSM
- Antisocical.Psychopathic
- Avoidant
- Borderline
- Narcissistic
- Obsessive-Compulsive
- schizotypal
54
Theoretical - psychodynamic Traditional
-traditional Freudians focused on problems arising form the Oedipus complex as the foundation of abnormal behavior. They mirror and internalize the parent they model, which can hinder development of emotions and end up leading them to lack remorse or empathy
55
Heinz Holt - psychodynamic
- self-psychology: theory that describes processes that normally lead to the achievement of a cohesive sense of self of, in narcissistic personality disorder, to a grandiose but fragile sense of self
- children who did not have empathetic parents, the stage is set for them to develop pathological narcissism in adulthood
56
Otto Kernberg - psychodynamic
—views borderline personality in terms of pre-Oedipal failure to develop a sense of constancy and unity in ones image of the self and others.
- childhood failure failure to synthesize these images of successes and failures (or good and bad) results in a failure to develop a consistent self image and in tendencies toward splitting - his own take on splitting
- parents failed to meet all their child’s needs
57
Margaret Mahler - Psychodynamic
- childhood separation from the mother
- symbiotic attachment to the mother (interdependent on each other)
- separation-individualism - when children eventually separate psychologically from their mothers and to perceive themselves as separate and distinct
- suggests that there may have been a failure to master this developmental challenge
58
Learning Perspective - theory
- tend to focus more on the acquisition of behavior than on the notion of enduring personality traits, more in terms of maladaptive traits
- interested in defining the learning histories and situational factors that give rise to maladaptive behavior and the reinforcers that maintain them
- reinforcement history
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Family Perspective - theory
- argued that disturbances in family relationships underlie the development of personality disorders
- parenting styles (more controlling, more strict, less caring)
- splitting has been learned to help cope with unpredictable and harsh behavior from parental figures or other caregivers
- fear of abandonment
- Rigid family environment may lead to Obsessive-compulsive PD
60
Cognitive Behavioral Perspective
- role of observational learning in aggressive behavior, which is a common component in anti-social behavior
- only used when provoked because they will believe that they will be rewarded rather than punished for it
- people with PD tend to interpret their social experiences or other peoples behavior as threatening
- problem-solving therapy - for of therapy that focuses on helping people develop more effective problem solving skills
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Biological Perspectives
- evidence points to genetic factors playing a role in the development of PD
- identical twins show more probability of having the same disorder
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Neuropsychological factors
- reinforcement sensitivity theory has now evolved into the behavioral approach system, the flight-fight-freeze system and the behavioral inhibition system
- Gray suggests that each NPHYL system functions in unique ways.
- BAS system seeks out please, sensitive to reward
The same reinforcement for one person, may not reinforce another. Same with punishers
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Socio-cultural views
Examines the social conditions that may contribute to the development of the behavior patterns identifying PD
-SES, trauma, parenting style, cultural norms
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Treatment
- these conditions are highly refractory
- difficult for the patient to see, therefore limited insight
- inherent stability for personality
- treatment is difficult for various PDs
- “stepped care” model
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Psychodynamic treatment
- help those become more aware of the roots of the self-defeating behavior pattern and learn more adaptive ways of relating to others
- insight re historical basis
- insight re how their interpersonal conduct undermines relationships
66
CBT treatment
- see their task as changing clients behavior rather than their personality structures
- replace maladaptive behavior with adaptive behaviors
- conceptual personality as persistent behaviour patterns established and maintained by Rf contingencies
- general strategy is to utilize modelling, RF and extinction to replace maladaptive behaviours
- can utilizer social skills training, identification of distorted beliefs, coaching family members
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Dialectal Behavior Therapy
- Developed primarily for BPD
- BPD patients habitually “test” relationships
- frequent crises
- unscheduled phones calls
- suicide threats/attempts
- “splitting” professional teams and social groups
- caregiver “burnout”
- mindfulness techniques
- accept it is what it is
- distress tolerance
- emotion regulation strategies
- interpersonal effectiveness
- usually team-delivers two full days/weeks
68
Biological treatment
- drug therapy does not directly treat PD
| - SSRIs can be effective sometimes in terms of aggression and such
69
Canadian treatment services
- approach that personality disorders are clusters of traits that can be viewed as amplifications of normal personality traits
- should focus on the reduction if the traits in part by identifying the maladaptive behavior patterns and bringing forward to the patient
- given historical perspective e
- then move towards change
70
-stepped care model
In which all patients are initially offered short-term interventions flowed by intermittent follow-ups. Only those who did not benefit from short term should move into long term treatment
