Chapter 7 - Personality disorders

Question 1

Personality disorders

Answer 1

Heterogeneous group of disorders regarded as long standing, pervasive and inflexible patterns of behaviour that deviate from cultural expectations, cause impairment and emotional distress.

We all have those traits from time to time; the disorders are marked by EXTREME versions of those traits - inflexible traits

Question 2

Egosyntonic disorders

Answer 2

Hard to notice; people wont usually come in FOR help with a personality disorder, since most people will not realize that they have one (called egosyntonic disorders) - they will seek help for other parallel problems, and discover this along the way

Question 3

3 key factors for all personality disorders

Answer 3

1. Rigid and inflexible behaviour
2. Self-defeating behaviour that fosters vicious cycles
3. Structural instability: fragility of the self that cracks under stress

Question 4

Unable to do any of those tasks indicate a PD

Answer 4

1. Form a clear view of the self
2. Develop positive relationships with others
3. Function in society (prosocial behaviours

Question 5

Diagnosis challenges in PD

Answer 5

• People are not aware of their disorders - their relatives see it differently
• Most people are diagnosed with PD not otherwise specified (general PD)
• Self-report measures are often used (recently MMPI and PSY-5)

Question 6

History of PD

Answer 6

Started with Hippocrates humoral theory; first DSMs were very unreliable; DSM-III a bit more; in DSM-5 we now understand that episodic problems can be accompanied by a long term personality disorder

Question 7

Reliability of PD

Answer 7

For many personality disorders, they do not test reliably over time
Except for anti-social, borderline, and OC

The type of assessment (dimensional or categorical) most likely plays a role in the reliability of the disorders

Question 8

Name/ define the 3 clusters

Answer 8

A: odd, eccentric cluster (paranoid, schizoid, schizotypal)
B: dramatic, emotional, erratic cluster (anti-social, borderline, histrionic, narcissistic)
C: fearful (avoidant, dependent, OC)

Question 9

Alternative Model for PD (AMPD)

Answer 9

Why is there no dimensional ratings in the DSM-5?
Instead they used the Alternative Model for PD (AMPD):
Critertion A: levels of personality functioning
Self
Interpersonal
Criterion B: rating across 5 trait dimensions
Negative affectivity,
Detachement,
Antagonism,
Disinhibition,
Psychoticism
This has clinical relevance, but a dimensional approach seems to be more fit to the data - personality disorders seem to be extreme version of traits everyone have
Personality scales (Big Five, HEXACO) can be useful dimensional tools to assess PD
Dimensional approach is best: that’s a fact, but WHICH dimensions are best? Still debated

Question 10

Can people fit into a single personality disorder category?

Answer 10

It’s rare to have someone with 1 specific personality disorder; they are known to have elements from more than 1 disorder at the same time
That can explain why there is poor test-retest reliability
At time 1, they may see 1 aspect and see another after (depending on what they are going through at the moment, certain traits may be expressed more strongly at different times)
Need to keep in mind that being in a single category at all times is RARE

Question 11

Characteristics - Paranoid PD

Answer 11

Suspicious of others
Expect to be mistreated/exploited
Reluctant to confide
Tend to blame others
Extremely jealous 
No hallucinations nor delusions

Question 12

Prevalence/comorbidity - Paranoid PD

Answer 12

about 1% prev.
Occurs + in men
Comorbid in schizotypal, borderline, avoidant PD

Question 13

Characteristics - Schizoid PD

Answer 13

No desire for or enjoyment of social relationships
Appear dull, bland, aloof
Rarely report strong emotions (reflected in their facial expressions)
Have no interest in sex
Experience few pleasurable activities
Indifeerent to praise/criticism
May seem like they have issues and are avoidant of the world (similar to avoidant PD but not the same)

Question 14

Prevalence/comorbidity - Schizoid PD

Answer 14

< 1% prev
+ common in men
Comorbid with schizotypal, avoidant, paranoid PD

Question 15

Characteristics - Schizotypal PD

Answer 15

Noticeable oddness - may dress/act weird
Interpersonal difficulties of schizoid PD
High social anxiety
Eccentric symptoms like in pre and post phases of SZ
Odd beliefs/magical thinking
Recurrent illusions (ex: feeling ghost passing through them)
Odd speech
Ideas of reference (events have particular meaning)
Suspiciousness
Paranoid ideation
Eccentric behaviour/appearance
Constricted/flat affect
Cognitive impairments like in SZ

Question 16

Dissociative experiences

Answer 16

(depersonalization and derealization) those in particular don’t have memory component (no memory loss, etc)

Question 17

Depersonalization

Answer 17

you are doing something and you feel like you are no longer connected to your body and it seems like you are no longer controlling it, you are simply observing

Question 18

Derealization

Answer 18

when you are doing something and everything around you seems surrealistic

Question 19

Prevalence/comorbidity - Schizotypal PD

Answer 19

3% prev
+ frequent in men
Highest comorbidity of all
With borderline, avoidant, paranoid PD

Question 20

Etiology - Schizotypal PD

Answer 20

Genetically linked to SZ
Maybe it’s a less severe form of it
Can be linked to history of PTSD/childhood trauma

Question 21

Etiology of Cluster A

Answer 21

May all be genetically linked to SZ
The schizoid in particular seems to be the most related to schizophrenia, but they all are in this cluster
The family members of ppl with SZ seem to be more at risk for those PD, also the relatives of depressed people

Question 22

Characteristics - Borderline PD

Answer 22

Core features are impulsivity and instability in relationships, mood and self-image
Attitudes and feelings toward others vary dramatically
Emotions are erratic and can shift abruptly (AKA emotional dysregulation)
Argumentative, irritable, sarcastic, quick to take offence, etc
High risk for suicide and self harm
Transient episodes of paranoia, dissociation
High neuroticism
Low on trust/compliance (agreeableness)
Dichotomous thinking (splitting)

Question 23

Prevalence/comorbidity - Borderline PD

Answer 23

1-2% prev
+ common in women
Comorbid with mood disorders, substance abuse, PTSD, eating disorders, and cluster B PDs

Question 24

3 main dimensions of borderline PD

Answer 24

Affect instability (inappropriate anger, drastic mood shifts, reactive mood, feelings of emptiness)
Dysfunctional relationships (unstable/intense, efforts to avoid abandonment)
Impulsivity (self-damaging behaviours, attempts of self-harm/suicide)

Question 25

Splitting

Answer 25

Black-and-white thinking: everything is GREAT or everything is AWFUL; they LOVE you or they HATE you Can use splitting in all realms of their life

Question 26

Etiology of borderline PD - biological

Answer 26

Strong genetic component in twins Heritability of impulsivity and affective instability Reduced response to serotonin in orbital, ventromedial and cingulate cortices linked to impulsive aggressivity Increased noradrenergic responsiveness linked to affective instability

Question 27

Etiology of borderline PD - psychosocial

Answer 27

negative experiences in childhood- abuse, neglect, separation, loss, trauma Parental psychopathology

Question 28

Etiology of borderline PD - Diathesis-stress

Answer 28

Genetic/biological diathesis: affective instaibility and impulsivity traits Stress: trauma, parental failure or psychopathology, loss/rejections

Question 29

Etiology of BPD - object-relations theory

Answer 29

Neo-freudian theory Premise: when you are a kid, you integrate and interject parts of significant people in our life (everyone does that) When the signals by the caregivers are inconsistent, it results in an incohesive/fragmented sense of self - we integrate the mixed messages and we struggle to recognize our self They have weak egos - ability to decide is weakened - links to splitting

Question 30

Etiology of BPD - Linehan's diathesis-stress theory

Answer 30

Cycle of emotional dysregulation in child > demands on the family > invalidation from parents > emotional outbursts/dysregulation Even if you are a well-intending parent, it is difficult to deal with the child, it can lead to this cycle Difficult to tell what is the chicken / what is the egg Linehan's: trauma + invalidation = BPD

Question 31

Treatment - BPD (general + medication)

Answer 31

Have troubles estabilishing trust - idealize AND vilify their therapist (hardest to treat) Medication: SSRIs, antipsychotic, mood stabilizers

Question 32

Treatment of BPD - dialectical behaviour therapy

Answer 32

Tolerance of negative affect, interpersonal skills, emotional regulation (combines client-centered acceptance with CBT Therapy developped by Linehan to deal with this problem of idealize/vilification)

Question 33

Treatment of BPD - Object relation

Answer 33

strengthen ego, address direclty the splitting defense

Question 34

Characteristics - Histrionic PD

Answer 34

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 (over the top) and lacking in detail

Question 35

Prevalence/comorbidity - Histrionic PD

Answer 35

2-3% More common in women Comorbid with depression and BPD

Question 36

Etiology - Histrionic PD

Answer 36

Unknown | A deep insecurity/need for approval seems to be underlying

Question 37

Characteristics - Narcissistic PD

Answer 37

grandiose view of own uniqueness and abilities preoccupied with fantasies of great success require almost constant attention/excessive admiration lack empathy envious of others arrogant, exploitive, entitled Likely to have other traits of the dark triad as well (psychopathy and machiavellism), dark tetrad - sadism

Question 38

Prevalence/comorbidity - Narcissistic PD

Answer 38

< 1% prev | Comorbid with BPD

Question 39

Etiology - Narcissistic PD

Answer 39

Product of our time/values? Especially North America; individualistic/capitalist society makes it easier for narcissistic individuals to be accepted/to function Theory: Self-psychology Self: bi-polar scale with immature grandiosity at one pole and dependent overidealization of others at the other pole Imbalance on the scale results from inadequate response of the parents to the child's competency

Question 40

Characteristics - Antisocial PD

Answer 40

2 major components 1. conduct disorder present before 15 2. pattern of antisocial beahviour continues in adulthood (irresponsible, work only inconsistently, break laws, irritable, physically aggressive, impulsive/fail to plan ahead) Sometimes people fill the requirements for #2, but we don't know their history so it's hard to establish - and they tend to lie a lot so it's hard to determine

Question 41

Prevalence/comorbidity - Antisocial PD

Answer 41

3% of adult men, 1% women 3% in Canada Comorbid with substance abuse

Question 42

Conduct disorder criteria

Answer 42

``` Presence of at least 3 of: aggression - people and animals theft vandalism lying bullying run away truancy or staying out all night before 13 ```

Question 43

Problem with diagnosis of conduct disorder

Answer 43

Relies on patients reports on past life events, but they are often pathological liars Many argue that a diagnostic concept in psychopathology should not be linked with criminality; conveys stereotypes, can lead to false/wrong associations/convictions

Question 44

Key characteristics - psychopathy

Answer 44

Lack of remorse no shame superficially shaming manipulates other for personal gain lack of anxiety (Important one: anxiety cannot guide us in situations where it can usually be useful You react and deal with the world different way; you dont have a sense that you should be cautious about some things) Poverty of emotions (both + and -)

Question 45

Differences/similarities between APD and Psychopathy

Answer 45

APD 20% also have psychopathy 75-80% felons meet criteria for APD Lack of remorse not required ``` Psychopathy All have ADP as well 15-25% felons meet criteria Lack of remorse - core symptom low fear disposition ``` Similarity factors: Both are prone to suicide acts (psychopaths are not immune) Both are prone to cognitive control deficits

Question 46

Cleckley's definition of psychopathy

Answer 46

``` Lack of remorse Poverty of emotions (+/-) Inadequate conscience development Irresponsible/impulsive behaviour Ability to impress/exploit others Pathological liars ```

Question 47

Hare's 2 factor checklist for psychopathy

Answer 47

1. Affective/interpersonal (selfish, remorseless, inflated self-esteem, exploits others) 2. Antisocial lifestyle/behaviour (marked by impulsivity and irresponsibility)

Question 48

Emotions of Psychopaths

Answer 48

Unresponsive to punishment/no conditioned fear response (low fear hypothesis) Lower than normal levels of skin conductance at rest Hear rate normal under rest, but high when anticipating intense/aversive stimuli (Indicates that psychopaths cannot be regarded as simply under-aroused; their increased heart rate indicates that they are tuning out the stimulus) Some features of psychopaths might result from a lack of empathy (were less responsive to images of distress than controls in a study) - linked with brain dysfunctions

Question 49

Etiology of psychopathy - biological

Answer 49

Response modulation/impulsivity and psychopathy might arise from slow brain waves and spikes in temporal area, and less activity in the amygdala (involved in aversive conditioning) - reduced volume and response to negative stimuli Reduction of grey matter observed in children

Question 50

Etiology of APD and psychopathology - heritability

Answer 50

Criminality/APD have genetic components High concordance for MZ twins (DZ less but still) Higher rates of antisocial behaviour in adopted children of biological parents with APD

Question 51

Etiology of APD and psychopathy - family environment

Answer 51

Lack of affection Severe parental rejection Physical abuse Inconsistencies in disciplines (could be reaction to child's behaviour) - That's a theory Failure to teach child responsibility towards others *Many individuals from those backgrounds do not become psychopaths* Fathers likely to have antisocial personalities

Question 52

Etiology of Psychopathy - stress reactivity theory

Answer 52

Convicted psychopaths usually found to have lowe autonomic stress reactions and lower resting state autonomic activity Thought to play a role in development of psychopathology

Question 53

Successful vs unsuccessful psychopaths

Answer 53

Successful psychopath: have been diagnosed, but figured out a way to deal with the world without getting into trouble (adapted to society) Baseline heart rate is even lower than control Response is similar to the controls Unsuccessful psychopath: were not able to adapt to society Baseline heart rate is lower than control

Question 54

Etiology of psychopathy - frontal hypothesis

Answer 54

Executive functions deficits thought to underlie psychopathic features studies supporting the theory mainly included violent offenders no executive dysfunction was found in successful psychopaths

Question 55

Characteristics - Avoidant PD

Answer 55

Fearful in social situations Keenly sensitive to criticism, rejection, disapproval Reluctant to enter relationships unless sure they will be liked

Question 56

taijinkyoufu

Answer 56

extreme fear of how they appear to others, resulting in avoidance of social contacts like in avoidant PD and social anxiety (in Japan)

Question 57

Prevalence/comorbidity - Avoidant PD

Answer 57

1% prev | Comorbid with dependent PD, depression and generalized social phobia

Question 58

Difference between avoidant and dependent PD

Answer 58

Only difference between avoidant and dependent PD is that avoidant struggles to approach/initiate social relationships

Question 59

Characteristics - Dependent PD

Answer 59

``` Lack self-reliance overly dependent on others intense need to be taken care of uncomfortable when alone subordinate own needs ```

Question 60

Prevalence/comorbidity - Dependent PD

Answer 60

1.5% prev + common in women Comorbid with bipolar, depression, anxiety, bulimia

Question 61

World views on dependent PD

Answer 61

Maladjusted to the rest of the world; studies on DPD have been too focused on North America, where being dependent on others is a flaw; but in collectivistic cultures it can actually be ok

Question 62

Characteristics - Obsessive-Compulsive PD

Answer 62

Perfectionistic approach to life Peroccupied with details, rules, schedules, etc Serious, rigid, formal, inflexible Unable to discard worn out and useless objects Does not include obsessions/compulsions in OCD

Question 63

Prevalence/comorbidity of Obsessive-Compulsive PD

Answer 63

1% prev | Comorbid with OCD, panic disorder, depression, avoidant PD

Question 64

Etiology of cluster C

Answer 64

Unknown - little data

Question 65

Therapies for PDs

Answer 65

Not much research-based information Object relations therapy for BPD Dialectical therapy for BPD Schema therapy: cognitive schemas that underlie PD can be corrected

Question 66

Treatment - Psychopathy

Answer 66

Virtually impossible to treat | Unable to form a trusting relationship with a therapist

Question 67

Where does the word dialectical come from (dialectical therapy)

Answer 67

Word dialectical comes from dialectics: worldview that holds that reality is an outcome of a constant tension between opposites (any event (thesis) generates a force opposite to it (antithesis), which is resolved by the creation of a new event (synthesis)) Therapists' paradox: accepting the client as they are, yet helping them to change

Question 68

Carrers associated with PDs?

Answer 68

Antisocial: Computer science (don't need to deal with ppl and follow rules) Avoidant: accountant (no dealing with people) Borderline: Acting, anything creative Dependant: caretaker, personal assistant Histrionic: wedding planner, waitress/bartender, also acting maybe but they are quite shallow Narcissistic: politician, businessman, model, finance, job where they can show their charismatic personality and where they can be the boss of people Obsessive compulsive: Pharmacist, doctor, librarian, wedding planner Paranoid: bodyguard, detective Schizoid: artistic, working from home Schizotypal: fashion designer, author, fortune teller/psychic