Chapters 9 & 10: Personality Disorders and Schizophrenia Flashcards
What are the three “Odd-Eccentric Personality Disorders?”
- Schizoid
- Paranoid
- Schizotypal
Symptoms of Schizotypal Personality Disorder
- Ideas of reference (excluding delusions of reference)
- Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural normals
- Unusual perceptual experiences, including bodily illusions
- Odd thinking and speech
- Suspiciousness or paranoid ideations
- Inappropriate or constricted affect
- Behavior or appearance that is odd, eccentric or peculiar
- Lack of close friends or confidants other than first-degree relatives
- Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative fears rather than negative judgements about self
Causes of Schizoid Personality Disorder
Related to schizophrenia because of reductions in temporal lobe volume. Can actually lead to full-blown schizophrenia.
Treatments of Schizotypal Personality Disorder
Cognitive Behavioral Therapy
- Objective observation and thinking without subjective responses
- Establishing a safe social network
Drugs
- Antipsychotics: clozapine, olanzapine
- Fewer short-term side effects but still unknown for long-term
-Treating people with Schizotypal Personality -Disorder does help prevent schizophrenia
Schizoid Personality Disorder
Like schizotypal except with stronger symptoms of antisocial behavior.
- Indifference to both praise and criticism
- Insensitivity to the feelings of others
- Extreme introvertedness
- Perceived as cold, aloof or distant
- No abnormal ideas or perceptions
- Simply at the extreme end of the continuum of introversion
Prevalence of Schizoid Personality Disorder
Prevalence and causes
.4-.9% of the population, more common in men than in women
Treatment of Schizoid Personality Disorder
CBT
-Increase social interaction and decrease isolation
Group Therapy
-Good for social connection and interaction and establishing a social network for schizoid individuals.
-Setting for disclosure and social feedback
Can be taught how to handle positive and negative and neutral reactions from others
Role-playing
Paranoid Personality Disorder Symptoms and DSM
- Pervasive distrust and suspicious of others.
- Motives are seen as malevolent, beginning by early adulthood and present in a variety of contexts as indicated by four or more of the following
- Suspects without sufficient basis that others are exploiting, harming or deceiving them
- Doubts of loyalty and trustworthiness of others
- Reluctant to confide in others for fear that information will be used against them
- Reads hidden meaning or threatening meanings into benign remarks or events
- Persistently bears grudges, i.e., is unforgiving of insults, injuries or slights
- Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
- Recurrent suspicions without justification, regarding fidelity of spouse or sexual partner
- Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, or another psychotic disorder and is not due to the direct physiological effects of a general medical condition
Prevalence of Paranoid Personality Disorder
- .4-1.8% of the population
- More men than women
Treatment
CBT
- Self-disclosure and trust
- Objectivity
Dramatic-Erratic Disorders
- Antisocial Personality Disorder
- Histrionic Personality Disorder
- Narcissistic Personality Disorder
- Borderline Personality Disorder
Overview of Antisocial Personality Disorder
- Most widely studied personality disorder in the laboratory
- Previously called “sociopathy” and “psychopathy”
- Overlap on antisocial, psychopathy and criminality disorders
- Criminal disorders are characterized as the intent to get rich quick and gain respect amongst peers
- In antisocial disorder, the acts are aimless, random and impulsive.
Characteristics of Antisocial PD
- Pervasive patterns of disregard and violation of the rights of others occurring since age 15.
- Basis for it in conduct disorder
- Takes form of truancy, petty theft, and rule violating behavior.
- Failure to conform to social norms with respect to lawful behavior as indicated by repeatedly performing acts that are grounds for arrest
- Deceitfulness as indicated by repeated lying, use of aliases or conning others for personal profit or pleasure
- Impulsive or failure to plan ahead
- Irritability and aggressiveness as indicated by repeated physical fights or assaults
- Reckless disregard for safety of self or others
- Consistent irresponsibility as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
- Lack of remorse as indicated by being indifferent to or rationalizing having hurt, mistreated or stolen from another
- Individual is at least 18 years of age
- Conduct disorder with onset before age 15
- Occurrence is not exclusively during a course of schizophrenia or manic episode.
Prevalence of Antisocial Disorder
- 2-3% with men accorded the diagnosis as much as four times more often than women
- Females with same symptoms seen as histrionic, whereas men with symptoms are labeled as antisocial.
Causes of Antisocial Disorder
Prenatal and birth complications
-Smoking and alcohol exposure, low birth weight, early maternal rejection
Physiological dysfunctions
Broken families
-Arguments, instability, neglect, all contribute to antisocial personality disorder
Defects in learning
- People with APD were deficient in avoidance learning.
- Low arousal level
Treatments and Preventions of Antisocial Disorder
Early intervention
- Paying special attention to neglected children
- Prevention programs that are tailored to the unique needs of various groups of children
- Accessible resources for at-risk youth and their families.
- Change the environment of at-risk youth
Histrionic Personality Disorder
- Is uncomfortable in situations where they are not the center of attention
- Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
- Displays rapidly shifting and shallow expression of emotions
- Consistently uses physical appearance to draw attention to self
- Has style of speech that is excessively impressionistic and lacking in detail
- Self-dramatization, theatricality and exaggerated expression of emotions
- Easily influenced by others or circumstances
- Considers relationships to be more intimate than they actually are.
- Once they form relationships, they become demanding, inconsiderate, egocentric and self-absorbed.
- 1.3-3% of the population
Narcissistic Personality Disorder
-Grandiose sense of self-importance
-Preoccupied with fantasies of unlimited success, power brilliance, beauty or ideal love
-Believes that he can or she is special and unique and can only be understood by or should associate with other special or high status people
-Requires excessive admiration
Sense of entitlement, unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
-Is interpersonally exploitative
-Lacks empathy, unable or unwilling to recognize or identify the feelings and needs of others
-Often envious of others or believes that others are envious of him or her
-Shows arrogant, haughty behavior or attitude.
->.5% of the population
Causes of Histrionic and Narcissistic Personality Disorders
- Failure to develop empathic relationships with caregivers fails to develop, resulting in a fragmented sense of self that is especially vulnerable to feelings of emptiness and low self-esteem and the compensatory behaviors that these generate.
- Expects too much from others.
Borderline Personality Disorder
- Frantic efforts to avoid real or imagined abandonment
- Pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
- Identity disturbance, markedly and persistently unstable self-image or sense of self
- Impulsivity in at least two areas that are potentially self-damaging
- Recurrent suicidal behavior, gestures, threats or self-mutilating behavior
- Affective instability due to a marked reactivity of mood
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger
- Transient, stress-related paranoid ideation or severe dissociative symptoms.
- High likelihood of suicide (8%)
- Equally prevalent in men and women.
- Disorder becomes less severe as the person ages: erratic behavior decreases, interpersonal relationships improve
- Likely to misremember or misinterpret social interactions, to be manipulative and enter into destructive relationships
- Unusual perceptiveness and insight into the feelings of other people.
- Higher than average education level and come from upper class families
Etiology of BPD
Psychodynamic View
- Sufferers dichotomize the world.
- Causes person to behave in extreme, erratic ways
- Early childhood abuse and trauma
Biological
- Reduced serotonin activity
- Brain trauma
Treatment of BPD
Dialectical Behavioral Therapy
- Systematic treatment that includes weekly individual psychotherapy and group skills training.
- Based on motivational skills deficit model that presumes that people with borderline personality disorder lack important interpersonal, self-regulation and distress tolerance skills
Psychodynamic Approach
- Transference Focused Psychotherapy
- To bring patient’s unconscious reactions and conflicts to the surface so that they can be discussed and worked through within a structured therapeutic setting.
- Aimed to help control impulses that can undermine therapeutic process.
Drugs
-Antipsychotic drugs, SSRIs,
Anxious Fearful Disorders
- Avoidant Personality Disorder
- Dependent Personality Disorder
- Obsessive Compulsive Personality Disorder
Symptoms of Avoidant Personality Disorder
- .4-1.3% of population
- Can be an overlapping of generalized social phobia
- Axis I diagnosis
DSM-IV
- Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval or rejection
- Is unwilling to get involved with people unless certain of being liked
- Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
- Is preoccupied with being criticized or rejected in social situations
- Is inhibited in new interpersonal situations because of feelings of inadequacy
- Views self as socially inept, personally unappealing or inferior to others
- Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing
Treatment for Avoidant Personality Disorder
- Progressive exposure
- Social skills training that emphasizes the development of intimate relationships
Symptoms of Dependent Personality Disorder
- 7% of population
- More in women than men
DSM-IV
-Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
-Needs others to assume responsibility for most major areas of his or her life
-Has difficulty expressing disagreement with others because of fear of loss of support or approval
Has difficulty initiating projects or doing things on his or her own because of a lack of self-confidence in judgement or abilities rather than a lack of motivation or energy
-Goes to excessive lengths to obtain nurturance and support from others to the point of volunteering to do things that are unpleasant
-Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for him or herself
-Urgently seeks another relationships as a source of care and support when a close relationship ends
Is unrealistically preoccupied with fears of being left to take care of him or herself
Obsessive Compulsive Personality Disorder Symptoms
- 1% of population
- More common amongst men
DSM-IV
- Pervasive pattern of preoccupation with orderliness, perfectionism and mental 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 of the following:
- Preoccupied with details, rules lists, order, organization or schedules to the extent that the major point of the activity is lost
- Shows perfectionism that interferes with task completion
- Excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by economic necessity)
- Is overconscientious, scrupulous and inflexible about matters of morality, ethics or values not accounted for by cultural or religious identification
- Is unable to discard worn-out or worthless objects even when they have no sentimental value
- Is reluctant to delegate tasks or to work with other unless they submit to exactly his or her way of doing things
- Adopts a miserly spending style toward both self and others; money is viewed something to be hoarded for future catastrophes
- Shows rigidity and obstinance.
Emil Kraeplin’s (1856-1926) theory of schizophrenia
Not until 1880 when schizophrenia was properly differentiated from other forms of madness
-Called it dementia praecox, meaning “early deterioration.”
-Hypothesized that it was caused by malfunctioning glands that interfered with the nervous system.
Therefore, a biomedical procedure would be the cure.
Adolf Meyer’s (1866-1950) view of schizophrenia
- Said that it was a cognitive and behavioral disorganization associated with schizophrenia arose from inadequate early learning and reflected “adjustive insufficiency” and habit deterioration
- Individual maladjustment rather than biological malfunction lay at the root of the disorder.
- Meyer gave impetus to a tradition that focused on learning and interpersonal processes.
Schizophrenia’s Five Types of Delusions
1) Delusions of Grandeur
2) Delusions of Control: one’s thoughts and behaviors are being controlled from the outside.
3) Persecution: higher powers at work and are out to get them.
4) Ideas of reference: involve beliefs that certain events or people have special significance for the person, such as newscaster speaking to them
5) Somatic delusions: Something seriously wrong with their body
Schizophrenia’s Auditory Hallucinations
Auditory
-Either a running voice giving commentary on the individual’s behavior, or two voices conversing with each other about the patient.
Visual
-Like dreams except there is no mechanism in the brain to tell the person they are dreaming.
Schizophrenia’s Disorganized Speech
- “Word salads”
- Derailment: speech that drifts from one topic to the other
- Tangential: bearing little or no relationship to the question asked
- Loose association
- Clang associations: rhyming words
- Neologisms: new words that have a private meaning
- Repetition
Schizophrenia: Grossly disorganized
- Quickly polarizing behavior
- Disheveled, poor hygiene, inappropriate clothes or excess clothing.
Schizophrenia: Catatonic Behavior
- Little to no movement, frozen in space, sometimes in an uncomfortable or awkward position
- Amount of this has decreased, likely due to the effective medications being used to treat schizophrenia
Diagnosis Process for Schizophrenia
1) 6 or more months with one month of characteristic symptoms
2) Schizoaffective and Mood Disorder exclusion:
- No major depressive, manic or mixed episode have occurred concurrently with active-phase symptoms or
- If mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods
3) Substance or general medical condition exclusion
4) Relationship to a pervasive developmental disorder
Subtypes of Schizophrenia: Paranoid
- Delusions of persecution are complex and coherent
- Either intensely emotional or very formal
- No severely disorganized behavior, incoherence or loose associations.
- No blunted or inappropriate emotions
- Often attracted to prominent places
Subtypes of Schizophrenia: Disorganized
- Inappropriate reaction or emotion to external stimuli
- Voluble, bursting into meaningless conversation for long periods of time.
- Sometimes involves delusions or hallucinations
- Often center on patient’s own body
- Poor hygiene and grooming, sometimes -incontinence
Subtypes of Schizophrenia: Catatonic
- Either enormously excited or strikingly frozen: occasionally may alternate between the two states.
- Danger to self and others in state of excitability and needs prescriptions to control them
- Frozen states: often done because of hallucinations of death and destruction and the tiniest amount of movement will cause enormous catastrophe
Subtypes of Schizophrenia: Undifferentiated
- Undifferentiated Schizophrenia
- When the type of schizophrenia does not fit into any other categories but there is still the presence of psychotic symptoms and interpersonal maladjustment
Subtype of Schizophrenia: Residual Schizophrenia
- Delusions, hallucinations, incoherence or grossly disorganized behavior.
- Social isolation
- Withdrawal
- Marked impairment in role functioning
- Very peculiar behavior
- Serious impairment of personal hygiene and grooming
- Blunt, flat, inappropriate or emotional expression
- Odd, magical or bizarre thinking
- Unusual perceptual experiences
- Apathy or lack of initiative
- Can occur after a period of paranoid or differentiated schizophrenia
Acute Schizophrenia
-Sudden onset of very florid symptoms caused by a precipitating event.
Chronic schizophrenia
- Prolonged and gradual period of decline
- No specific stressor or crisis can be identified
- Childhood history gives evidence of interpersonal problems, poor school adjustments and social withdrawal
Positive vs. Negative Symptoms
Type I/Positive
-Delusions, hallucinations, certain forms of thought disorder
Type II/Negative
- Flat affect, poverty of speech, social withdrawal, loss of volition
- Reflect absence of diminution of normal functions
-Most patients have positive and negative
Prevalence of Schizophrenia
-1% of population
-Varies among countries, though differences are not significant
-Surprisingly rates between countries are
similar.
-Onset is in late adolescence and adulthood
-Mainly men before age of 25, with majority at
age 24
-Women have better prognosis since they better retain social skills:
-Estrogen reduces severity of symptoms.
-Children rarely diagnosed
-Rarely past age of 35
Schizophrenia: Cognitive deficits
1) General intelligence, reasoning, memory and attention
2) Inclusiveness: Related unrelated ideas to a concept
- Patient illustrated a person’s hair as caterpillar heads, fingers and worms
3) Memory: both implicit and explicit
4) Lack of abstract reasoning
5) Communication
6) Perceptual Deficits
Schizophrenia: Perceptual Deficits
1) Spatial distortions
- Spaces are smaller, objects farther away
2) Backward masking: patients with schizophrenia require longer time period between the presentation of the target and the mask in order to identify the target
-Even patients with 20/20 vision have these deficits, therefore, a faulty neuron processing might be to blame.
Schizophrenia: Motor Deficits
1) Movement abnormalities
2) Spontaneous movement: motor efficiency and coordination deficits
3) Slower reaction times
Schizophrenia: Emotional Deficits
- Less likely to be able to correctly identify emotions
- Therefore offer impractical solutions to interpersonal problems because of a lack of ability to read or interpret social motives.
- May have something to do with visual perception deficits
Birth complications leading to schizophrenia
1) Swelling of the limbs during pregnancy
2) Hypoxia
3) Viral infections
4) Stress
Early Onset Indicators
1) Impeded neurological development: cognitive, motor, attention and focus, perception and senses,
2) Emotional instabilities
3) Abnormal temperament
Predating Schizophrenia: Schizotypal Personality Disorder
1) Abnormal thoughts and unusual ideas
2) Social withdrawal
3) Axis I disorders
4) Involuntary movement of the upper limbs, face and trunk
Neurochemistry of Schizophrenia: The Neuotransmitters involved
1) Dopamine: treated with L-Dopa.
- Schizophrenia patients who take it sometimes end up with symptoms of Parkinson’s
- People with Parkinson’s who take it are at risk of psychosis.
- Greater release of dopamine by neurons in the striatum, a subcortical region of the brain.
- Increased cortisol increases dopamine activity.
2) Decrease in GABA
3) Increased serotonin levels
Schizophrenia: Brain Structure
1) Larger ventricle areas
2) Decrease in size of:
- Frontal lobes (Also a decrease in activity)
- Temporal lobes
- Amygdala
- Hippocampus (most common)
Treatment of Schizophrenia: Drug
1) Chlorpromazine and haloperidol
- Has decreased the average hospital stay to two weeks rather than months, years to lifetime.
Side-Effects
- Dystonia
- Muscle rigidity
- Akathisia: peculiar itchiness in the muscles that results in an inability to sit still and an urge to pace
- Parkinsonism
- Hypotension
- Constipation
- Dry mouth
- Blurred vision
- Sleepiness
Treatment of Schizophrenia: Antipsychotics
- Ameliorate thought disorders and hallucinations
- Only treats negative symptoms
Side Effects
-Dry mouth and throat, drowsiness, visual disturbances, weight gain or loss, menstrual disturbances, constipation, depression, Parkinson’s like movements and spasms
-Akathisia: peculiar itchiness in the muscles that results in an inability to sit still and an urge to pace the halls continuously and energetically.
-Tardive dyskinesia: sucking, lip-smacking, tongue movement that seem like fly-catching.
Affects 24% of patients and does not always go away.
Increases with age
Treatment of Schizophrenia: Clozapine
- Agranulocytosis: deficiency in white blood cells, leading to infection, severe fever and even death
- As a consequence, Clozapine must be monitored closely, making it very expensive
Treatments for Schizophrenia: Interpersonal Therapy
1) Interpersonal Therapy
- Discussion of social experiences, role playing of social interactions and various didactic procedures intended to improve social problem solving.
- Beneficial, especially with medication
- Education, stress-management and skills training
- Treatment is lengthy, lasting sometimes three years.
Treatments for Schizophrenia: Cognitive Rehabilitation
2) Cognitive rehabilitation: Attention, memory and executive function
- Although it is debatable that it works since these are just the symptoms of the illness, not the illness itself
- Shows no signs in improving reasoning deficits.
Treatments for Schizophrenia: Integrated Psychological Therapy
3) Integrated Psychological Therapy
- Set of structured intervention programs that are derived from both cognitive rehabilitation and principles of social skills training.
- Attempts to remedy the cognitive and behavioral dysfunctions that are characteristic of schizophrenia
Treatments for Schizophrenia: Ideal Treatment
4) Ideal Treatment
- Carefully monitored psychopharmacological intervention, psychological intervention into a framework of community program.
Treatments of Schizophrenia: PACT Treatment
5) Program of Assertive Community Treatment
- Recipients receive the multidisciplinary, round-the-clock staffing of a psychiatric unit, but within the comfort of their own home and community
