Lecture 11: Personality disorders: Chapter 15 Flashcards
How can you define personality disorders?
Enduring problems with forming a stable positive identity and with sustaining close and constructive relationships. They are characterized by extreme and inflexible traits
What are the 3 clusters of personality disorders?
A: odd/eccentric
B: dramatic/erratic
C: anxious/fearful
What are the 3 disorders in the cluster A: odd/eccentric category?
- Paranoid
- Schizotypical
- Schizoid
What are the 4 disorders in cluster B: dramatic, emotional, erratic?
- Histrionic
- Narcissistic
- Antisocial
- Borderline
What are the 3 disorders in Cluster C: anxious/fearful?
- Avoidant
- Dependent
- Obsessive Compulsive
What are the 3 P’s of personality disorders? What do they mean?
- Pervasive: inflexible, in many different situations
- Persistent: stable, long term, start early adulthood
- Pathological: distress/dysfunction
A personality disorder has an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. It manifests in 2 or more of 4 domains. Which domains?
- Cognition
- Affectivity
- Interpersonal functioning
- Impulse control
What are 3 characteristics of personality traits in a personality disorder?
- Extreme
- Inflexible
- Dysfunctional
What does it mean that personality disorders are ego-syntonous?
The disorder is not seen as a problem by the person itself. Situations impact their behavior, not their personality
What are common comorbidities of personality disorders?
Other PD’s, autism, mental retardation, chronic syndrome disorder, circumstances
When is the typical onset of a general personality disorder according to the DSM?
In early adulthood, persists for a long duration
What percentage of people meets the diagnostic criteria of a personality disorder?
1 out of 10
What is the impact of culture on classification of PD?
Cultural attitudes toward emotion expression (especially cluster C)
What is a comorbid disorder for cluster B, cluster C and antisocial disorder?
B: mood disorders
C: anxiety disorders
Antisocial: substance use disorder
What is the best way of assessing PD’s? On which diagnosis do many experts often disagree?
Use structured interviews –> high interrater reliability
Schizoid PD is ofted disagreed upon
What are 3 concerns of classifying PDs using the DSM?
- Disorders are not as stable as the definition implies
- Extremely high rates of comorbidity
- Thresholds for defining diagnosis are arbitrary
What is the top 3 of most prevalent PD’s in treatment settings? And what is the top 3 of most prevalent PDs in the community?
Treatment:
1. Avoidant
2. Borderline
3. Obsessive compulsive
Community:
1. Antisocial
2. Borderline
3. Obsessive compulsive/paranoid
What is the issue with the DSM concerning the fact that personality disorders aren’t stable over time?
The definition of personality disorders suggest it should be stable over tiem, but it seems that about half of the people diagnosed with a personality disorder at one point in time did not meet the criteria for the same diagnosis 2 years later.
So personality disorders may not be as enduring as the DSM asserts
What is an explanation of the high comorbidity of PDs? What percentage of people with PD meets criteria of another PD?
A lot of PDs share similar symptoms, e.g. schizotypical, avoidant and paranoid emphasize social withdrawal –> these PDs often co-occur
50% meets criteria other PD
How is the test-retest stability of personality disorders?
Low, because 16 years after the diagnosis, 99% doesn’t meet criteria anymore
What is the problem of arbitrary thresholds for diagnosing PDs?
These thresholds aren’t based on scientific evidence. Subthreshold symptoms can interfere with functioning as well
The number of symptoms required is arbitrary. People who meet the criteria for a PD are extremely varied in the severity of their functional impairment
What is the alternative DSM model for personality disorders?
- It includes only 6 of the 10 DSM PDs (no schizoid, histrionic, dependent disorders (rarely occur) and paranoid PD (often co-occurs))
- Diagnosis only when person shows persistent and pervasive impairments in functioning from early adulthood
- Clinician determines the personality traits that explain difficulties in functioning
How do clinicians assess the personality traits that explain difficulties in functioning in the alternative approach to the DSM? (2)
- Five personality trait domains
- 25 more specific personality trait facets (dimensions)
What are the 3 key strengths of focusing on personality traits in diagnosing PDs?
- Personality trait ratings are more stable over time
- 25 dimensional scores provide richer detail than categorical PD diagnoses
- Personality traits are related to many psychological disorders
- Personality traits robustly predict important outcomes (happiness, friends, stress, health)
- Clinicians rate the personality trait profile as easier to discuss with clients and more helpful for treatment planning
What are the 5 personality trait domains?
- Negative affectivity vs. emotional stability
- Detachment vs. extraversion
- Antagonism vs. agreeableness
- Disinhibition vs. conscientiousness
- Psychoticism
What are facets of negative affectivity vs. emotional stability?
Anxiousness - emotional lability - hostility - perseveration - separation insecurity - submissiveness
What are facets of detachment vs. extraversion?
Anhedonia - depressivity - intimacy avoidcance - suspiciousness - withdrawal - restricted affectivity
What are facets of antagonism vs. agreeableness?
attention seeking - callousness - deceitfulness - grandiosity - manipulativeness
What are facets of disinhibition vs. conscientiousness?
Distractibility - impulsivity - irresponsibility - (lack of) rigid perfectionism - risk taking
What are facets of psychoticism?
Eccentricity - cognitive perceptual dysregulation - unusual beliefs and experiences
What is the expectancy of the development of the alternative model (ICD-11) compared to the classic DSM model for PDs?
The alternative model will become major approach for classification PDs
What is the prevalence of PD in:
1. General population
2. Outpatient care
3. Inpatient clinics
4. Prisons
?
- 9-13%
- 30-50%
- 50-70%
- 60-70%
What is the main explanation of PDs in psychoanalytic and behavioral theory?
Emphasis on parenting and early developmental influences
What is a possibility why genetics contribute to vulnerability of PDs?
Personality traits (neuroticism and impulsivity)
What are the heritability estimates of PDs? Which has the highest heritability?
between 0,6-0,8
Highest for obsessive-compulsive, schizotypical, narcissistic and antisocial
Which PD has the highest correlation with child abuse/neglect?
Narcissistic (18x more likely than controls), then borderline (7x more likely)
What does it mean that personality disorders are strongly related to early adversity?
Offspring who experienced childhood abuse or neglect had a higher risk of PDs
How can we integrate findings regarding genetic and environmental influences?
There is a large impact of genetics on PDs. So we have to be careful about interpreting results of parenting and early environments
Describe the magnitude of the effect of childhood adversity on the risk for personality disorders as observed in the Children in the Community Study
- Children who experienced abuse or neglect were 18 times more likely than those with no history of abuse/neglect to develop narcissistic personality disorder, 7 times more likely to develop borderline and 5 times more likely to develop antisocial PD.
- Parental neglect increased the risk of avoidant personality disorder
- All 6 PDs were related to aversive or unaffectionate parental styles
What is the similarity between cluster A odd/eccentric PDs and schizophrenia? What is the difference with schizophrenia?
They both have bizarre thinking and experiences
Difference: less severe functional impairments, no hallucinations
What is the difference between Cluster A PDs and delusional disorder?
Full blown delusions aren’t present in delusional disorder
What are the 7 symptoms of paranoid PD? How many symptoms have to be present?
Presence of four or more of following signs of distrust and suspiciousness from early adulthood across many contexts:
- Unjustified suspiciousness of being harmed, deceived or exploited
- Unwarranted doubts about the loyalty or trustworthiness of friends
- Reluctance to confide in others because of suspiciousness
- Tnedency to read hidden meanings into benign actions of others
- Bearing grudges for perceived wrongs
- Angry reactions to perceived attacks on character or reputation
- Unwarranted suspiciousness of partner’s fidelity
What are the 7 defining symptoms of schizoid personality disorder? How many symptoms have to be present?
Presence of 4 or more of the following signs of aloofness and flat affect from early adulthood across many contexts:
- Lack of desire for or enjoyment of close relationships
- Almost always prefers solitude to companionship
- Little interest in sex
- Few or no pleasurable activities
- Lack of friends
- Indifference to praise or criticism
- Flat affect, emotional detachment, coldness
What are the 9 symptoms of schizotypical personality disorder? How many symptoms have to be present?
5 or more of signs of unusual thinking, eccentric behavior and interpersonal deficits from early adulthood across many contexts
- Ideas of reference
- Odd beliefs or magical thinking (belief in extrasensory perception)
- Unusual perceptions
- Odd thoughts and speech
- Suspiciousness or paranoia
- Inappropriate or restricted affect
- Odd or eccentric behavior or appearance
- Lack of close friends
- Social anxiety and interpersonal fears that don’t diminish with familiarity
What are the 2 axes in the old DSM?
1: syndromal
2: personality
What is the general impact of PDs on the individual and society?
- High disease burden
- High consumption of care
- Low quality of life
- High societal costs
Which personality traits improve with life normally? (4)
- Social dominance
- Conscientiousness
- Agreeableness
- Emotional stability
Which personality trait decreases with life? Which personality goes up and then goes down again with life?
Decrease: social vitality
Up then down: openness to experience
Why is it worth it to treat people with PD?
5x faster recovery with treatment then with natural course
What is the course of personality disorders through life?
Onset in adolescence with many symptoms that don’t persist. Slowly it becomes more mild, but participation in society and quality of life are lagging
Explain the diathesis stress model
Heritable predispositions + early experiences influence strenghts and vulnerability (diathesis)
Diathesis + support/stress result in complaints and symptoms, which have a feedback loop going back to diathesis and stress
What are 3 neurotransmitter systems involved in PDs? How do they impact symptoms?
- Dopamine (cognitive problems, cluster A)
- Serotonin (anger, impulse control)
- MAO (aggression)
Which 2 brain areas are generally speaking involved in PDs and what are their functions in PDs?
- Lack of frontal cortical control: impulses/emotions
- Dysfunction amygdala: hyperemotionality or hypo-emotionality
Why did we think personality disorders were untreatable? (3)
- Low motivation to help these people, because they often don’t want to be helped, drop out and because of clinician’s biases (they’ve done it all themselves so why help).
- Too short treatment time available
- Cases that are treated the longest often don’t benefit
What is the main take away of research on specific genes involved in personality disorders?
Almost all genetic factors involved in PDs are not specific for 1 PD only. So the categories of PDs are dimensional and mixed in nature
What are 4 things that influence PD etiology concerning family environment?
- Abuse/neglect
- Nurture
- Modelling
- Divorce
What are besides family, 2 other environmental factors contributing to PDs?
- Low SES
- Peer influences
What were the results of Caspi’s MAOA study?
- MAOA is a gene that breaks down serotonin
- If low activity MAOA combined with maltreatment –> more violent behavior
Why is Caspi’s research so famous?
He had the best sample ever and did 22 years of research on this topic
How can the HPA axis be involved in PDs?
HPA axis controls stress hormones
What are 2 types of early experiences contributing to PDs in the diathesis stress model?
Trauma + deprivation
What are 3 things of strenghts and vulnerabilities (diathesis) contributing to PDs in the diathesis stress model?
Schemas, neuro-endocrine (HPA), personality
Give an example of magical thinking in schizotypical PD
Belief that they can read other people’s minds or see into the future
What are ideas of reference in schizotypical PD? Give an example
Belief that events have an unusual meaning for them personally
E.g. idea that a TV program is conveying a special message designed for them
What are inaccurate sensory perceptions in schizotypical PD?
Recurrent illusions
E.g. sensing the presence of a force or a person who’s not actually there
What is a typical symptom in speech in schizotypical PD?
Use words in unusual and unclear fashion
Give an example of eccentric behavior in schizotypical PD
Talk to themselves, wear disheveled clothing
What is the relation between schizotypical PD and schizophrenia? (4)
- Some people with schizotypical PD develop more psychotic symptoms over time and a small proportion develops schizophrenia over time
- Genetic vulnerability overlaps with schizophrenia (so relatives of people with schizophrenia have a higher risk of developing schizotypical PD)
- Similar cognitive and neuropsychological functioning deficits
- Both have enlarged ventricles
What are possibly the causes of odd thinking and bizarre behavior in schizotypical PD?
Genetics and childhood adversity
Which PD is most centrally characterized by an aloof interpersonal style?
Schizoid PD
What is the similarity between antisocial and borderline PD?
Both involve high levels of impulsivity
What is the similarity between the cluster B: dramatic/erratic?
Highly inconsitent behavior, inflated self-esteem, rule-breaking and exaggerated emotional displays
What are 7 symptoms of histrionic personality disorder? How many symptoms have to be present?
5 or more of signs of excessive emotionality/attention seeking from early adulthood across many contexts
- Strong need to be center of attention
- Inappropriate sexually seductive behavior
- Rapidly shifting and shallow expression of emotions
- Use of physical appearance to draw attention to self
- Speech that is impressionistic and lacking in detail
- Exaggerated, theatrical emotional expression
- Being overly suggestible
- Misreading relationships as more intimate than they are
What is the similarity between antisocial PD and psychopathy?
Similar: law breaking
Difference: antisocial is in DSM, psychopathy not
What are the 3 defining symptoms of antisocial personality disorder?
- Age at least 18
- Evidence of conduct disorder before age 15
- Pervasive pattern of disregard for the rights of others since the age of 15
One of the symptoms of antisocial PD is: Pervasive pattern of disregard for the rights of others since the age of 15. Which 7 ways are often seen for this? How many are needed to fulfill this symptom?
3 needed of the following:
1. Repeated law breaking
2. Deceitfulness, lying
3. Impulsivity
4. Irritability, aggressiveness
5. Reckless disregard own safety and that of others
6. Irresponsibility (employment, financial history)
7. Lack of remorse
What is the difference in prevalence of antisocial PD between genders?
Men are 5x more likely to meet the criteria
What percentage of prison inmates meet criteria of antisocial PD?
More than 50%
What are the 5 criteria of psychopathy?
- Lack of emotions (positive and negative)
- No sense of shame
- Superficially charming and use that charm to manipulate for personal gain
- Lack of remorse –> irresponsible behavior and cruel acts toward others
- Rule-breaking behavior for thrills and financial gain
What are 3 core traits that underpin psychopathy symptoms? What does each one explain?
- Boldness –> explains social poise, successfulness and charm
- Meanness
- Impulsivity
2 and 3 explain negative outcomes of psychopathy
What are the 2 main differences between antisocial PD and psychopathy?
Antisocial:
1. Less affective symptoms (shallow affect, lack of empathy)
2. Requires symptoms before age 15
What is the PCL-R (Psychopathy Checklist Revised)? What are the 2 factors?
Scale to assess psychopathy. It also covers many criteria of antisocial PD, but has more affective symptoms included as well
factors:
1. Affect/interpersonal: callous/unemotional
2. Behavior: antisocial/impulsive
What are the main issues of integrating findings of research into the etiology of antisocial PD and psychopathy?
- Research is conducted on persons with 2 different diagnoses, so potential differences in etiologies are missed
- Most research was on people who were convicted of crimes, so it may not be generalizable to people who haven’t done crimes or avoid it
The genetic vulnerability of antisocial PD overlaps with the genetic vulnerability of …
What does this explain?
Substance use disorders
It explains the high comorbidity
What is the children in the community study?
It describes that parenting qualities can predict antisocial behavior
Adoption research has shown that genetic, behavioral and family influences are hard to disentangle. Why is that?
The genetically influenced antisocial behavior can provoke harsh discipline and lack of warmth in parents and these may in turn affect the child’s antisocial tendencies
Why do people with psychopathy often repeat misconduct that has been harshly punished?
They seem unable to learn from experience, because they are insensitive to threats
What symptoms at age 3 predict psychopathy at a later age?
Lower skin conductance to aversive stimuli
What is the consequence of lower skin conductance to aversive stimuli in psychopathy?
It contributes to difficulty of learning from aversive feedback. So there is diminshed classical conditioning
What causes a person with psychopathy to become even more unresponsive to threats and break more rules?
When they are trying to gain a reward (money, resources)
Which brain area is responsible for the low response to threats in people with antisocial PD and psychopathy?
Lower activity in amygdala
What might explain the callous exploitation of others in psychopathy?
Lack of empathy, poor emotion recognition
Which 2 brain regions are involved in the insensitivity of other people’s emotions in psychopathy?
Amygdala and ventromedial PFC
Why has borderline PD been a major focus of research interest? (3)
- Very common in clinical settings
- Hard to treat
- Associated with recurrent suicidality
What are 2 core features of borderline PD?
Impulsivity + instability in relationships and mood
What is experience sampling? Why is it used?
Method in which people report on their feelings or behavior several times per day for weeks
Used to understand emotional and interpersonal responses
Give an example of the fact that people with borderline PD don’t have a clear and coherent sense of self
They experience major swings in their values, loyalties and career choices. E.g. switching carreer plans from business man to actor to becoming an artist
What percentage of borderline PD died from suicide? What percentage of people with BPD engage in self harm?
7,5%
2/3 engage in self-harm
What are the 9 defining symptoms of borderline PD and how many do you need to get the diagnosis?
5 or more of the signs of instability in relationships, self-image, impulsivity from early adulthood across many contexts:
- Frantic efforts to avoid abandonment
- Unstable interpersonal relationships in which others are idealized or devalued
- Unstable sense of self
- Self-damaging (spending, substance abuse, binge eating)
- Recurrent suicidal behavior or gestures or self-injurious behavior
- Marked mood reactivity
- Chronic feeling of emptiness
- Recurrent bouts of intense or poorly controlled anger
- During stress, a tendency to experience transient paranoid thoughts and dissociative symptoms
What is a good predictor of borderline PD?
difficult parental relationships
What may be a neurobiological explanation of borderline PD?
Diminished connectivity between regulatory control regions (PFC/ACC) and emotion response regions (amygdala)
This leads to poor control over emotions and impulsivity when emotions are present
What is Linehan’s biosocial theory of borderline personality disorder? Describe in 5 steps + what drives it
Biological vulnerability leads to:
1. emotional dysregulation in the child
2. great demands on the family
3. Invalidation by parents through punishing or ignoring the demands
4. emotional outbursts by child to which parents attend
5. more emotional dysregulation in the child
According to Linehan’s specific borderline model, what is the core of borderline?
Emotional regulation
How do parents end up reinforcing borderline behavior in Linehan’s model? Describe in 3 steps
- If parents ignore or suppress child’s outbursts, it leads to suppression of emotions in child.
- The suppressed emotions build up to an explosion, which gets attention of the parent
- Reaction of parent reinforce the behaviors they find aversive
What is the common pattern in borderline PD in family setting?
A chronic back-and-forth between dysregulation and invalidation
What finding indicates that abuse is not the driving force that sets BPD in motion?
Research in monozygotic twins where 1 kid was abused. The twin pairs had similar levels of BPD symptoms, so childhood abuse doesn’t predict BPD after controlling for genetic risk
How can we make sense of high rates of abuse among those with borderline PD?
Impulsivity and emotionality are genetically driven, meaning that parents of kids with BPD have elevated levels of impulsivity and emotionality. This could increase the risk that both abuse and BPD will occur
What are the 9 symptoms of narcissistic personality disorder? How many have to be present?
5 or more of the following signs of grandiosity, need for admiration and lack of empathy from early adulthood across many contexts
- Grandiose view of one’s importance
- Preoccupation with one’s success, brilliance, beauty
- Belief that one is special and can be understood only by other high-status people
- Extreme need for admiration
- Strong sense of entitlement
- Tendency to exploit others
- Lack of empathy
- Envy others
- Arrogant behavior or attitudes
Why are interpersonal relationships disturbed in narcissistic PD?
Lack of empathy, arrogance, their feelings of envy, feelings of entitlement and expectations that others will do special favors for them
In some studies, researchers provided feedback that they were successful. What is the difference in reaction between narcissistic PD and controls?
Narc: attribute successes to their abilities rather than to chance
What is the main goal of social interaction in people with narcissistic PD?
Bolster their own self-esteem and get admiration of others
When are people with narcissistic PD most likely to be aggressive?
When they’re faced with a competitive threat or a put-down
Why do people with narcissistic PD often have problems in romance?
They seek out high-status partners whom they idealize and proudly show off, which eventually leads to marital dissatisfaction
What is some evidence that a bit of narcissism is adaptive?
US presidents who are rated as more narcissistic were more persuasive and won more of the popular vote
What are 2 main factors contributing to the etiology of narcissistic PD?
- Parenting style that promote children’s belief that they’re special
- Fragile self-esteem
What is Kohut’s fragile self-esteem model? What theory is it derived from?
Derived from psychodynamic theory
- Characteristics of self-absorption and self-importance mask a fragile self esteem
- People with NPD want to bolster self worth through unending quests for respect from others
- Denigration + good self-worth are defense mechanisms against feelings of shame
What is some evidence of research on self-esteem and external feedback in narcissistic PD?
These people show more reactivity than others in case of negative feedback or social exclusion
Which brain regions are more active in a social exclusion experiment in narcissistic PD?
Higher activation in anterior insula and ACC, that are associated with processing social and other forms of pain
Why may it be questioned that fragile self esteem is core to the diagnosis of narcissistic PD?
It’s present only in a subset of those with this disorder and many of the patients are rated as highly grandiose with no signs of showing feelings of vulnerability by clinicians
So many with narcissistic traits may not show fragile self-esteem
What are the 8 symptoms of dependent personality disorder and how many symptoms have to be present?
Excessive need to be taken care of, as shown by the presence of at least 5 of the following from adulthood across many contexts
- Difficulty making decisions without excessive advice and reassurance from others
- Need for others to take responsibility for most major areas of life
- Difficulty disagreeing with others for fear of losing their support
- Difficulty doing things on onw or starting projects because of lack of self-confidence
- Doing unpleasant things to obtain approval and support of others
- Feelings of helplessness when alone because of fears of being unable to care for self
- Urgently seeking a new relationship when one ends
- Preoccupation with fears of having to take care of self
What are the 7 symptoms of avoidant personality disorder and how many have to be present?
Pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to criticism, as shown by 4 or more of the following from early adulthood across many contexts:
- Avoidance of occupational activities that involve significant interpersonal contact, because of fears of criticism or disapproval
- Unwilling to get involved with people unless certain of being liked
- Restrained in intimate relationships because of the fear of being shamed or ridiculed
- Preoccupation with being criticized or rejected
- Inhibited in new interpersonal situations because of feelings of inadequacy
- Viewing self as socially inept, unappealing or inferior
- Unusually reluctant to try new activities because they may prove embarrassing
What is a common comorbid disorder of avoidant PD? Why (2)?
Social anxiety disorder
- The criteria for both disorders are so similar
- The genetic vulnerabilities overlap
What are the 8 symptoms of obsessive-compulsive personality disorder? How many have to be present?
Intense need for order, perfection and control as shown by presence of at least 4 symptoms from early adulthood across many contexts
- Preoccupation with rules, details and organization to the extent that the point of activity is lost
- Extreme perfectionism interferes with task completion
- Excessive devotion to work to the exclusion of leisure and friendships
- Inflexibility about morals and values
- Difficulty discarding worthless items
- Reluctance to delegate unless others conform to one’s standards
- Miserliness
- Rigidity and stubbornness
Why do people with obsessive compulsive PD seem to have less interpersonal difficulty than those with other PDs?
It’s not tied to major problems in friendships, family relationships or romantic relationships, regardless of whether their own report or another’s report is used to evaluate those relationships
it’s less related to functional impairment than other personality disorders
What is the difference between obsessive compulsive personality disorder and obsessive compulsive disorder?
The PD doesn’t include obsessions and compulsions that define the latter
What are the 3 main models of PDs? Give 2 examples of each
- Learning/behavioral: conditioning/modelling & Linehans emotion-regulation
- Cognitive: Beck & Young (maladaptive schemas)
- Psychodynamic: Mentalization & object-relations
What are the 3 learning/behavioral theories of PDs? Explain each one
- Classical conditioning: if I attach to a person I will be hurt
- Operant conditioning: if I force my way, I get what I want
- Modelling: witnessing your parents resolve conflict with clashes over and over again
What is the cognitive model of Beck? Describe in 4 steps
- Situation occurs (he’s leaving earlier then expected)
- Activation of schema (people are selfish and abusive)
- Thought (he doesn’t care about me, he’s abusing me)
- Alarm
What is young’s maladaptive schema theory?
Extension of Beck’s cognitive theory
Basic needs are not met (safety, autonomy, boundaries etc)
–> activation of early maladaptive schemas that were useful/adaptive in the past
How many maladaptive schemas did young describe?
18
E.g. mistrust/abuse: expectation that others will hurt, abuse, humiliate, lie, manipulate or take advantage
What is the object relations model? How can you link it with PDs?
Internalized representation of self in relation to the object (other person)
In PD there are immature defense mechanisms, such as splitting (it’s either all good or all bad, no in between)
What is the mentalization model? How does it link to PDs?
Understanding the behavior of the other and self in terms of one’s mental states
PD: when stressed, mentalization goes out the window
What is the hypothesis on how mentalization develops?
Mentalization is learned as primary caretakers mirror and name the child’s emotions
What are 3 roadblocks in treating PD? What are 3 requirements of treating PD?
Roadblocks:
1. Life threatening behaviors
2. Therapy damaging behaviors
3. Motivation
Requirements:
1. Safety
2. Incentive to change
3. Possibility of new positive experiences
What are the big 4 treatments in borderline personality disorders?
- Dialectical behavioral therapy
- Schema (focused) therapy
- Mentalization based treatment
- Transference focused psychotherapy
For what issues do people with personality disorders seek treatment? Give an example
Often for a condition other than their PD
E.g. antisocial: substance abuse
dependent: depression
What kind of results are made in psychotherapy of PDs?
Changing personality traits such as neuroticism
Which medications are often used to supplement psychotherapy and why?
Antidepressants to alleviate some of the depressive symptoms
What does psychodynamic theory state about the root of personality disorders? So what would be the aim of psychodynamic therapy?
Childhood problems are at the root of PDs
Aim: help patients reconsider early experiences, become aware of how these experiences drive current behaviors and reconsider their beliefs and responses
For example, a psychodynamic therapist might guide a man with obsessive-compulsive personality disorder to realize
that his need to be perfect is based on a childhood quest to win his parents’ love and that
this quest does not need be carried into adulthood—that others will love him even with his
imperfections
What does cognitive theory state about the root of PDs?
Negative cognitive beliefs are the root of PDs and that feelings and behaviors are primarily a function of thoughts.
Cognitive therapy explores biases in thinking and dysfunctional assumptions or schemas
What is an effective treatment of schizotypical PD? Treatment of what other disorder overlaps with this?
Antipsychotic drugs
Schizotypical personality disorder overlaps with schizophrenia
What is an effective treatment of avoidant personality disorder?Treatment of what other disorder overlaps with this?
Cognitive Behavioral therapy with at least 20 sessions + antidepressants
CBT focuses on challenging negative beliefs about social interactions by teaching behavioral strategies + exposure treatment to take part in social situations
Social anxiety disorder
Why is the therapeutic relationship hard in borderline PD? What is the consequence of this?
These clients find it hard to trust others. Borderline patients idealize and vilify the therapist with no in between
This often leads to therapy sessions at odd hours and countless phone calls in crisis periods
How do therapists deal with working with borderline PD patients?
They are often overwhelmed and overly involved. They often consult with other therapists for advice and support. Sometimes phone calls at 2 am can be because someone is suicidal or it’s just a manipulative ask for help
What is dialectical behavioral therapy?
It combines empathy and acceptance with cognitive behavioral problem solving, emotion regulation techniques and social skills training
Therapists examine the triggers for risky behaviors and provide the client with tools to manage and reduce these symptoms
What is dialectics?
The constant tension between any phenomenon (e.g. an idea or event) and its opposite, which is resolved by creating a new phenomenon
What are the 4 stages of DBT (dialectical behavioral therapy)?
- Addressing dangerous impulsive behaviors
- Focus on modulating extreme emotionality –> notice emotions in non-judgmental manner
- Improving relationships and self-esteem
- Promote connectedness and happiness
On which model is dialectical behavioral therapy based (DBT)?
Linehan’s model
What is transference-focused therapy? Which theory is linked to it?
Emphasis on relationship with therapist and on the powerful feelings that clients can sometimes develop toward their therapists
Help consider parallels between their response to the therapist and their experiences in other relationships. It helps clients understand and manage their relationships in a healthy manner
Based on psychodynamic theory, object-relations theory
What is mentalization therapy and what theory is it linked to?
Focus on helping clients to be more reflective about their own feelings and those of other people, to avoid acting automatically without thinking when emotions or interpersonal stressors occur
mentalization theory, psychodynamic theory
What is schema focused therapy and what theory is it linked to?
Identifying maladaptive schemas from childhood and reducing these
cognitive theory (beck, young)
What are the first, second and third wave therapies of borderline?
- behavioral therapy (learning principles applied to overt behavior)
- classic CBT (inclusion of maladaptive cognitions)
- Meta cognitive therapy, mindfulness based cognitive therapy, acceptance and commitment therapy (transdiagnostic), dialectical behavioral therapy
What is transference?
When someone redirects their feelings about one person to someone else
What are the similarities between all theories of borderline? (3)
- Influence of early childhood
- Internal working model of the world is involved in all patients
- Distorted experiences of the other or events in all patients
What borderline therapy has the lowest dropout and therefore is most effective?
Schema therapy
What is a downside of transference focused psychotherapy (TFP)?
High dropout risk
Which therapy is good for stabilizing and reduction of auto-mutilation in borderline?
Dialectical behavioral therapy
What is the benefit of mentalization based treatment?
It’s simple and works well for severe cases of borderline
What is a benefit and a downside of schema focused therapy?
It has a very wide scope, but it’s very demanding of capacities
How is theory of mind in cluster B and C personality disorders?
They have a better ToM than average, but no stress induction
What is the empty chair technique in treatment of PDs?
It lets a client switch roles between themselves and for example a parent
It diminishes the punitive parent mode
What percentage of people with antisocial PD is also psychopathic?
15-25%
What are 4 common factors in treatments of PDs?
- Intensive/prolonged
- Consistent model/rationale
- Holding & incentive to change
- Healthy alternative
What is the common factor in most theories of difficulties of personality?
Genetically inherited vulnerabilities are combined with internal working model of the world that is too rigid and not adaptive
