Lecture 12 - Personality Disorders Flashcards
Personality
*Traits and behaviors that characterize a person
* “Big Five” Factors– FFM
*Neuroticism
*Extraversion
*Openness to Experience
*Agreeableness
*Conscientiousness
Personality disorders
*Personality Disorders
* Introduced in 1980, in DSM-III
*Means of distinguishing longstanding maladaptive
ways of relating to the world from phasic clinical
“syndromes”
*Largely ignored by researchers until 1980
-DSM-III devoted Axis II to these conditions
Varying degree in different situations
-Rigidity in personality pathology (doesn’t really adapt in different situations)
Extreme levels of normal personality traits for personality disorders
DSM-5 Definition
*“A Personality disorder is:
* an enduring pattern of inner experience and behavior that:
*deviates markedly from the expectations of the individual’s
culture
*is pervasive and inflexible (maladaptive to circumstances)
*has an onset in adolescence or early adulthood… Develop gradually over time
*is stable over time
*and leads to distress and impairment.”
-Really dramatically interfere with people’s functioning
Not thought of as diathesis-stress disorders
Not all them cause distress to the person, some cause distress to others
Egosyntonic
-Does not cause distress to the individual
Egodystonic
-Does cause distress to the individual
Categories of Personality Disorders
*Cluster A: Odd / Eccentric
-paranoid
-schizoid
-schizotypal
*Cluster B: Dramatic / Emotional / Erratic
-antisocial
-borderline
-histrionic
-narcissistic
*Cluster C: Anxious / Fearful
-avoidant
-dependent
-obsessive compulsive
Prevalence and Problems
*Prevalence:
*Varies hugely, depending on study
and population
*4- 15% in the general population
*Much higher in inpatient settings
*Comorbidity rates are extremely
high
-With other PDs (the norm)
-With major disorders: Mood,
anxiety, substance use, etc.
Since the DSM-III…
*Quite a bit more research on
Personality Disorders
*However, many of these
conditions are poorly researched
*Controversies:
* Is there a difference between
Axis I and II conditions?
*Are personality disorders a
difference of degree or a
difference of kind?
*What does it mean to be
diagnosed with 2+ personality
disorders?
Lack of research problems in prevalence
More typical to have 2 pds than only 1
Problems with Assessment
* Insight– who reports?
-Limited insights on how they interact with other people/what effect they have on other people
* Informants? ? (people in the person’s life)
-but if nominated informants, might have a different relationship than with most other people
*Who nominates the
informants?
*Current mood states can
exacerbate PD symptoms
-Most seek treatment when acutely distressed
-hard to untangle what is actually going on
*Different assessment
instruments often deliver
different dx
- Inter-rater reliability for categorical
diagnoses
-Reasonable: .86 to .97
*Test-retest reliability (agreement in
diagnosis over time)
-People can fluctuate in their presentation of the disorder (can explain test-retest reliability)… but if supposed to be chronic…
*Weak: .11 to .57
*These estimates have been
improving somewhat in recent
years
*Personality disorders can be
successfully treated!
-If can be treated… is it really personality? It is really chronic?
Revisions proposed
Categorical vs. Continuous
*Many argue better viewed as
constellations of traits
*Each along a continuum
*Proposed as a revision for DSM-5
*Hybrid dimensional-categorical
model
Proposed Revision to DSM-5
*Categorical component:
*Winnow list of PDs from 10 to 6.
Keep:
*Antisocial/ psychopathic
*Avoidant
*Borderline
*Narcissistic
*Obsessive-Compulsive
*Schizotypal
*Eliminate:
*Dependent, Histrionic, Schizoid, Paranoid
Why wanted to eliminate those 4
-very limited research
But proposition did not pass
Much easier with categorical definition
Gender and Cultural Issues
*Potential for misdiagnosis based on
perspective of clinician
*Few clear behavioral indicators, no
discrete time-period
*3 or more drinks in 3 hours on 3 or more
occasions
*Much more leeway to the clinician
*
“Disregard for – and failure to honor –
financial and other obligations or
commitments; lack of respect for – and
lack of follow through on – agreements
and promises.”
Not as specific
Not always sensitive to context
*Clinicians are typically RELUCTANT to
-Diagnose women with APD
-Diagnose men with Histrionic PD
*Aggression in APD may take different forms in
men and women, depending on culture
* “Histrionic” explicitly gendered
-Histrionic comes from histeria:
- Histeria (womb drying up (by not having children) and start to rise towards throat to get humidity, impeding breathing = problems behaving normally…).. funny how only females have wombs
*Warner (1978)
- 175 mental health professionals diagnose
case history
-½ of cases described as a woman
-½ described as a man
* 76% of female cases dx HPD (histrionic) vs. 49% male
cases
*80% of individuals identified as BPD
are women
*Men can have BPD
-may manifest differently in men and
women
*15 to 25% of male federal inmates dx of
Psychopathy
*VERY few female federal inmates
*Does not seem to represent true
prevalence if look at responses on a
checklist
*Biases in Dx or true differences?
Comorbidity and Diagnostic Overlap
*Both problems with PDs
* Of people diagnosed with
BPD
-47% met criteria for APD
-57% for histrionic
*APD has overlapping
symptoms with both Schizoid
and NPD (narcissistic)
*Huge conceptual overlap
within clusters
*Highly comorbid with “Axis I”
disorders
*Avoidant, dependent highly
comorbid with anxiety and
depression
*BPD comorbid with unipolar,
bipolar, PTSD
*Substance use disorder
comorbid with ASPD, BPD,
NPD
*Avoidant comorbid with all
Eating Disorders (ED)
*Highest comorbidity for AN-R
and BED = OCPD
Diagnostic heterogeneity
Two people with same diagnosis can have vastly different symptoms
Example: in borderline personality disorder, could have just 1 symptom in common yet same diagnosis
The notion of a personality
disorder is clinically compelling
*Clinically, difficult patients present with problems
that primarily appear to arise from problems in
interpersonal relationships
- Intrapersonal vs. Interpersonal
*They may have anxiety, depression, etc - but these
appear to be secondary to problematic ways of
interacting with the world
*Complicates treatment
Personality disorders… more like interpersonal disorders?
Cluster A PDs: Paranoid, schizoid, schizotypal
*Odd and Eccentric Disorders
*Least well-studied of the PD clusters
Paranoid Personality Disorder
*Pervasive
Suspiciousness
*Tendency to see self
as blameless
*On guard for
perceived attacks by
others
* Occurs more commonly in the
families of people with
Schizophrenia
- Viewed as a related disorder– a
“cousin”
* Primary difference is in the severity
- Often a very fine line between the
two
-my neighbour is plotting to steal my land = paranoid
-neighbour plotting with the devil to steal my land = paranoid and schizophrenia
* Significant diagnostic overlap with
avoidant and BPD
Schizoid Personality Disorder
*Near total lack of interest in
intimate involvement with others
*Limited emotional responsiveness
* “Loners”
-Perceived as cold, indifferent
*Diagnostic criteria overlap with
Schizotypal Personality Disorder
*Recent data suggest it may be
more related to asocial disorders
(e.g., Autism spectrum)
-Desire to connect in people on autism spectrum, but no desire in schizoid pd
-Prefer to be a loner
*One of those proposed for
exclusion
Schizotypal Personality Disorders
*Cognitive and perceptual
distortions
*Eccentricity of thought or
behavior
-Odd beliefs, odd speech
-Magical thinking
–(thoughts bring about reality…like in ocd), looking for “signs” like numbers, have magic powers…
-Telepathy, clairvoyance
-Ideas of reference: Ideas of reference: Thinking that conversations or gestures made by other people have special meanings, patterns
*Has to be atypical for the person’s culture (ex: if part of religious community, normal to have these kinds of beliefs. So wouldn’t be diagnosed)
*Contact with reality maintained
*Great deal of overlap with
Schizophrenia
*Severity and quality of
symptoms
*Eccentric and odd, but not
delusional
*Some argue a mild or
prodromal Schizophrenia
-Similar lab things in schizotypal and schizophrenia: Eye tracking deficits, sustained attention, working memory, language abnormalities…
*Familial co-aggregation
*Found in both Schizophrenia
spectrum Disorders and
Personality Disorders in DSM
Within Cluster A
Paranoid and schizotypal (using twin study)
-long-term stability
-genetic overlap
Cluster B: Borderline, histrionic, narcissistic, antisocial
Dramatic/ Emotional/ Erratic
Histrionic PD
*Highly dramatic, lively,
extraverted
*High excitement seeking
*Low self-consciousness
*Preoccupation with physical
appearance
* Irritability and temper outbursts
if attention seeking is frustrated
*Demanding in amount of attention needed from others
*Sexually provocative
*Very dependent
*Need for center of attention, but more emotionally expressive and less dismissive of others than people with narcissistic pd
*Often comorbid with bipolar disorder
*Abt 2-3% prevalence
*Sex differences
-Much more likely diagnosed in women
-but not really difference if in checklist
Narcissistic PD
*Grandiosity: Inflated sense of self-importance
-grandiose vs. vulnerable (unstable self-esteem) (2 profiles)
*Preoccupation with receiving
attention
*Self-Promoting
*Lack Empathy
*Easily offended
*Highly variable clinical
presentation
*Complicates treatment
- Increased likelihood of
dropout
-Slow symptom change
*Hypercritical and retaliatory
if they are not validated
*Male students w/ high
narcissistic tendencies
-more likely sexually coercive and aggressive
*< 1%
*May be more common in
males than females
*Etiology:
-Grandiose associated with
parental overvaluation
- Vulnerable associated with
emotional, physical, sexual
abuse/ intrusive, controlling,
cold parenting styles
*In couple’s therapy, often a lot of advice for the therapist.. lol
*Histrionic, borderline and antisocial comorbidity
Borderline and antisocial PDs in other lecture
Cluster C: Avoidant, dependent, obsessive-compulsive
*Anxious and fearful
Avoidant Personality Disorder
*Avoiding interpersonal
contact
-Extreme sensitivity to
criticism and disapproval
*Avoid intimacy, though they
desire it
*Extreme Loneliness, low selfesteem, excessive selfconsciousness
*Contrast with Schizoid?
-Not because interpersonal contact undesirable, want it! But scared
-Want contact and more emotionally expressive than people with schizoid pd
* Differential Dx with Generalized Social Phobia
very difficult
* Substantial overlap
* Can find SP without Avoidant
* Very rare to find avoidant without SP
* Shared genetic vulnerability
* Fear of evaluation is also heritable
* Distinct diagnoses may not be warranted
* Chopping block
Dependent Personality Disorder
Helpless when alone
People pleasing
Bpd and separation anxiety overlap
More common in women
* Inability to function independently
*Adopt a submissive role in
relationships
*Allow other people to assume
responsibility for multiple
important aspects of their lives
- Jobs, classes, clothes, hair styles
*Some data to suggest more likely
to be involved in abusive
relationships (limited)
*Relatives of male DPD:
increased depression
*Relatives of female DPD:
increased panic
*Very culture-specific:
-More prevalent in
individualistic cultures
-Much less prevalent in
collectivist cultures
*Chopping Block
Obsessive-compulsive PD (OCPD)
* Inflexibility and a desire for
perfection
*Preoccupation with rules and
order
*Often moralistic and judgmental
*Viewed by others as rigid,
stubborn, cold
*Most stable features: rigidity,
stubbornness, perfectionism,
reluctance to delegate most
common and stable features
*VERY limited research since 1980
*NO true obsessions or compulsive
rituals
-Not always associated with
anxiety and/or extreme distress
-Can be egosyntonic
*About 20% of OCD pts comorbid
OCPD
*About 20% of Panic Disorder
comorbid OCPD
*OCD more likely to be comorbid
with avoidant or dependent pd
*Perfectionism, preoccupation with
details, hoarding
