Module 7 - Personality Disorders Flashcards
What is schizotypal PD associated with (diagnostic overlap and comorbidity)
2.5x more likely to have a substance abuse disorder
7.6x more likely to have anxiety disorder
7.5 mood disorder
6.6 PTSD a year later
26.5 lifetime likelihood of BPD
13.6 lifetime likleihood of NPD
In a Denmark study how many schizotypal cases developed into schizophrenia?
33.1%
Treatment for schizotypal
Treatments are underdeveloped.
Antipsychotics and psychotherapeutic intervention (CBT, cognitive remediation, social skills) produce mixed results
Anx and paranoia symptoms appear most responsive to psychotropics
ASPD criminality association
Approx half of people with Antisocial personality disorder have a history of criminal offending and is more prevalant among those who have longer criminal sentences (46%) in comparison to shorter sentences (36%)
Unlike other PD”s the DSM requires that essential ASPD features…
begin in childhood or early adolescence.
Specifically individuals must show evidence of conduct disorder with onset prior to 15 y/o.
Risk factors for ASPD early in life
adverse childhood experiences (abuse, neglect)
coercive parenting
neurological abnormalities (reduced volume in PFC), and pre and perinatal complications
General ASPD risk factors
50% appears to be genetic variance (specific genes actually confer general risk of developing externalizing behaviour broadly).
These broad vulnerabilities are shaped into an ASPD-specific presentation overtime via interactions with environmental risk factors (child adversity, prenatal complications)
ASPD treatment
Underdeveloped.
A few small scale RCT’s provide support of CBT efficacy, menatlization based therapy, and schema therapy
BPD clinical features
One of the most debilitating and stigmitized Psychiatric conditions.
-High rates of self inflicted injury (SII)
-Co-occuring illness
-impaired social functioning
-Functional impairment (often so severe they require public assistance
-Approx 8-10% will die from suicide
-Hallmark feature is chronic and profound instability across emotional, behavioural, cognitive, interpersonal and identity related domains
BPD diagnostic criteria
1) frantic efforts to avoid real or imagined abandonment
2) Pattern of unstable and intense interpersonal relationships characterized by idealization and devaluation
3) Markedly and persistently unstable self-image or sense of self
4) impulsivity in at least two areas that are potentially self damaging (excessive spending, reckless driving, substance use, unsafe sexual behaviour, or binge eating)
5) recurrent deliberate self-injurious behaviours and/or threats of suicide
6) affective liability and marked mood reactivity
7) chronically feeling empty
8) inappropriate or intense anger or difficulty controlling anger
9) transient, stress-related paranoid ideation or severe dissociative symptoms ( feeling unreal, losing sense of time)
BPD Treatment
Evidence based psychosocial interventions:
-Dialectical based treatment (DBT)
-Mentalization based treatment (MBT)
-Transference-focused psychotherapy (TFP)
DBT
Dialectical based treament is an outpatient program for BPD that includes weekly individual therapy and skills-based group sessions where clients learn mindfulness, emotion regulation, distress tolerance, and interpersonal skills.
*DBT is strong evidence based
How do we conceptualize personality disorders?
PD’s are associated with maladaptive, extreme or overly rigid traits.
Dimensional frameworks like the FFM that are based on
1) personality traits are continuously distributed in population
2) personality pathology reflects extreme variants of typical personality traits
Categorical framework like DSM assumed manifestation of PD was through a number of discrete disorders defined by a polythetic criteria set (diagnosed with only a subset of symptoms w/o meeting all criteria)
Ex: meeting 4 out of 8 list of symptoms - leaving room for variability in individual disorder presentation.
PD revision in DSM 5 - alternate framework in section III
Limitations on diagnostic model of PD’s (challenges presented in conceptualization)
Cultural issues:
Research is often on WEIRD samples and even when research does focus on underrepresented groups they do so with one non-majority group at a time, therefore any moderating effects or intersectional identities (such as combined marginalized status as a result fo sexual and ethnic identity) on PD development are largely unknown
Gender Issues:
Effects if internalized homophobia may resemble the patterns of stormy relationships that characterize BPD. But because gender identity and sexual orientation are not typically questioned we risk increased misdiagnosis for these communities.
Comorbity:
Co-occurance of among personality disorders is excessive, but this may result from significant redundancy of PD criteria. More study in etiological factors are needed to understand why some co-occur at an elevated rates.
Reliability:
-Base rates of these disorders are low and epidemilogical research is limited, thus studying these conditions is limited.
-PD’s are associated with a # of inaccurate and harmful stereotypes
-PD’s long considered untreatable and to this day few disorders have empirically supported treatments
What are the different kinds of PD’s
Cluster A: Odd and Eccentric
Cluster B: Dramatic, emotional or erratic
Cluster C: Anxious and fearful
What are the key characteristics of Paranoid Disorder
Pervasive mistrust, suspiciousness, and resentment of others.
Hypersensitive to interpersonal cues, assume innocuous stimuli have special meaning for them, inclined to interpret others’ behaviour as spiteful
Hypervigilence, inclined to attribute negative events to outside sources - specifically another person
Treatment for PPD
Critically understudied. Limited research on interventions that target paranoia as a symptom of other disorders.
What are the key characteristics of Schizoid Disorder
-Detatchment
- Withdrawal from social relationships
- Restricted range of emotional expression in social settings
- Reduced sensitivity to pleasure (bodily, sensory, interpersonal)
4 of 7 symptoms:
1) no desire or enjoyment of close relationships
2) Indifference to praise or criticism from others
3) Little to no interest in having sexual experiences with other
4) Almost always choosing solitary activities
5) Lack of close friends/confidants other than first degree relatives
6) Displaying emtoional coldness, detacthment, or flat affect
7) Taking pleasure in few, if any, activities
Treatment for Schizoid
Evidence based treatments are lacking.
Condition is largely related to social isolation so treatment is rarely seeked and if it is it is usually about other concerns (depression)
What are the key characteristics of Shizotypal Disorder
Eccentric behaviour - odd mannerisms
Cognitive and perceptual distortions(believing clairvoyance, hearing voice whisper one’s name)
Impaired interpersonal functioning
Transient psychotic symptoms - lasting minutes to hours (lower in severity and frequency than a psychotic disorder)
Features groups in 1) interpersonal 2) Cognitive 3) disorganization
5 of 9 symptoms:
COG:
1) non-delusional ideas of reference
2) odd beliefs and magical thinking
3) paranoia
4) unusual perceptional or somatic experiences
IP::
5) lacking close friends
6) persistent social anxiety even with familiarity
7) Constricted or inappropriate affect
DISORGANIZED:
8) odd/eccentric behaviours and appearance
9) odd thinking/speech
Treatment for schizotypal
Underdeveloped.
Studies examining psychotropics focus on antipsychotics and produce mixed results - anxiety and paranoia seem most responsive.
Psychotherapeutic results are mixed.
What are the key characteristics of Narcisstic Disorder
Lac of empathy
Grandiose sense of self importance
Socio-emotional dysfunction
Significant interpersonal problems
Diminish importance of failure and avoid responsibility
Seek out high status individuals
High achieving
Prosocial behaviours when result in personal gain
Treatment of Narcisstic Disorder
Challenging to treat due to consider variabiity in presentation, highs rates of comorbidity, poor insight and high dropout rates.
Individuals with NPD are more likely to seek out treatment for co-occuring issues (substance use, mood disorders) and IP.
Evidence based treatments are very much needed, guidelines are lacking. But some researchers have proposed psychodynamic-oriented therapies, scheme therapy, CBT and DBT
What are the key characteristics of Histrionic
Remains less studied than most PD’s.
-Exaggerated emotional expressions
-Excessive attention-seeking behaviours
-Difficulty developing and maintaining IP intimacy and perceive relationships to be more intimate than they are
- DSM -displays provactive or sexually seductive behaviours in socially inappropriate social contexts
Treatment of Histrionic
2 single studies found significant reductions in symptoms after functional analytical psychotherapy - a theraputic approach using behavioural principles like shaping through positive reinforcement to treat presenting problems
Another study showed CBT for violence reduction
What are the key characteristics of Anti Social
Disregard for and violation of others’ rights.
Aggression
Impulsivity
Poor self regulation
May lack remorse for wrongdoings
May display indifference for hurting someone
Irresponsibility
ASPD features are understudied and poorly understood
What are the key characteristics of Avoidant PD
Maladaptive avoidance of social experiences, driven by perceptions of inadequacy and extreme sensitivity to negative evaluation and rejection.
Anxiety, fear, low self esteem = core features
Tend to be colder, more submissive
A interpersonal disorder. Associated with impairment in major life domains. Low self efficacy, mental distress, lower education achievement, lower income.
Functional impairment among highest or all PD’s.Co-occuring with Dependent PD.
Treatment for APD
Treatments with most empirical support are CBT, schema therapy (and to lesser extent psychodynamic therapies).
CBT targets maladaptive beliefs and incporporates social skills training as well as beh. experiments to challenge fears.
Group CBT shows efficacy with improving fears of negative evaluation
Social schema - 80% recovery rates copared with treatment as usual.
What are the key characteristics of Dependant PD
Submissive attitudes and behaviours
Extreme reliance on others
Maladaptive persuits of IP connection
BEH. Features:
-Clinging to others
-Frequent reassurance seeking
-Inappropraite bids for help (asking others to make every day decisions)
Patterns of passivity and accomodation of others, however not always passive and submission, bc DPD is also tied to perpetuating aggression and violence.
They report more general health problems - seek out medical advice, high treatment adherence and low drop out
DPD treatment
Individuals with DPD and other cluster C PD”s show greater treatment progress when recieving short term care (6 months or less).
Some positive evidence with CBT, short-term dynamic therapy and relational therapy.
One study found evidence for adapted mindfulness for reducing dependency related problems
2 RCT’s showed clarification-oriented psychotherapy (COP) effective for reducing symptoms and increasing self efficacy
What are the key characteristics of Obsessive compulsive PD
Perfectionism and preoccupation with control and orderliness
Often rigidly adhere to rules/procedures and take great pains to avoid making mistakes
Get lost in trivial details
Repeatedly scan for mistakes
Extremely critical of own and others work
4 of 8 symptoms:
1) Preoccupation with rules, details, orders, lists, organization or schedules to the point that the main purpose is lost
2) Perfectionism that interferes with task completion
3) excessive devotion to work and productivity to the point of excluding leisure activities and friendships
4) excessive concientiousness, inflexibility regarding values, morality and ethics
5) unwillingness to discard worn out or worthless objects
6) reluctance to delegate tasks
7) extreme frugality with one’s or other’s money
8) rigidity and stubbornness
Treatment of OCPD
Empirical evidence limited.
Preliminary evidence for certain psychotropic med’s (carbamazepine; anti convulsant, fluvoxamine; SSRI)
Pharmacological and psychological RCT’s are lacking
Difference between schizotypal and schizotypy
Terms are often used interchangeably. The two constructs overlap significantly however not all your have schizotypy will develop schizotypal PD.
Schizotypy is a person with genetic liabilty for schizophrenia, but who may or may not progress to full blown psychotic illness.
Why are ASPD individuals more likely to engage in aggressive activity?
Due to cognitive biases, whereby ambiguous or neutral social cues are interpreted as hostile (hostile attribution bias)
Dialectical Behavioural therapy
CBt appraoch to BPD.
Main feature is acceptance of therapist of the patients demanding and manipulative behaviours.
Using exposure treatment for internal and external cues that evoke distress, skills training, contingency management, and constructive restructuring.
Criteria for assessing abnormal behaviours
Personal distress
Violation of norms
Personal dysfunction
Statistical rarity
Difference between OCPD and OCD
OCPD:
-do not view symptoms as problematic (egosyntonic)
- do not experience obsessive symptoms and demonstrate greater capacity to delay rewards than OCD
- rigidity and excessive self-control appear to be specific to OCPD
OCD:
-Egodystonic (view symptoms as problematic)
-Obsession appear to be specific to OCD
