Personality and psychopathology

Question 1

What is the DSM?

Answer 1

Diagnostic and Statistical Manual of Mental Disorders

Question 2

What was DSM-IV like?

Answer 2

• Axis 1: depression, anxiety, schizophrenia, and others – basically all psychological diagnostic categories except mental retardation and personality disorder
• Axis 2: personality disorders – Borderline, obsessive-compulsive; narcissistic personality disorder, etc.
• Disorders change as science advances

Question 3

What was DSM-V like?

Answer 3

• Now grouped on a single axis
• Logic: no rational basis for separating personality disorders from Axis 1 condition
• Evolving debate

Question 4

What are DSM-V Personality Disorders?

Answer 4

• Antisocial
• Borderline
• Avoidant
• Dependent
• Narcissistic
• Histrionic
• Obsessive-Compulsive
• Paranoid
• Schizoid
• Schizotypal

Question 5

What is Borderline personality disorder (DSM)?

Answer 5

-A pervasive pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following

Question 6

Borderline personality disorder (criteria) criteria 1-4

Answer 6

1) Frantic efforts to avoid real or imagined abandonment
2) A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation (e.g. thinking really highly of someone, but the following week feeling negative feelings towards them)
3) Identity disturbance: markedly and persistently unstable self-image or sense of self (e.g. don’t know who they are or what they stand for)
4) Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5.

Question 7

Borderline personality disorder (criteria) criteria 5-9

Answer 7

5) Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour (e.g. if you leave me I’ll kill myself)
6) Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
7) Chronic feelings of emptiness
8) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
9) Transient, stress-related paranoid ideation or severe dissociative symptoms

Question 8

Differences between Medical vs Dimensional Model?

Answer 8

• Diagnosis implies dichotomous distinction
• One has the disorder vs one does not (you either have the disorder or not don’t)
• Akin to diagnosis for infectious disease etc.
• This is a problematic assumption
• Can be seen as a continuum rather that it being black and white

Question 9

What did Widiger and Trull argue?

Answer 9

• Plate tectonics in the classification of personality disorder
• Argues that the DSM is wrong for being categorical

Question 10

Failures of the Categorical Model - Excessive co-occurrence:

Answer 10

• If these disorders are unique entities one should not see very much co-occurrence (shouldn’t be diagnosed with multiple disorders)
• i.e. we don’t expect to see cancer diagnoses correlate with, say, heart problems.
• However, many individuals with one personality disorder meet diagnostic criteria for others
• e.g. sizeable proportion (c. 20%) with antisocial PD also meet diagnosis for narcissistic PD

Question 11

Failures of the Categorical Model - Heterogeneity among persons with the same diagnosis:

Answer 11

• e.g. two individuals can receive OC PD diagnosis, but share few of the clinical features!
• If someone has a physical disease, they are unlikely to have all of the same symptoms
• Categorising people can put people into blunt categories

Question 12

Failures of the Categorical Model - Unstable boundaries

Answer 12

• How does one know when a clinical feature has been sufficiently met?
• e.g. “Rigid perfectionism: Rigid insistence on everything being flawless, perfect, without errors or faults, including one’s own and others’ performance; sacrificing of timeliness to ensure correctness in every detail; believing that there is only one right way to do things; difficulty changing ideas and/or viewpoint; preoccupation with details, organization, and order. ”

Question 13

What did Haslam, Holland and Kuppens do with a statistical technique?

Answer 13

• Use a certain statistical technique
• Allows you test whether for a group of individuals there is a continuum for symptoms, or whether there are separate distinctions
• Dimensions are present, have mental disorders to varying degrees

Question 14

Difficulties with adopting a dimensional approach

Answer 14

• Clinical utility – Helpful to have a firm diagnosis: aids communication; can matter for insurance purposes
• Psychiatrists are not in the academy; learning a new taxonomy stemming from a different research tradition can be an issue
• Many dimensional models exist – More than a dozen; which one should we adopt?

Question 15

A Five-Factor Model of Personality Disorder: Advantages

Answer 15

• Universality – FFM traits are established to be, more or less, cross culturally valid
• Better understandings of why disorders co-occur – NB Not specific to the FFM approach
• Heterogeneity can be better understood – e.g. OCD features may differ across individuals because of the N and C facet scores – Again, not specific to the FFM; HEXACO etc could provide this benefit

Question 16

What did Lynam and Widiger find when looking at NEO scores and personality disorders?

Answer 16

-Authors had several experts score each of the personality disorders on NEO-PI-R facets
-Asked to answer what someone with borderline disorder would look like
– So, 6 facets per dimension
– 30 facets in total
-Good agreement across raters
-Overlapping between antisocial, narcissistic and compulsive behaviours

Question 17

Does DSM-V Alternative Model for PDs?

Answer 17

-DSM-V recognises these concerns – Includes a section on dimensional models
-Key points:
– Addresses 6 PDs: antisocial; avoidant; borderline; narcissistic; obsessive compulsive; schizotypal
-Highlights impairments in personality functioning and traits
-Functioning is a bit like the main DSMV diagnostic criteria
-The traits add something new

Question 18

What 5 broad domains are noted, which largely reflect the FFM/B5 ?

Answer 18

– Negative affectivity (i.e neuroticism)
– Detachment (i.e. introversion)
– Antagonism (ie. low agreeableness)
– Disinhibition (i.e. low conscientiousness)
– Psychoticism (not very well captured in FFM/B5 terms)
– And each of these domains has 5 facets.

Question 19

Borderline Personality Disorder – Alternative Diagnostic Criteria (section A)

Answer 19

Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following:
– Identity: self-image, emptiness, dissociative states under stress
– Self-direction: goals, values.
– Empathy: failure to recognise needs of others; prone to feel slighted/insulted.
– Intimacy: intense, unstable, conflicted close relationships

Question 20

Borderline Personality Disorder – Alternative Diagnostic Criteria (section B)

Answer 20

-Four or more of the following seven pathological personality traits, at least 1 of which must be impulsivity, risk-taking or hostility.
– Emotional lability (facet of Negative Affectivity)
– Anxiousness (facet of Negative Affectivity)
– Separation insecurity (facet of Negative Affectivity)
– Depressivity (facet of Negative Affectivity)
– Impulsivity (facet of Disinhibition)
– Risk taking (facet of Disinhibition)
– Hostility (facet of Antagonism)

Question 21

Borderline Personality Disorder – Alternative Diagnostic Criteria ADVANTAGES

Answer 21

• Clinicians can document a severity index (vs have or have not); sub-clinical cases can be acknowledged. E.g. give a less severe diagnosis
• Focuses on traits as well as diagnostic labels/behaviours - Might aid with intervention

Question 22

What did Kotov et al find when doing a quantative review of associations between the higher order personality traits in the Big Three and Big Five models and specific depressive, anxiety, and substance use disorders (SUD) in adults.?

Answer 22

• Meta-analytic approach
• Quantitative review of associations between the higher order personality traits in the Big Three and Big Five models and specific depressive, anxiety, and substance use disorders (SUD) in adults.
• Included 175 studies published from 1980 to 2007
• All diagnostic groups were high on neuroticism and low on conscientiousness – Many disorders also showed low extraversion, with the largest effect sizes for dysthymic disorder and social phobia. Disinhibition was linked to only a few conditions, including SUD.
• Big 5 traits are associated with certain personality disorders

Question 23

Explaining the Casual Pathway

Answer 23

-Depression (but other disorders are relevant too):
– Spectrum model
– Vulnerability model
– Scar model

Question 24

What is the spectrum model?

Answer 24

-A depressive diagnosis is simply the most extreme score on a relevant trait (e.g. neuroticism)
-E.g. High or low end on neuroticism which shows depression

Continued…
-Make some intuitive sense
- Does it account for episodic depressive episodes? - i.e. traits are stable
-And what about depression that occurs in people with low levels of N? - major life events (e.g. bereavement; job loss)
-So perhaps better as an account of chronic depression than episodic depression?

Question 25

What is the Vulnerability Model?

Answer 25

-Having a higher/lower level of a specific personality trait increases the probability of developing psychopathology.
-Example: Maladaptive personality traits (e.g. Borderline PD) evoke particular responses from others (e.g. ostracism, rejection); – May in turn facilitate the development of depression.
-Another example: An individual who is very low in conscientiousness; – In turn at higher risk for developing conduct disorder because of the lack of inhibition.

Continued…
-“Ideally, personality would be measured in a large, representative sample early in adult life when most individuals are free of a history of depressive illness…Years later, the lifetime history of MD would be assessed.”

Question 26

What did Kendler, Gatz, Gardener, and Pedersen (2006) find in a longitudinal study?

Answer 26

• Individuals who were measured at their year of birth
• In 1972, they completed a questionnaire about personality
• 25 years later, there was an interview using a mental health measure
• Neuroticism predicted first-onset major depression
• NB they removed anyone from the analysis who had had MD prior to 1974

Question 27

What is the Scar Model?

Answer 27

• If personality traits levels are much higher after the episode has remitted, it would suggest that scarring has occurred
• The scar hypothesis can be evaluated by assessing persons before and after a first depressive episode.
• NB what level of analysis has this scarring occurred?
• Costa and McCrae would presumably argue that its not at the basic tendency level (e.g. Five Factor Theory)

Question 28

Thoughts about all of the models?

Answer 28

-These models are not mutually exclusive – Possible for any given individual to experience all
-Hard to test in many cases
– All require large samples (i.e. low prevalence rates of psychopathology)
– Before and after measurement - Sometimes in early childhood

Question 29

How did Ormel et al question neuroticism?

Answer 29

• Questions whether neuroticism is a waste of time
• Spectrum model
• Neuroticism is the same thing as subthreshold internalising symptoms
• Might be a causal pathway to internalising disorders
• Might be a common cause