Personality Disorder I

Question 1

What is Personality?

Answer 1

• A persona (plural personae/personas): Latin for ‘mask’
• Used by Greek & Roman amphitheater actors
• Outward or surface aspect presented to audience

Question 2

DSM-5: What is a Personality Disorder?

Answer 2

Enduring pattern of inner experience and behaviour that:

• Deviates markedly from the individual’s culture
• It is pervasive, inflexible & stable over time
• Leads to distress or impairment

The pattern is manifested in two or more areas:

• Cognition (ways of interpreting self, others & events)
• Affect (range, intensity, stability & appropriateness of emotional response)
• Interpersonal functioning
• Impulse control

Others:

• Early onset during early childhood (e.g. lack of empathy)
• Tend to externalise their mistakes (hold others accountable for their mistakes, instead of themselves)

Question 3

Core features of Personality Disorder

Answer 3

1. Functional inflexibility
   - Failure to adapt to situations: rigid response
2. Self-defeating
   - Behavioural responses damaging
3. Unstable in response to stress
   - Emotional, behavioural & cognitive instability
4. Lack of insight
   - failure to recognise dysfuntional aspect of personality

Question 4

DSM-5 Personality Disorder Cluster A

Answer 4

Odd/eccentric

• Paranoid
• Schizoid
• Schizotypal

All typified by high levels of introversion (i.e., low extroversion)

Question 5

DSM-5 Personality Disorder Cluster B

Answer 5

Dramatic/emotional/erratic

• Antisocial
• Corderline
• Distonic
• Narcissistic

Question 6

DSM-5 Personality Disorder Cluster C

Answer 6

Anxious/fearful

• Avoidant
• Dependent
• Obsessive-Compulsive

Question 7

Categorical vs. dimensional approach in classifying Personality Disorders

Answer 7

• DSM-5 represents a categorical approach
  
  • assumes that personality disorders represent distinct clinical syndromes
• Advantages: clarity and ease of communicating information
• Disadvantages: difficult to distinguish the threshold where the person goes from a ‘normal’ personality traits through to meeting criteria for a personality disorder
• A gradual move towards a dimensional approach to classifying personality disorders

Question 8

DSM-IV: AXIS I vs. AXIS II

Answer 8

• AXIS I: Major clinical disorders with acute symptoms that need treatment
• AXIS II: Personality disorders (& intellectual disabilities)
  
  • early age of onset
  • enduring and more pervasive effects on daily functioning
  • involvement of self & identity
  • presumed poorer self-awareness
  • lower treatment response
• BUT high degree of co-occurrence of symptoms
  
  • heterogeneity within diagnoses
  • diagnostic unreliability
  • lack of robust scientific evidence
• DSM-5: single-axial model

Question 9

Paranoid PD

Answer 9

Consistent & pervasive pattern of distrust, suspiciousness and prolonged grudges held:

• Believes others intentionally exploit, harm or deceive them
• Reluctance to disclose personal information for fear it may be used against them
• Severely sensitive to criticism & threat => hypervigilant for signs of others to harm them
• Misinterprets comments to indicate concealed, hidden or malevolent intent or motivation
• Hostility, aggression & anger to perceived insults
• Jealousy (distrust & misinterpretation)

Two thirds meet criteria for other PDs

• e.g., Schizotypal, Narcissistic, Borderline & Avoidant

Question 10

Schizoid PD

Answer 10

• Detachment and disinterest in social relationships
  
  • withdrawal into internal world to avoid affect and maintain distance from others
• Sees others as intrusive and controlling
• Flatness of affect: coldness, aloofness, self-absorption, social ineptitude or conceit
• Unresponsive to social criticism: sexually apathetic reflecting incapacity to form interpersonal bonds
• Anhedonia
• Comorbid with schizotypal and avoidant PDs

Question 11

Schizotypal PD

Answer 11

• Marked interpersonal deficits, behavioural eccentricities and distortions in perception & thinking
• Manifest a number of positive and negative psychotic symptoms,
• BUT do not meet criteria for schizophrenia
  
  • e.g. magical thinking, extreme superstition, belief in paranormal phenomenon, bodily illusions, sensory alterations
• Odd thoughts & speech patterns: vague, abstract but retains coherence
• Often seek treatment for anxiety, depression & affective dysphoria (constricted or inappropriate affect)
• Comorbid with borderline, avoidant, paranoid and schizoid PDs

Question 12

Antisocial PD

Answer 12

• Repeated reckless disregard for others
• Victimising& blaming others for inadequacies
• Shallow & manipulative interpersonal relationships
• Self-centered focus & failure to adhere to regulations
• Impulsive, aggressive, charismatic, deceitful
• Experience guilt & depression but lack capacity to empathize
• Anti-social behaviour: criminal behaviours may or may not be present
• Co-morbidity with borderline, narcissistic, histrionic & schizotypal PDs

Question 13

Histrionic PD

Answer 13

• Roots in the concept of hysteria: conversion disorders, emotional instability, anxiety & phobias
• Excessive emotionality, attention-seeking, ego-centric, flirtatious, seductiveness (focus on grooming),
• Denial of anger and hostility
• Gregarious, manipulative, low frustration tolerance, suggestibility, somatization
• Displays of emotions: shallow and fickle in interpersonal relationships
• Comorbid: narcissistic, borderline, anti-social PDs & psychoactive substance abuse

Question 14

Narcissistic PD

Answer 14

• Personalities organised around maintenance of self-esteem by eliciting external adulation to compensate for internal sense of falseness
• Fragile self-esteem, envy, self-consciousness, & vulnerability: “image replaces substance”
• Compensatory reaction: self-righteousness, pride, contempt, vanity & superiority
• Pervasive pattern of grandiosity, sense of entitlement, privilege, or expectation of preferential treatment, exaggerated sense of self-importance, arrogant behaviour & attitudes
• Focus on own issues with insensitivity or impatience to problem of others: cold, disinterested, snobbish, patronising
• Comorbid with: anti-social, histrionic, borderline PDs & substance abuse

Question 15

Avoidant PD

Answer 15

• Pervasive social inhibition, discomfort in social situations, feelings of inadequacy, low self-esteem, hypersensitivity to criticism, disapproval, shame, ridicule & rejection
• Avoidance of activities involving personal contact & groups
• Socially inept/incompetent, personally unappealing, inferior to others
• Comorbid with dependent PD & Axis I mood, anxiety, & eating disorders

Question 16

Dependent PD

Answer 16

• Pervasive need to be taken care of
• Exaggerated fear of being incapable of doing things or taking care of things on their own – reliance on others
• Lacking in self-confidence & requiring constant reassurance
• Often find themselves exploited and in abusive relationships fearing abandonment

Question 17

Core features of Dependent PD

Answer 17

• Self view: needy, weak, helpless & incompetent
• View of Others: Strong caretaker idealised.
• Function well as long as the idealized figure is accessible
• Threats: Rejection or abandonment
• Strategy: Cultivate a dependent relationship by subordinating
• Affect: Anxiety heightened – disruption to the relationship. Depression if their strong figure is removed, euphoria/ gratification when dependent wishes granted

Question 18

Obsessive-Compulsive PD

Answer 18

• Pervasive pattern of perfectionism and orderliness
• Rigidity, inflexibility & stubbornness
• Excessive need for control interfering with ability to maintain interpersonal relationships or employment
• Preoccupied with rules, minor details, structure
• Attention to detail interferes with ability to complete tasks
• Unrealistic standards of morality, ethics or values
• Reluctance to delegate tasks
• Comorbid: borderline, narcissistic, histrionic, paranoid,
• schizotypal PDs
• No significant relationship between OCD & OCPD

Question 19

Core features of Obsessive-Compulsive PD

Answer 19

• Self view: Responsible for themselves & others. Driven by ‘shoulds’.
• View of others: Too casual, irresponsible, self-indulgent and incompetent
• Threats: Any flaws, errors, disorganisation. Catastrophic thinking: things will be out of control
• Strategy: System of rules, standards & ‘shoulds’. Overly directing, punishing and disapproving
• Affect: Regrets, disappointment, and anger toward self and others because of perfectionistic standards

Question 20

Borderline PD: Primary Disturbances

Answer 20

• Emotional instability/affective dysregulation in reaction to environmental & interpersonal situations
  
  • wide range of extreme emotions, intense anxiety, anger, dissociation
• Impulse control
  
  • promiscuity, suicidal behaviour (10% suicide), self-harm, spending, binge eating, poor limit setting
• Identity/insecure attachments
  
  • Unstable self-concept, frantic efforts to avoid real or imagined relationships
  • Inability to integrate +ve and -ve aspects of self-leading of emptiness

Question 21

Psychopathy Checklist-Revised (PCL-R)

Answer 21

• a standardised, semi-structured interview that currently constitutes the most widely accepted instrument for diagnosing psychopathy.
• 2 factors:
  
  • emotional detachment: core personality traits of psychopathy such as callousness, manipulativeness and remorselessness
  • antisocial behaviour: a history of antisocial behaviour, impulsiveness and violence

Question 22

What is the difference between Antisocial PD and Psychopathy?

Answer 22

• A psychopath may score highly on both factors of the PCL-R, but particularly in terms of the emotional detachment factor
• Someone with antisocial personality disorder will score highly on the antisocial behaviour factor alone
• Antisocial PD is more prevalent in prison population
• Also because many psychopaths are endowed with higher socioeconomic status, are socially skilled, and may possess high intelligence,

Question 23

Epidemiology of PDs

Answer 23

• Despite high prevalence, Borderline PD is under-recognised & under-diagnosed
• Symptoms displayed (mood shifts, suicidality, or paranoia) co-occur with other mental disorders
• Concern diagnosis is pejorative & may interfere with clinician’s ability to be empathic