Personality Disorders

Question 1

DSM-5 Definition of Personality Disorder

Answer 1

a persistent pattern of emotions, cognitions and behavior that results in enduring emotional distress for the person affected and or for others and may cause difficulties with work and relationships

Question 2

Personality Disorder
The pattern of maladaptive experience and behavior must also be:

Answer 2

-inflexible and pervasive across a broad range of personal and social situations
-the source of clinically significant distress or impairment in social, occupational or other important areas of functioning
-stable and long duration with an onset that can be traced back at least to adolescence or early adulthood

Question 3

What are the DSM-5 Personality Disorders?

Answer 3

Cluster A: Odd or Eccentric Disorders
1. Paranoid PD
2. Schizoid PD
3. Schizotypal PD
Cluster B: Dramatic, Emotional or Erratic Disorders
1. Antisocial PD
2. Borderline PD
3. Histrionic PD
4. Narcissistic PD
Cluster C: Anxious or Fearful Disorders
1. Avoidant PD
2. Dependent PD
3. Obsessive-compulsive PD

Question 4

What is the reliability of the personality disorder diagnoses?

Answer 4

Low!
-there is a lot of overlap among PD clusters
-gender bias

Question 5

Prevalence of PD

Answer 5

10 to 14%

Question 6

Paranoid PD (cluster a)

Answer 6

a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent and 4 or more of the following:
-suspects others are exploiting, harming or deceiving
-preoccupied with unjustified doubts about loyalty or trust of friends
-reluctant to confide in others because of fear that it will be used against them
-reads hidden meanings into benign remarks or events
-persistently bears grudges
-perceives arrack on character and is easily angered
-recurrent suspicions without justification with fidelity of partner

Question 7

Schizoid PD (cluster a)

Answer 7

A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, as indicated by four or more of the following:
-Neither desires nor enjoys close relationships, including being part of a family
-Almost always chooses solitary activities
-Has little, if any, interest in having sexual experiences with another person
-Takes pleasure in few, if any, activities
-Lacks close friends or confidants other than first-degree relatives
-Appears indifferent to the praise or criticism of others
-Shows emotional coldness, detachment, or flattened affect

Question 8

Schizotypal PD (cluster a)

Answer 8

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior as indicated by 5 or more of the following:
-Ideas of reference (excluding delusions of reference)
-Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, beliefs in clairvoyance, telepathy, or “sixth sense”, bizarre fantasies or preoccupations)
-Unusual perceptual experiences, including bodily illusions
-Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped)
-Suspiciousness or paranoid ideation
-Inappropriate or constricted affect
-Behavior or appearance that is odd, eccentric, or peculiar
-Lack of close friends or confidants other than first-degree relatives
-Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

Question 9

Antisocial PD (cluster b)

Answer 9

There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years (and meets criteria for Conduct Disorder before the age of 15), as indicated by 3 or more of the following:
-Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
-Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
-Impulsivity or failure to plan ahead
-Irritability and aggressiveness, as indicated by repeated physical fights or assaults
-Reckless disregard for safety of self or others
-Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
-Lack or remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
**2-3 million in North America (only 100 are serial killers)
**no sense of shame or guilt or empathy for others & unable to learn from experience (Dr. Harvey Cleckley)
**Lee Robins (1996) did a longitudinal study of children with conduct disorder (30 years, compared psychotic and antisocial children’s characteristics)

Question 10

Etiology of Antisocial PD

Answer 10

Bio: amygdala is less active and smaller, orbital cortex functions differently, ventromedial prefrontal cortex is defective, less reaction to emotional words
Enviro: parental loss, alcoholism, drug abuse, violence acts at home, pornography, violent media
Beh: modeling, reinforcement, childhood behavior problems

Question 11

Treatment for Antisocial PD

Answer 11

-consequences for behavior
-empathy training
-transcranial stimulation

Question 12

Example of Antisocial PD

Answer 12

Ted Bundy

Question 13

Histrionic PD (cluster b)

Answer 13

A pervasive pattern of excessive emotionality and attention seeking, as indicated by 5 or more of the following:
-Is uncomfortable in situations in which he or she is not the center of attention
-Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
-Displays rapidly shifting and shallow expression of emotions
-Consistently uses physical appearance to draw attention to self
-Has a style of speech that is excessively impressionistic and lacking in detail
-Shows self-dramatization, theatricality, and exaggerated expression of emotions
-Is suggestible (i.e., is easily influenced by others or circumstances)
-Considers relationships to be more intimate than they actually are

Question 14

Example of Histrionic PD

Answer 14

Scarlett O’Hara

Question 15

Narcissistic PD

Answer 15

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, as indicated by 5 or more of the following:
-Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
-Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
-Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
-Requires excessive admiration
-Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
-Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
-Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
-Is often envious of others or believes that others are envious of him or her
-Shows arrogant, haughty behaviors or attitudes

Question 16

Example of Narcissistic PD

Answer 16

Breaking Bad

Question 17

Narcissistic PD: Gaslighting

Answer 17

-manipulated into ignoring your better instincts and judgements
-a pervasive pattern for people with this disorder

Question 18

Danger of Narcissistic PD

Answer 18

-people with this diagnosis can be dangerous mentally (gaslighting, blaming, projection) and physically (trigger rage/interpersonal violence, careful when breaking up)

Question 19

Malignant Narcissism?

Answer 19

-A combination of narcissistic and antisocial and paranoid personality disorders along with sadism
-Very egocentric
-Project their own “bad behavior” onto others
-Lack of conscience
-Lack true empathy
-Enjoy inflicting psychological, emotional, and/or physical harm or humiliation on others
-Manipulative
-Lie
-Paranoid

Question 20

Borderline PD (cluster b)

Answer 20

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, as indicated by 5 or more of the following:
-Frantic efforts to avoid real or imagined abandonment (don’t include suicidal or self-mutilating behavior covered in criterion 5)
-A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
-Identity disturbance: markedly and persistently unstable self-image or sense of self
-Impulsivity in at least 2 areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge-eating). Do not include suicidal or self-mutilating behaviors.
-Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior
-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)
-Chronic feelings of emptiness
-Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
-Transient, stress-related paranoid ideation or severe dissociative symptoms

Question 21

What is Otto Kernberg’s Psychodynamic Formulation for Borderline PD

Answer 21

-Faulty ego structure (weak ego)
-Primary process thinking (id impulses rule!)
-Lack of impulse control
-Splitting (Experience of self and other is divided into rigid categories—black and white, all good or all bad) (may explain mood swings and unstable relationships)

Question 22

What is Masterson’s “The Search for the Real Self”?

Answer 22

Borderline PD
-Rewarded for regression and withdrawal
-As children, they submitted to parental wishes and expectations versus “self-activation”
-As adults, Self-activation triggers feelings of abandonment and leads to original defenses
-Depression develops from feelings of loss

Question 23

What is Linehan’s Dialectical Behavior Theory and Therapy for Borderline PD?

Answer 23

-Primary problem is dysregulation of emotion combined with an invalidating environment
-High intensity of negative emotions
-Focus is on skill deficits in emotional regulation and interpersonal skills
-Key components include radical acceptance and distress tolerance
-Treatment focuses on individual and group therapy to learn new skills primarily in the areas of affect regulation and interpersonal relationships

Question 24

Bio and treatments for Borderline PD

Answer 24

-no clear genetic link but being studied
-study focused on emotional reactivity
-medication somewhat helpful (mainly antidepressants)

Question 25

Avoidant PD (cluster c)

Answer 25

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, as indicated by 4 or more of the following:
-Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
-Is unwilling to get involved with people unless certain of being liked
-Shows restraint within intimate relationships because of the fear or being shamed or ridiculed
-Is preoccupied with being criticized or rejected in social situations
-Is inhibited in new interpersonal situations because of feelings of inadequacy
-Views self as socially inept, personally unappealing, or inferior to others
-Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Question 26

Dependent PD (cluster c)

Answer 26

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, as indicated by 5 or more of the following:
-Has difficulty making everyday decisions without an excessive amount of advise and reassurance from others
-Needs others to assumer responsibility for most major areas of his or her life
-Has difficulty expressing disagreement with others because of fear of loss of support or approval
-Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)
-Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
-Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself
-Urgently seeks another relationship as a source of care and support when a close relationship ends
-Is unrealistically preoccupied with fears of being left to take care of himself or herself

Question 27

Obsessive-Compulsive PD (cluster c)

Answer 27

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, as indicated by 4 or more of the following:
-Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
-Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met)
-Is excessively devoted to work and productibity to the exclusion of leisure activities and friendships
-Is over-conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)
-Is unable to discard worn-out or worthless objects even when they have no sentimental value
I-s reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things
-Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes
-Shows rigidity and stubbornness