Personality Disorders

Question 1

Personality:

Answer 1

Personality is the consistent pattern of an individual’s thinking, feeling and behaving that is pervasive across time and contexts (Hulbert et al., 2011).

Question 2

The Five Factor Model (Costa & Widigier, 2002; McCrae & Costa, 1985) identifies 5 essential personality traits:

genetic basis

environmental

Answer 2

• Neuroticism (N)
• Extroversion (E)
• Openness to Experience (O)
• Conscientiousness (C)
• Agreeableness (A)
• These core personality traits have a 40-60% genetic basis (Livesley, 2008).
• Environment:
  
  • Modulates trait expression
  • Shapes behaviours for trait expression

Question 3

• Personality Disorders
• what is considered a “personality disorder”

Answer 3

• Personality Disorders: a persistent pattern of emotions, cognitions and behaviour that results in enduring emotional distress for the person affected and/or for others and may cause difficulties with work and relationships
  
  • When personality characteristics interfere with relationships with others, cause the person distress, or in general disrupt activities of daily living, we consider these to be “personality disorders”

Question 4

• DSM-5 definition of Personality Disorders:
• Core Features:

Answer 4

• DSM-5 definition of Personality Disorders:
  
  • “An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment”
  • PDs show low to moderate stability?
• Core Features:
  
  • Functional inflexibility
  • Self-defeating behaviour patterns
  • Tenuous stability under stress

Therapists especially need to guard against letting their personal feelings interfere with treatment when working with people who have personality disorders (countertransference, Freud)

Question 5

General Personality Disorder diagnostic criteria

Answer 5

• A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two or more of the following areas:
  
  • Cognition (i.e., ways of perceiving and interpreting self, other people, and events)
  • Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
  • Interpersonal functioning
  • Impulse control
• B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations
• C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning
• D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood
• E. The enduring pattern is not better explained as a manifestation or consequences of another mental disorder
• F. The enduring pattern is not attributable to the physiological effects of a substance or another medical condition

Question 6

How PDs complicate treatment

Answer 6

• Not untreatable, but among most difficult disorders to treat -> involve pervasive and entrenched behaviour patterns that have been present throughout most of a person’s life
• Traits often experienced as integral to the self
• May significantly impact treatment of other comorbid disorders
• May help to explain why some clients fail to respond in treatment as expected

Question 7

General Issues with PD Assessment

Answer 7

• Question regarding validity/utility of diagnoses
• Question in regards to whether personality disorders should be measures on dimension rather than category
  
  • What does it mean when there is disagreement amongst clinicians? Meeting all the criteria but no functional impairment?
• PDs within each cluster share many characteristics
• May not be apparent on first meeting
• Clients may try to hide/minimize/justify symptoms
  
  • “It’s everyone else’s problem, I’m fine”
• Countertransference issues

Question 8

3 clusters of personality disorders:

Answer 8

• Cluster A- Odd or Eccentric Disorders (paranoid, schizoid, schizotypal disorders)
• Cluster B- Dramatic, Emotional or Erratic Disorders (antisocial, borderline personality, histrionic, narcissistic)
• Cluster C- Anxious or Fearful Disorders (avoidant, dependent and obsessive-compulsive personality disorder)

Question 9

Difficulties in Research and Diagnosis of PDs

Answer 9

• Misdiagnosis
  
  • Criteria not as sharply defined
  • Categories not mutually exclusive
  • Characteristics are dimensional but diagnostic criteria are not (yet)
• Little known about causal factors
  
  • High level of comorbidity among personality disorders
  • Little prospective research

Question 10

Main beliefs associated with specific personality disorders

Answer 10

Question 11

Other

Answer 11

• Personality disorders are sometimes described as chronic because they originate in childhood and continue through adulthood
• Although gender differences are evident in the research of personality disorders, some differences in the findings may be a result of bias

Question 12

General Causal Factors

• Biological
• Psychological

Answer 12

• Biological factors
  
  • Inborn temperament
  • Genetic contributions
• Psychological factors
  
  • Learning-based habit patterns and maladaptive cognitive styles
  • Parental psychopathology
  • Abuse

Question 13

Paranoid Personality Disorder (cluster A)

• Prevelance
• Diagnostic Criteria

Answer 13

• Prevalence: 2.3% – 4.4%

Diagnostic Criteria

• A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
  
  • Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
  • Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
  • Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
  • Reads hidden demeaning or threatening meanings into benign remarks or events
  • Persistently bears grudges (i.e., unforgiving of insults, injuries, slights)
  • Perceives attacks on his/her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
  • Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
• B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological affects of another medical condition

Question 14

Paranoid PD: Clinical Presentation

Answer 14

• Generally difficult to get along with and thus have problems in/with close relationships
• May engage in overt argumentativeness, recurrent complaining, or by quiet, apparently hostile aloofness
• May act in a guarded, secretive or devious manner
• Appear to be “cold” and lacking in tender feelings
• May appear to be objective, rational, and unemotional, more often display a labile (changing) range of affect with hostile, stubborn, and sarcastic expressions dominating
• Have an excessive need to be self-sufficient and strong sense of autonomy
• Need a high degree of control of those around them (for whom they are often hostile and critical)
• May be litigious
• Tend to develop negative stereotypes of others, particularly those from population groups distinct from their own
• May experience very brief psychotic episodes in response to stress

Cognitive and cultural factors may interact to produce the suspiciousness observed in some people with paranoid personality disorder

Question 15

Paranoid PD: Treatment

Answer 15

• Unlikely to seek professional help, even when needed
  
  • Trust is a major part of therapy
  • Meaningful therapeutic alliance is difficult to establish
• Cognitive therapy
  
  • Counter person’s mistaken assumptions about others
  • Focus on changing person’s beliefs that all people are malevolent and most people cannot be trusted

There are no confirmed demonstrations that any form of treatment can significantly improve the lives of people with paranoid personality disorder

Question 16

Schizoid Personality Disorder (cluster A)

• Prevelance
• Diagnostic Criteria

Answer 16

• Prevalence: 3.1% - 4.9% but uncommon in clinical settings

Diagnostic Criteria

• A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, 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 praise or criticism of others
  • Shows emotional coldness, detachment, or flattened affectivity
• B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder or autism spectrum disorder and is not attributable to the physiological affects of another medical condition

Question 17

Schizoid PD: Clinical Presentation and Treatment

Answer 17

• May lack desire for intimacy, seem indifferent to opportunities to develop close relationships, and do not seem to derive much satisfaction from being part of a family or other social group
• Often appear to be socially isolated or “loners”
• Reduced experience of pleasure from sensory, bodily, or interpersonal experiences
• May be oblivious to normal subtleties of social interaction and often do not respond appropriately to social cues
• React passively to adverse circumstances and have difficulty responding appropriately to important life events
• Often do not marry
• Treatment?
  
  • Point out value in social relationships
  • Empathy and social skills training

Question 18

Schizotypal Personality Disorder

• Prevalence
• Diagnostic Criteria

Answer 18

• Prevalence: 3.9% - 4.6%

Diagnostic Criteria

• 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 behaviour, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Ideas of reference (excluding delusions of reference)
2. Odd beliefs or magical thinking that influences behaviour and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense;” in children and adolescents, bizarre fantasies or preoccupations)
3. Unusual perceptual experiences, including bodily illusions
4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, over-elaborate, or stereotyped)
5. Suspiciousness or paranoid ideation
6. Inappropriate or constricted affect
7. Behaviour or appearance that is odd, eccentric, or peculiar
8. Lack of close friends or confidants other than first degree relatives
9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

Question 19

Schizotypal PD: Clinical Presentation and Treatment

Answer 19

• Most often seek treatment for associated symptoms of anxiety/depression
  
  • 30% - 50% also have a concurrent diagnosis of a major depressive disorder when entering clinical setting
• May experience transient episodes of psychosis during times of stress
• Is different from schizophrenia by absence of delusions and hallucinations
• Ideas vs. delusions: defined by strength of conviction
• May believe that they have magical control over others, which can be implemented directly
• Often suspicious and paranoid
• Anxious in social situations—behaviour suggests a decreased desire for intimate contacts
• Found to be a genetic relationship between schizotypal and schizophrenia (with the former considered to be a precursor to the latter)
• Schizotypal disorder has been associated with mild to moderate decrements in ability to perform on tests involving memory and learning (suggesting damage to left hemisphere) as well as generalised brain abnormalities (using magnetic resonance imaging)
• Treatment
  
  • Early intervention (cognitive therapy and antipsychotics) to reduce chance of full-blown psychosis
  • Treat comorbid diagnoses (e.g., anxiety, depression)

Question 20

Cluster B characterised by traits that are:

Answer 20

• • Impulsive
    
    • Dramatic
    • Exciting
    • Emotional
    • Erratic
    • Acting Out
    • Flamboyant
• Commonly seen at mental health services
• Often attract other people/partners
• Have many unsuccessful relationships
• Need to differentiate from a manic episode

Question 21

Antisocial Personality Disorder

• Prevalence
• Diagnostic criteria

Answer 21

• Prevalence: 0.2% - 3.3%

Diagnostic Criteria

• A. There is a pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:

1. Failure to conform to social norms with respect to lawful behaviours, as indicated by repeatedly performing acts that are grounds for arrest
2. Deceitfulness, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure
3. Impulsivity or failure to plan ahead
4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults
5. Reckless disregard for safety of self or others
6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations
7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

• B. The individual is at least age 18 years
• C. There is evidence of Conduct Disorder with onset before age 15 years

Question 22

ASPD: Clinical Presentation and Treatment

Answer 22

• Frequently lack empathy and tend to be callous, cynical, and contemptuous of feelings, rights, and sufferings of others
• May have an inflated and arrogant self-appraisal, and be excessively opinionated, self-assured, or cocky
• Irresponsible and exploitative in their sexual relationships
• May receive dishonorable discharges from armed services, become impoverished or homeless, or may spend many years in penal institutions
• May experience dysphoria, including complaints of tension, inability to tolerate boredom, and depressed mood
• May have associated anxiety/depressive disorders, substance use disorders, somatic symptom disorder, gambling disorder, other disorders of impulse control
• Treatment?
  
  • Few documented success stories
  • Don’t feel they need treatment, not likely to engage in it honestly
  • Cognitive Behaviour Therapy
  • Parent training

Question 23

ASPD and Psychopathy

Answer 23

• Considered subtype of Antisocial PD
  
  • Obsolete terms in the DSM-5 and ICD-10
• Term still used in clinical practice and in general
• Psychopathy Characterized by (Clerckley/ Hare Criteria):
  
  • Lack of empathy
  • Inflated and arrogant self-appraisal
  • Very often glib and superficially charming
  • Deceitful and manipulative
  • Callously use others to achieve their own ends
  • Also included are hostile people who are prone to acting out impulses in remorseless and often senseless violence
• Problems in 3 basic categories
  
  • Inadequate conscience development
  • Irresponsible and impulsive behavior
  • Ability to impress and exploit others

Question 24

Inadequate Conscience Development Psychopathy

Answer 24

• Appear unable to understand and accept ethical values except on a verbal level
• May glibly claim to adhere to high moral standards that have no apparent connection with their behavior
• Behave as though social regulations and laws do not apply to them
• Intellectual development typically normal

Question 25

Ability to Impress and Exploit Others Psychopathy

Answer 25

• Are often charming and likeable
• Disarming manner that easily wins new friends
• Typically have a good sense of humor and an optimistic outlook
• Frequent liars who usually seem sincerely sorry if caught in a lie and promise to make amends, but will not do so
• Seem to have good insight into other people’s needs and weaknesses and are adept at exploiting them
• Seldom able to keep close friends -> cannot understand love in others or give it in return
• Manipulative and exploitative in sexual relationships -> irresponsible and unfaithful mates

Question 26

Physiological Evidence? ASPD and Psychopathy

Answer 26

• Diminished aversive emotional arousal and conditioning
  
  • Fearlessness hypothesis: Less prone to experience fear and anxiety in stressful situations and less prone to normal conscience development and socialization
  • Underarousal hypothesis: psychopaths have abnormally low levels of cortical arousal and therefore seek more stimulus
  • Show deficient conditioning responses when anticipating an unpleasant or painful event, slow to stop responding in order to avoid punishment
    
    • It is these negative experiences that help to develop our conscience -> if we don’t have them, we don’t learn to avoid bad things (deficient behavioural inhibition system)

Question 27

Borderline Personality Disorder (BPD) diagnostic criteria

Answer 27

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

1. Frantic efforts to avoid real or imagined abandonment
2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealization and devaluation
3. Identity disturbance: markedly and persistently unstable self-image and sense of self
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
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 28

BPD characteristics

Answer 28

• Prevalence rate of 1.6% - 5.9%
• 6% in primary care settings, 10% amongst individuals seen in outpatient mental health clinics, 20% amongst psychiatric inpatients
• 75% diagnosed are females (ratio F, 3:M, 1)
• Suicide rate: 10%
• Deliberate self-harm/parasuicidal behaviour
• Onset is late childhood/adolescence
• Chronic but can decline with age
• 88% achieve remission after 10 years of treatment

Question 29

BPD: Clinical Presentation

Answer 29

• Pattern of undermining themselves at the moment a goal is about to be realized
• Psychotic-like symptoms during periods of stress
• May feel more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships
• Recurrent job losses, interrupted education, and separation or divorce are common
• Physical and sexual abuse, neglect, hostile conflict, and early parental loss are common in childhood histories

Question 30

Causes/Aetiology of BPD

Answer 30

• Biological vulnerability (impulsivity and affective instability)
• High emotionality and invalidating environment
• Childhood trauma, particularly sexual abuse
• Multidimensional theory (awaits validation and future research)
  
  • Diathesis (hereditary or constitutional predisposition) to develop borderline PD, combined with presence of certain psychological risk factors such as trauma, loss, and parental failure
  • When one or more of these risk factors occur in someone who is affectively unstable, he or she may become dysphoric and labile, and if he or she is also impulsive, may engage in impulsive acting out to cope with the dysphoria
  • Children who are impulsive and unstable tend to be difficult/troublesome children -> may be at an increased risk for being rejected and/or abused
  • Parental psychopathology and personality disorders

Question 31

BPD: Treatment

Answer 31

• Quite likely to seek out and engage in treatment
  
  • Often quite distressed
• Mood stabilizers have shown efficacy
• Dialectical Behaviour Therapy (DBT) results show may help reduce suicide attempts, dropouts from treatment and hospitilisations
  
  • Treat behaviours that may result in harm (suicidal behaviours)
  • Treat behaviours that interfere with therapy
  • Treat behaviours that interfere with client’s quality of life
  • Problem-solving (so patients can handle problems more effectively), trauma work (if relevant)
  • In final stage of therapy patients learnt to trust their own responses rather than depend on the validation of others

Question 32

Histrionic Personality Disorder diagnostic criteria

Answer 32

• A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Is uncomfortable in situations in which he or she is not the centre of attention
2. Interaction with others is often characterised by inappropriate sexually seductive or provocative behaviour
3. Displays rapid shifting and shallow expression of emotions
4. Consistently uses physical appearance to draw attention to self
5. Has a style of speech that is excessively impressionistic and lacking in detail
6. Shows self-dramatization, theatricality, and exaggerated expression of emotion
7. Is suggestible (i.e., easily influenced by others or circumstances )
8. Considers relationships to be more intimate than they actually are

Question 33

Histrionic PD

• Prevalence
• Aetiology

Answer 33

• Prevalence
  
  • Lifetime: Around 2%
  • Gender prevalence considered to be equal now, though it was previously diagnosed more frequently in women
    
    • Many criteria for histrionic PD involve maladaptive variants of gender-related traits (overdramatization, vanity, seductiveness)
• Causal factors
  
  • Very little systematic research done on histrionic PD
  • Some evidence for a genetic link with ASPD -> may be some underlying predisposition that is more likely to be manifested in women as histrionic PD and in men as antisocial PD
    
    • Characterized by extreme versions of two normal personality traits (neuroticism and extraversion)
  • Cognitive theorists—importance of maladaptive schemas revolving around the need for attention to validate self-worth
    
    • “Unless I captivate people, I am nothing”

Question 34

Histrionic PD: Clinical Presentation and Treatment

Answer 34

• May have difficulty achieving emotional intimacy in romantic or sexual relationships
• Often act out a role in their relationships with others (e.g., “victim” or “princess”)
• May have difficulty with same-sex friends, as their sexually provocative interpersonal style may be experienced as a threat
• May crave novelty, stimulation, and excitement and have a tendency to become bored with their usual routine
• Often intolerant of, or frustrated by, situations involving delayed gratification
• Longer-term relationships may be neglected to make way for excitement of new relationships
• Treatment?
  
  • Little demonstrated success
  • Focus on problematic interpersonal relationships and how short-term gains associated with negative behaviours result in long-term costs.
  • Need to be taught more appropriate ways of negotiating their wants and needs

Question 35

Narcissistic Personality Disorder Diagnostic Criteria

Answer 35

• A pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognised as superior without commensurate achievements)
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
3. 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)
4. Requires excessive admiration
5. Has a sense of entitlement (i.e., unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations)
6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends)
7. Lacks empathy; is unwilling to recognize or identify with the feelings and needs of others
8. Is often envious of others or believes that others are envious of him or her
9. Shows arrogant, haughty behaviours or attitudes

Question 36

Narcissistic PD

• Prevalence
• Histrionic vs Narcissistic

Answer 36

• Prevalence
  
  • Lifetime: 0% - 6.2%
  • 50% - 75% of those diagnosed are male
• Is it a cover up?
  
  • Most researchers and clinicians believe that people with narcissistic PD have a very fragile and unstable sense of self-esteem -> need for admiration may help regulate and protect their fragile sense of self
• Histrionic vs. Narcissistic -> both are exhibitionistic, but the histrionic seeks attention, whereas the narcissist seeks admiration

Question 37

Narcissistic PD: Clinical Presentation and Treatment

Answer 37

• Vulnerability in self-esteem makes individuals with NPD very sensitive to “injury” from criticism or defeat
• Criticism may make them feel humiliated, degraded, hollow, and empty (though they likely will not show it)
• May react with disdain, rage, or defiant counterattack
• Interpersonal relations typically impaired because of problems derived from entitlement, need for admiration, and relative disregard for the sensitivities of others
• Vocational (occupation or employment) functioning may be very low
• Sustained periods of grandiosity may be associated with hypomanic mood
• Because narcissists often fail to live up to their own expectations, they are often depressed
• Treatment?
  
  • Limited data on success
  • Cognitive therapy to focus on grandiosity, hypersensitivity to evaluation, and lack of empathy toward others
  • Coping strategies focused on relaxation training to help accept and face criticism

Question 38

Narcissistic PD: Causal Factors

Answer 38

• Normal development gone wrong
  
  • All children go through this phase -> parents must do some mirroring of the child’s grandiosity to help them get past it -> helps the child to develop normal levels of self-confidence and a sense of self-worth to sustain them later in life
  • If parents are neglectful, devaluing, or unempathetic, the child will be perpetually searching for affirmation of an idealized and grandiose sense of self
• Unrealistic parental overvaluation
  
  • Bandura ->”These parents pamper and indulge their youngsters in ways that teach them that their every wish is a command, that they can receive without giving in return, and that they deserve prominence without even minimal effort”

Question 39

Cluster C

• Characterised by traits and behaviours that are mainly:

Answer 39

• Characterised by traits and behaviours that are mainly:
  
  • Anxious
  • Fearful
• High levels of:
  
  • Neuroticism (anxiety, fear, moodiness, worry, envy, frustration, jealousy, and loneliness)
  • Introversion
• Need to differentiate from an anxiety disorder

Question 40

Avoidant Personality Disorder

• diagnostic criteria
• prevalence

Answer 40

• A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection
2. Is unwilling to get involved with people unless certain of being liked
3. Shows restraint within intimate relationships because of fear of being shamed or ridiculed
4. Is preoccupied with being criticised or rejected in social situations
5. Is inhibited in new interpersonal situations because of feelings of inadequacy
6. Views self as socially inept, personally unappealing or inferior to others
7. Is unusually reluctant to take personal risks to engage in any new activities because they may prove embarrassing

• Prevalence: 2.4%
• Causal factors: Inborn temperament?

Question 41

Avoidant PD: Clinical Presentation and Treatment

Answer 41

• Often vigilantly appraise the movements and expressions of those with whom they come into contact
• Fearful and tense demeanour may elicit ridicule and derision from others, which in turn confirms their self-doubts
• Described by others as being “shy,” “timid,” “lonely,” and “isolated”
• May have impaired occupational functioning—try to avoid the types of social situations that may be important for meeting the basic demands of the job or for advancement
• Treatment
  
  • Behavioural interventions for anxiety and social skills problems

Question 42

Dependent Personality Disorder diagnostic criteria

Answer 42

• A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
2. Needs others to assume responsibility for most areas of his or her life
3. Has difficulty expressing disagreement with others because of fear of loss of support or approval (Note. Do not include realistic fears of retribution)
4. 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)
5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself
7. Urgently seeks another relationship as a source of care and support when a close relationship ends
8. Is unrealistically preoccupied with fears of being left to take care of himself or herself

Question 43

DPD characteristics and prevalence

Answer 43

• Prevalence: 0.5% - 0.6%
• Causal factors: Small genetic influence of neuroticism and agreeableness, cognitive beliefs about ability to take care of one’s self

Question 44

Dependent PD: Clinical Presentation and Treatment

Answer 44

• Often characterized by pessimism and self-doubt, tend to belittle their abilities and assets, and may constantly refer to themselves as “stupid”
• Take criticism and disapproval as proof of their worthlessness and lose faith in themselves
• May seek overprotection and dominance from others
• May avoid positions of responsibility and become anxious when faced with decisions
• Social relations tend to be limited to those few people on whom the individual is dependent
• Treatment
  
  • Few data, but generally work on getting clients to be more independent and personally responsible (care needs to be taken that the patient does not become overly dependant on the therapist)

Question 45

Obsessive-Compulsive Personality Disorder diagnostic criteria

Answer 45

• A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of activity is lost
2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are met)
3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)
4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)
5. Is unable to discard worn-out or worthless objects even when they have no sentimental value
6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things
7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes
8. Shows rigidity and stubbornness

Question 46

OCPD characteristics

Answer 46

• Don’t see true obsessions or compulsive rituals such as those seen in OCD (unless they also have OCD)
  
  • See lifestyles characterized by over-conscientiousness, inflexibility, and perfectionism
• Prevalence
  
  • Lifetime: 1% [males more than females (2:1)]
• Causal factors
  
  • High levels of conscientiousness -> lead to extreme devotion to work, perfectionism, and excessive controlling behavior
  • Low levels of novelty seeking (i.e., they avoid change) and reward dependence (i.e., they work excessively at the expense of pleasurable pursuits), but high levels of harm avoidance (i.e., they response strongly to aversive stimuli and try to avoid them)

Question 47

OCPD: Clinical Presentation

Answer 47

• When rules and established procedures do not dictate the correct answer, decision making may become a time-consuming, painful process
• Prone to become angry or upset in situations in which they are not able to maintain control of their physical or interpersonal environment
• Anger may be expressed as righteous indignation over a seemingly minor matter
• Especially attentive to their relative status in dominance-submission relationships, may display excessive deference to an authority they respect and excessive resistance to authority they do not respect
• Usually express affection in a highly controlled or stilted fashion; everyday relationships have a formal and serious quality
• May be preoccupied with logic and intellect, and intolerant of affective behaviour in others
• May experience occupational difficulties and distress, particularly when confronted with new situations that demand flexibility and compromise

Question 48

OCPD: Treatment

Answer 48

• Can be effective
• Attack fears that underlie need for orderliness
• Work on helping client relax or using distraction techniques to redirect compulsive thoughts
• Cognitive-behavioural therapy to address fears of inadequacy that lead to procrastination and rumination