Personality Disorders Flashcards
What is personality?
A persona (plural personae/personas): Latin for ‘mask’ Outward or surface aspect presented to audience
What determines personality?
NATURE: Innate Temperament (disposition): Genetic & constitutional
NURTURE: Character: Acquired values & attitudes
DSM-5: What is a Personality Disorder?
–> usually onset very early in childhood & develop into PDs
Enduring pattern of inner experience and behaviour that:
• Deviates markedly from the individual’s culture
• It is pervasive, inflexible & stable over time (NOT IN EPISODES, STABLE OVER TIME)
• Leads to distress or impairment
The pattern is manifested in two or more areas: (NOT ALL ARE NEEDED, ONLY 2 OR MORE)
• Cognition (ways of interpreting self, others & events)
• Affect (range, intensity, stability & appropriateness of
emotional response)
• Interpersonal functioning
• Impulse control
Personality Disoders - Core features (Millon, 1981)
- Functional inflexibility
- Failure to adapt to situations: rigid response - Self-defeating
- Behavioural responses damaging - Unstable in response to stress
- Emotional, behavioural & cognitive instability (especially in borderline, harming themselves)
(ALSO LACK OF INSIGHT, failure to recognise dysfunctional aspect of personality)
Two classification systems: DSM-5 & ICD-10
DSM-5
• 10 personality disorders categorised in 3 clusters
ICD-10
• 9 personality disorders but not clustered & with slightly
different labels –> E.g., Antisocial – Dissocial & Obsessive-compulsive - Anankastic
Cluster A
Odd/Eccentric –> often high introversion
- Paranoid
- Schizoid
- Schizotypal
Cluster B
Dramatic/emotional/erratic • Antisocial • Borderline • Histrionic • Narcissistic
Cluster C
Anxious/Fearful
- Avoidant
- Dependent
- Obsessive-compulsive
Categorical vs. dimensional approach
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
–> Dimensional approach acknowledges traits on a spectrum
Variable nature
Variable nature of area between clusters, diagnosis very dependent upon psychiatrists subjective opinion
heterogeneity within diagnoses
diagnostic unreliability
lack of robust scientific evidence
DSM-IV: AXIS I vs. AXIS II
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
DSM-3 & 4 used 2 axis approach, DSM-5 uses single axial model
Paranoid PD - Cluster A
Not delusional –> distinguishes from schizophrenia
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
Paranoid PD Thought Processes
Assumptions: People are malicious & out to get you, They will take advantage if they can, You will be okay as long as you do not let your guard down
Cognitions: Expectancy of hostility, Vigilance, Guardedness, Confirmatory evidence, Lack of trust
Interpersonal Behaviour: Suspiciousness & guarded against closeness, resentful, failure to trust others, Tendency to elicit hostility & distrust from others
Schizoid PD - Cluster A
- Like talking through glass wall, can see but not connect
Engage in solidarity activities ‘computer nerds’, not anxious just no interest in sociality
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 –> lack of ability to feel happiness
• Comorbid with schizotypal and avoidant PDs
Schizotypal PD - Cluster A
Eccentric/odd, often in fringe groups
Marked interpersonal deficits, behavioural eccentricities
and distortions in perception & thinking (that 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
Antisocial PD - Cluster B
lack of empathy
Repeated reckless disregard for others
• Victimizing & 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 (DON’T HAVE TO BE)
• Co-morbidity with borderline, narcissistic, histrionic &
schizotypal PDs
Borderline PD - Cluster B: Primary disturbances
Emotional lability, often self-harming, can be used for manipulation & attention, splitting & developing conflict for enjoyment, very possessive
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 to sense of emptiness
Borderline PD - Cluster B
Most prevalent PD in clinical settings: • 10% of outpatients • 15-20% of inpatients Rarely sole diagnosis: comorbid with mood disorders, substance-use disorders & anxiety disorders (PTSD) • 15% Major depression • 10% Dysthymia • 15% Bipolar I • 20% Bulimia/anorexia • 10% Substance abuse Meet criteria for BPD
• Reflects shared impulsivity/disinhibition & affective
instability personality traits
• Arguably associated with the greatest levels of
disability of all the PDs
Histrionic PD - Cluster B
attention seeking, conversion of psychological angst into physical symptoms, very dramatic & self-centred
Roots in the concept of hysteria: conversion
disorders, emotional instability, anxiety & phobias
• Kretschmer (1926): theatrical & egotistical
• DSM-II (1968): hysterical PD
• DSM-III : replaced by histrionic PD
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
Narcissistic PD - Cluster B
Important in small levels to have, PD if to huge extent, belief they have special skills, arrogance
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 behavior & attitudes
• Focus on own issues with insensitivity or impatience to
problem of others: cold, disinterested, snobbish, patronizing
• Comorbid with: anti-social, histrionic, borderline PDs &
substance abuse
Avoidant PD - Cluster C
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
Dependent PD - Cluster C
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
- Self view: needy, weak, helpless & incompetent
- View of Others: Strong caretaker idealized. 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
Obsessive-Compulsive PD - Cluster C
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
Obsessive-Compulsive PD - Cluster C: Views & Affect
- 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
Epidemiology: Prevalence of PDs
- Australia: 6.5% adult Australians have 1+ lifetime prevalence
• Younger unmarried males: higher presence of anxiety,
affective, or substance use disorder, & greater disability
than those without PD
• Females: More prevalent in borderline & histrionic
• International data: rates vary from 6.1 - 13.4%; average: 9.7%
Epidemiology of Most studied PDs: Antisocial & Borderline
Antisocial PD
• 0.2-3.3% general population
• gender difference: 3% males vs. 1% females
• 3%-30% of psychiatric outpatients
• 47% of male prisoners & 21% of female prisoners
Borderline PD
• Australia: 1-5%; USA: 1-2%; Norway: 0.7%
• Diagnosis:
• 4-6% in primary care (GPs)
• 25-40% in clinical population with mental illness
• Females 3x higher than males (diagnosed as antisocial)
• Suicide rate of 10%
–> Despite high prevalence, Borderline PD is under-recognised & under-diagnosed as 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
Antisocial PD: Aetiology - Constitutional Factors
Causes of APD not fully understood
• Constitutional factors (neurobiological correlates) establishes predisposition with expression of antisocial variant determined by environmental & familial influences
• Externalizing vulnerabilities: heritable broad trait dispositional factor reflecting disinhibitory personality & risk taking found in childhood conduct disorders, adult antisocial behavior, and substance-use disorders
Antisocial PD: Aetiology - Biological Factors
Reduced levels of serotonin (impulsive behaviours)
• Low resting heart rate –> physiological hypo-arousal –> sensation seeking
• Neuropsychological deficits on frontal lobe executive functioning
• Weak behavioural inhibition & emotional reactivity (less
responsive to threat & punishment)
• Evolutionary advantage
Antisocial PD: Aetiology - Psychosocial Factors
Personality & temperament, shaped by environment & learned coping skills to deal with stress
• Social factors: childhood dysfunctional role modeling & interactions with family
• Peer group interactions: deviant sub-cultures - ?cause or effect
Antisocial PD: Thought processes
Assumptions: Everyone is out to get what they can for themselves, Rules don’t apply to me: I can bend them, If you’re smart you can beat the system
Cognitions: Denial of fears, insecurity, Do not show weakness, Deception of others, Planning, conforming does not succeed, Lack of deliberation, Low expectation of success with pro-social, Rapid decisions with scant regard for consequences
Interpersonal Behaviour: Avoidance of pro-social, Avoidance of closeness, Rejection & punishment by system, Impulsive acts
Antisocial PD: Treatment
Literature reviews indicate inherent difficulties and
ineffectiveness of psychological interventions
(e.g., CBT, psychotherapy)
• Pharmacological agents to reduce aggressive
impulsivity (lithium, serotonin selective reuptake
inhibitors)
• Multifaceted interventions targeting impulsivity,
aggression, addictive urges, and narcissistic traits
required BUT outcomes not positive, particularly for
the severe end of the spectrum (psychopathy)
Borderline PD: Thought processes
Assumptions: world is dangerous and malevolent, I am weak and vulnerable, my feelings are unacceptable and dangerous
Cognitions: dependency vs. fear of dependency, anticipation of rejection, lack of clear goals, inconsistent motivation
Interpersonal Behaviour: depression & hopelessness, suicidality, lack of relationship, impulsiveness, manipulative behaviour
Borderline PD: Aetiology
- Complex, uncertain, no integrated model available
- Presumed contributory factors
Borderline PD: Aetiology - Genetic factors
- twin & familial data suggestive of heritability factor, traits: impulsive aggression & mood dysregulation transmitted rather than direct hereditary genes linked to BPD
- Most consistent perspective is that environmental factors influence genetic expression (intensity) of behaviours
• Distinct genetic contribution to individual traits + clustering of traits (emotional dysregulation & impulsivity in BPD)
Borderline PD: Aetiology - Genetic/Biological factors
Neurophysiological/biological dysfunctional emotional regulation & stress
- Serotonin regulates impulses, aggression & affect: linked to emotional instability, suicidal behaviours & impulsivity behaviours
- Low levels of serotonin impairs control of destructive urges
- Threatening/aversive stimuli activate amygdala → anterior cingulated prefrontal cortices
- Affect regulation (amygdala/AC), attention,
self-control & executive functions (PFC)
Borderline PD: Aetiology - Environmental/Childhood factors
Childhood complex traumas → emotional/sexual/physical childhood abuse implicated in aetiology BUT abuse alone neither necessary/sufficient
- Child-parent relationship mediating factors hinder/distorts development of secure attachments → emotional dysregulation
- Exacerbated if family member is perpetrator
- Attachment theory: infants construct internalized concepts of self & others based on experiences
- Sense of security and self-worth enhanced by family members shapes personality traits
Borderline PD: Aetiology - Psychosocial factors
Personality traits, personality functioning
o Parental failure to teach child to label and regulate emotional arousal, tolerate emotional distress, and when to trust own emotional responses during distress
o In adulthood, individuals invalidate their own emotional experiences & depend on others for accurate reflections of external reality
Primary/characteristic manifestations of psychopathology
emotional dysregulation, behavioural dysregulation, interpersonal dysfunction
Borderline Treatment: IMPULSIVE
- Impulsive
- Moodiness
- Paranoia under stress
- Unstable self-image
- Labile & intense relationships
- Suicidality
- Inappropriate anger
- Vulnerability to abandonment
- Emptiness (sense of identity)
Dialectical Behaviour Therapy (DBT)
- Developed for Borderline PD (1993)
- CBT-based intervention for chronically suicidal behaviours
- Bio-psycho-social model than builds on/modifies traditional behavioural approaches
- Dialectic → a synthesis or integration of opposites/contradictions of the central dialectics of DBT: acceptance and change
-Goals of DBT
o Changing behaviours causing suffering whilst simultaneously accepting oneself and current situation
o DBT consists of 4 modules of coping skills to achieve specific goals - Acceptance skills: mindfulness & distress tolerance
- Change skills: interpersonal effectiveness & emotion regulation
DBT Core Skills Module 1 – Mindfulness
- Observing/attending to events, emotions & behavioural responses even if distressing
o Step back & allow experience with awareness rather than leave or terminate emotions - Learning to apply verbal labels to behaviours and environmental events
o Overcome tendency for literal reflection – “I feel unloved” interpreted literally as “I am unloved” - Participating with attention as opposed to mindlessly engage in an activity
DBT Core Skills Module 2 – Distress Tolerance
- Assumes ability to tolerate and accept distress essential for mental health
- Skill is to accept non-judgmentally current situation
o Experience current emotional state without attempt to change it
o Observe own thoughts & actions without controlling or stopping these
o Acceptance of reality does not mean approval of reality
• Distress is accepted but does not mean that it is not nevertheless still painful
DBT Core Skills Module 3 – Emotion Regulation Skills
- Difficulties in regulating pain emotions are central to behavioural reactions
- Assumption is that emotional distress is a secondary response tointense shame, anxiety or rage
- Skills in identifying and labelling affect. Observe & describe
o Event triggering emotion
o Interpretation of event
o Phenomenonological experience (physical & emotional feelings)
o Behaviours associated with emotions
o After effects on functioning
DBT Core Skills Module 4 – Interpersonal Effectiveness
- Skills in specific interpersonal problem-solving, social & assertiveness skills to modify aversive environments & develop effective relationships
- How to ask for things and say ‘no’ to other people, while maintaining self-respect and important relationships.
- Limit setting on demanding behaviours –> need for reassurance and acceptance
DBT Standard Treatment Modes
- Individual therapy (1 hour/week)
- Group skills training (2.5 hours/week)
- Phone coaching (as needed)
- Therapist consultation team (1-1.5 hours/week)
Borderline PD: DBT Meta-analysis
- 16 studies: 8 were controlled RCTs
- Drop our rate: 27%
- Moderate global effect size
- Moderate effect size for suicidal & self-injurious behaviours
Schema-focused therapy for BPD
- Integrative approach to treatment, combining aspects of cognitive-behavioral, experiential, interpersonal and psychoanalytic therapies into one unified model (Young, 1990; 1999)
- SCHEMAS
o Long-standing self-defeating patterns/themes in thinking, feeling & behaving/coping (life-traps) e.g., “I’m unlovable”, “I’m a failure”
o Broad, pervasive dysfunctional themes developed during childhood developmental phase and persisting into adulthood
o Composed of memories, emotions, & cognitions defining perspective of self and relationship with others that result in significant degrees of impaired functioning
3 Stages of Schema-focused therapy for BPD
o Assessment: schemas are identified (use of questionnaires)
o Emotional awareness & experiential phase: identifying how schemas operate in day-to-day living
o Behavioral change: replacement of negative, habitual thoughts & behaviors with new, healthy cognitive and behavioral options
18 schemas elicited in Schema Questionnaire
o Abandonment, mistrust, emotional deprivation, defectiveness, social isolation, dependence, vulnerability to harm, enmeshment, failure to achieve, entitlement, insufficient self-control, negativism, self-punitiveness, emotional inhibition, unrelenting standards, subjugation, self-sacrifice, approval seeking
Schema therapy: Coping styles & Modes
- SCHEMA/COPING STYLE: refers to a trait
o Maladaptive Coping Styles: schema surrender, avoidance (disconnecting from others or emotions), overcompensation - MODE: consists of current mood state, behaviours & cognitions (exist along a continuum of dissociation)
o Innate Child Modes: Vulnerable / Angry / Impulsive / Contented child
o Maladaptive Parent Modes: Punitive / Demanding / Critical parent
o Healthy Adult Mode - Task for therapist & patient: to track the rapid shifts among modes
Schema-focused therapy: Outcomes
- A multi-centre randomized clinical trial (N = 86)
o Complete recovery: 50%
o Significant improvement: 66%
o Outcomes strongly related to duration & intensity of treatment (2 sessions/week for 3 years) - Results contradict prevailing notion that therapy does not lead to full recovery, and that longer-term psychotherapy is ineffective in Borderline PD
