Personality Disorders

Question 1

General Diagnostic Criteria

Answer 1

Defined as “an enduring pattern of inner experience and behavior 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”

Pattern not better accounted for as a manifestation or consequence of another mental disorder, and isn’t due to direct effect of a substance or general medical condition

Question 2

Pattern Manifestation in 2 or more of the following areas:

Answer 2

Cognition
Affectivity
Interpersonal functioning
Impulse control

Question 3

“State” dependent experiences and behaviors

Answer 3

Result of a given Axis I syndrome that may remit when the Axis I Syndrome is treated successfully (e.g. Depression or psychosis)
It’s usually temporary

Question 4

“Trait” or “enduring” experiences and behaviors

Answer 4

Patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts

When they’re inflexible, maladaptive and cause distress and/or functional impairment, they constitute a personality disorder

Question 5

3 Groups of Personality Disorders (“weird, wild and worried”)

Answer 5

Cluster A (Paranoid, Schizoid, Schizotypal) are generally introverted and appear odd or eccentric (they look a little strange)

Cluster B (Antisocial, Borderline, histrionic, Narcissistic) are generally more extroverted and appear dramatic, emotional, or erratic

Cluster C (Avoidant, Dependent, Obsessive-Compulsive) are anxious and fearful

When you’re diagnosing a state, start to narrow down the cluster you think they’re in. What you find is there’s a lot of overlap in clusters. Getting down to the cluster is the first step

Question 6

Multiaxial Dx

Answer 6

• this system was designed to identify clinical syndromes (Axis I) and the personality (Axis II), medical (Axis III) and the psychosocial factors (Axis IV) that may contribute to syndromes
• facilitates a biopsychosocial approach to understanding clinical states and illnesses
• Axis V: level of functioning

E.g. If a patient is exceedingly sensitive to rejection, as are most patients with borderline personality disorder (Axis II), and is breaking up with a partner (psychosocial stressor on Axis IV), the combo of the stressor with the personality trait of rejection sensitivity may lead to an episode of major depression (Axis I)

Question 7

Axis I and II relationship

Answer 7

-Axis I may create Axis II disorders as well

E.g. A patient with repeated panic attacks at a young age may develop a social phobia and avoidant personality

Question 8

Psychodynamic Models (Superego, Ego, Id)

Answer 8

“Structural model of the psyche”
Ego: part of us that copes with and adapts to the internal and external worlds, must reconcile demands from the Id and the superego and the reality of the world in which we live. These demands can conflict with each other and cause painful inner turmoil
Id: instinctual drives
Superego: conscience

The Ego employs “defense mechanisms” to protect itself from painful memories, thoughts, urges and conflicts. These are often employed unconsciously and if successful and persistent, they become an ingrained way of dealing with the internal and external world. They become important parts of our personality structure

Question 9

Schizotypal Personality Disorder

Answer 9

• seen as eccentric, different, weird, odd or strange
• they may have difficulty expressing their thoughts rationally and coherently
• they may seem emotionally distant and disconnected, and to have social anxiety
• they may have strange, odd or magical beliefs that border on being delusional
• they may have paranoid ideas as part of their strange belief system, but it’s not the core symptom as it is in paranoid personality
• biological level, they have enlarged ventricles as do those with schizophrenia, but the degree of enlargement is not as great with schizotypal personality
• shown to have high levels of dopamine activity (those with prominent positive symptoms)

Question 10

Signs and Symptoms of Schizotypal Personality Disorder

Answer 10

• may lie along a continuum with schizophrenia
• -positive symptoms include delusions, hallucinations, and ideas of reference
• -negative symptoms include apathy, low motivation, withdrawal and anhedonia
• -may have interpersonal difficulties
• —-the similarities between schizophrenia and schizotypal personality disorder suggest a common predisposition called schizotypy that may be primarily genetic in origin

Question 11

Paranoid Personality Disorder

Answer 11

• the capacity for trust is impaired
• they perceive others as threatening rather than supportive. They see themselves as victims of a cruel world with cruel people in it
• they seek info that confirms their fears and distort data to fit their perception. They see hidden meaning in what may be innocuous statements or events
• this forms a self-reinforcing cycle of fear, distortion of facts, and more fear which may lead to paranoid delusions
• reacts to the perception of danger by becoming detached, distant and hyper vigilant
• however, unlike the schizoid, he may seek the company of others who have similar beliefs and a cult is formed
• the paranoid patient is angry about being persecuted, and may act out his anger

Question 12

Causes of Paranoid Personality Disorder

Answer 12

• patients tend to have high sympathetic discharge
• no specific temperament, but hyperaggressiveness may come into play. An aggressive child may elicit reactive abuse from parents, thereby setting up a cycle of hostility that may leave the child feeling persecuted

Question 13

Environmental Causes of Paranoid Personality Disorder

Answer 13

• early physical/sexual abuse may be a major factor. Paranoid patients learn to mistrust rather than trust their ENV.
• a family may scapegoat the paranoid patient, attributing to negative qualities to him or her the family would like to disown
• there’s often an ENV of severe criticism which constitutes verbal abuse. The patient guards against such abuse by hypervigilance, avoidance, and a defensive retreat into a grandiose self image
• there may be an atmosphere of excessive shame, guilt, and envy. The patient incorporates these experiences into his superego structure and then projects the superego into the ENV
• the parents of a paranoid patient often expect autonomy and punish emotional dependency

Question 14

Borderline Personality Disorder

Answer 14

• CORE FEATURE: intense ambivalence about interpersonal relationships such that the patient can’t find a comfortable, acceptable, optimal distance
• have intense needs for intimacy, fear abandonment, and are exquisitely sensitive to rejection
• they need the structure of a relationship in order to feel stable. Without it, they feel empty and depressed. They’re very insecure
• they impose their need for relationship on others, and often drive them away, after which the borderline patient feels guilty, ashamed and regretful
• they hate themselves for having lost loved ones and exposing themselves to feelings of abandonment and rejection. They hate the loved one for leaving
• they often deal with their rage by ACTING OUT against themselves or others. They’re notorious for engaging in self-destructive behavior, whether or be substance use or more directly dangerous behavior like self-mutilation
• when needs for structure and relationship aren’t met, borderline patients tend to fall apart
• they become emotional, flooded with memories of abandonment and act impulsively to try and restore a sense of security and stability
• they’re vulnerable to severe anxiety, depression and to brief psychotic reactions
• if someone is perceived as supportive, he or she may idealized. BUt if perceived as unsupportive he or she is devalued and rejected, sometimes with paranoid hostility
• this alternation of idealized/devalued self and object images is called SPLITTING and is the hallmark defense mechanism of borderline personality disorder

Question 15

Causes of Borderline Personality Disorder

Answer 15

• patients may be born with excessive emotional needs that caregiver as cannot satisfy
• may also have a constitutional problem with internalizing positive experiences with caregivers. Their mothers sometimes report they were inconsolable as infants and toddlers. They have problems with object constancy (developmental skill most kids develop around 2-3 yrs old. Reliability of key people in their world. When mom leaves the room, she’s still on the same planet and will reappear again)
• “small stimuli may arouse a violent reaction”
• characteristics such as impulsivity, irritability, hypersensitivity, emotional lability, reactivity and intensity of response have been associated with biological foundation

Question 16

ENV causes of Borderline Personality Disorder

Answer 16

• some patients develop reaction to borderline mothers who cling to the child to satisfy their own emotional needs
• the child develops an intense ambivalence toward the mother, sometime as clinging, sometimes withdrawing from her care
• 4 major ENV features:
• —family chaos: fights, affairs, abortions, infidelity, drunken acting out, suicide attempts, murders. This becomes part of the patient’s structure
• —traumatic abandonment: the child is left alone without nurturance, and is often sexually abused
• —Attempts at autonomy are met with resistance and criticism, as if the child is being disloyal
• —The child learns that to receive love in the family he or she must be depressed and miserable, the way they are

MOST IMPORTANT: neglect and sexual abuse. up to 70% of female borderline patients have been abused

• abuse leaves the impression that adults are unsafe and interested in them only for gratification of their own needs
• the patient’s self image and self esteem are damaged. THey talk about feeling “dirty”
• this leads to a hunger for a good person who will genuinely care for them, and a hostile defensiveness against anyone who’s perceived as abusive

Question 17

Narcissistic Personality Disorder

Answer 17

• core feature: unconscious indemnification with a superior sense of self
• associated with the superiority is an egocentricity such that the patient feels entitled to special treatment even at the expense of others, who are considered at some level not as important
• really bad narcissists may in fact have contempt for others, who they consider to be “lesser than”
• even less severe narcissists may exploit others and rationalize the exploitation
• fantasies of unlimited success and the admiration of others, esp those in a position of power and importance. They’re envious of others who have achieved success, and often have an unconscious wish to bring them down
• may lack productivity due to concerns about what others think
• “narcissistic injury” inflated self-esteem is deflated. This can be painful and the person defends against it by warding off criticism
• along with the egocentricity goes a failure to empathize with others. “Stunted capacity to love”
• they have high divorce rates and job failure due to grandiosity, exploitiveness and lack of empathy
• MOST COMMON PERSONALITY DISORDER AMONGST PROFESSIONALS (along with OCD)

Question 18

OCD

Answer 18

• classic “workaholic”. But the work is not done of out of excitement or pleasure. It’s out of extreme sense of duty
• they’re meticulous, detail oriented and perfectionists
• they have very high standards for both the quantity and quality of work, but the perfectionism may compromise the quantity of work
• they tend to take a long time to do things, and to procrastinate about work, probably because it’s made so demanding
• may be hoarders
• tend to keep their instinctual drives and emotions under tight control
• control in general is a major issue for these patients
• they get anxious when they feel their losing control
• having fun requires letting go of oneself and being childlike and playful in activities such as music, sports and sex
• OCD patients tend to be too serious, too mature and have trouble being playful
• tend to be very critical of themselves and others
• they can be productive supervisors if not too extreme
• if too extreme, they tend to breed resentment and to elicit passive aggressive, unproductive behavior from those under them
• in families their spouses and/or children may resent them and tacitly or openly rebel against them
• often havre problem with decision making because they get caught up in perfectionism and ambivalence

Question 19

Avoidant Personality Disorder

Answer 19

• the core feature is a fear of humiliation and embarrassment
• fear leads to social isolation and work inhibition. These patients are afraid of exposing themselves in either situation. Whereas the histrionic and narcissistic patients may be exhibitionistic, the avoidant patient is extremely inhibited
• because of the inhibition they’re often underachievers at work and struggle in their love life
• they don’t like their isolation. They want intimacy but are deathly afraid of a humiliating rejection
• usually live a solitary life with one or two friends or family members as their only social contacts
• they would like to expand their horizons but often do not make progress because of the social phobia
• they have lively fantasies of intimacy which if taken to an extreme, may lead to erotomania, a belief that someone in a position of authority or celebrity is in love with them and is pursuing them
• if someone does get through to them, it’s usually because the person is determined and persistent and won’t take no for an answer

Question 20

ENV causes of Avoidant Personality Disorder

Answer 20

• parents can react to shy, sensitive children by protecting them and not challenging them to master their environment
• this leads to a reinforcing cycle of fear and avoidance. The child develops a sense of him or herself as inadequate and worries about failure and humiliation
• if there’s an actual experience of failure it can make matters worse. AN experience of abuse can lead to shame and avoidance
• these patients were sometimes humiliated within the family and given the message that no one would tolerate their flaws. This message may generalize to the idea that no one would tolerate their whole personality