Personality Disorders Flashcards
Cluster A Personality Disorders
Odd & eccentric; resembles schizophrenia
- Paranoid
- Schizoid
- Schizotypal
Cluster B Personality Disorders
Dramatic, emotional, erratic; primarily affective disturbance
- Antisocial
- Borderline
- Histrionic
- Narcissistic
Cluster C Personality Disorders
Anxious, fearful
- Avoidant
- Dependent
- Obsessive-Compulsive
Personality Disorder Definition
- Pervasive/inflexible patterns of behavior that deviate from expectations of one’s culture; cross-situational and enduring over time; onset during adolescence/early adulthood; distress or impairment
- Present in at least 2 areas/domains: cognition, emotions, relationships, impulse control
- Typically thought to be life-long and unresponsive to treatment (but maybe not? DBT?)
- Sometimes described as having self-centered/self-focused/selfish components
Potential Problems with Current System
- High comorbidity
- Instability of diagnoses
- Symptom thresholds arbitrary
- High rates of PD-NOS (Other/unspecified)
Five Dimensions of Personality
- Introversion vs extraversion
- Neuroticism vs emotional stability
- Conscientiousness vs irresponsibility
- Antagonism vs agreeableness
- Avoidant vs open to experiences
- Should we change to dimensional view?
General Personality Disorder
A) Enduring pattern of inner experience and behavior that deviates markedly from one’s culture; Manifested by 2+ of following:
-cognition, affectivity, interpersonal functioning, impulse control
B) Inflexible, pervasive, stable, long in duration
C) Leads to distress/impairment
D) Stable and long duration; onset adolescence/early adulthood
E) Not better explained by another MD
F) Not attributable to substance or medical condition
Prevalence of Cluster A PD’s
- Paranoid: 2.3-4.4%, more common in men
- Schizoid: 3.1-4.9%, slightly more common in men
- Schizotypal: 0.6-4.6%, slightly more common in men
Paranoid Personality Disorder
A) Pervasive distrust in/suspiciousness of others; others’ motives interpreted as malevolent. 4+ of following:
- Suspects that others are exploiting, harming, deceiving
- Preoccupied with doubt about others’ loyalty/trustworthiness
- Reluctant to confide in others (fear info will be used against them)
- Reads threats into benign remarks/events
- Bears grudges
- Perceives unapparent attacks on his/her character
- Recurrent concerns about partner’s fidelity
B) Not only during the course of broader psychosis
Schizoid PD
A) Detachment from social relationships and restricted emotional expression in interpersonal settings. 4+ of following:
- Neither desires nor enjoys close relationships
- Mostly chooses solitary activities
- Little interest in sexual activity with another
- Takes pleasure in few activities
- Lacks close friends
- Appears indifferent to praise or criticism
- Shows emotional coldness/flat affect
B) Not schizophrenia or some other psychotic disorder
Schizotypal PD
A) Social and interpersonal deficits, acute discomfort with close relationships, cognitive distortions, eccentricities of behavior. 5+ of following:
- Ideas of reference
- Odd beliefs/magical thinking
- Unusual perceptual experiences
- Odd thinking and speech
- Suspiciousness/paranoid ideation
- Inappropriate/restricted affect
- Behavior/appearance that’s odd, eccentric, or peculiar
- Lack of close friends
- Excessive social anxiety (maybe associated with paranoia)
B) Not a psychotic disorder
Etiology of Cluster A
- Genetic link to schizophrenia?
- Risk of schizotypal associated with family history of schizophrenia
- Schizotypal similar to positive symptoms of schizophrenia?
- Schizoid similar to negative symptoms of schizophrenia?
Cluster B Epidemiology
- Antisocial: 0.2-3%, more common in men
- Borderline: 1.6-6%, more common in women
- Histrionic: 2%, more common in women
- Narcissistic: up to 6%, more common in men
Antisocial PD
A) Pervasive disregard for and violation of the rights of others, occurring since age 15. 3+ of the following:
- Breaking the law repeatedly
- Deceitfulness, repeated lying, use of aliases, conning others
- Impulsivity/failure to plan ahead
- Irritability/aggressiveness
- Reckless disregard for self and others
- Consistent irresponsibility as indicated by failure to maintain job or financial obligations
- Lack of remorse
B) At least 18 years old
C) Evidence of CD before age 15
D) Not during course of schizophrenia or Bipolar
Borderline PD
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity. 5+ of following:
- Frantic efforts to avoid abandonment
- Unstable and intense interpersonal relationships, vacillate between idealization and devaluation
- Unstable self-image or sense of self
- Self-damaging impulsivity
- Recurrent suicidal behavior, threats, self-mutilating bx
- Highly reactive and labile moods
- Feelings of emptiness
- Inappropriate, intense anger/inability to control anger
- Transient paranoid ideation or severe dissociation
Most common PD seen in treatment
Borderline PD
Borderline ego-dystonic or ego-syntonic
Ego-dystonic (others are ego-syntonic)
Risk factors for Borderline PD
- History of childhood trauma/abuse, family discord, loss of parent, exposure to violence common
Linehan’s Biosocial Model of Borderline PD
1) Emotional dysregulation stresses parents
2) Parents respond harshly/confrontationally or with abuse/neglect
3) Invalidates emotional experiences and increases emotional dysregulation
4) Child learns to cope by tantruming (parents eventually attend to tantrums); never learns to manage emotions
Identity Disturbance and Borderline PD
- Identity disturbance/chronic emptiness at the core; drive emotional instability and other symptoms
- Identity disturbance may be related to invalidation/abuse by parents
- Don’t know how to feel because those who they are supposed to love are hurtful towards them
- Bowlby’s internal working models of attachment: expect lack of care, unreliability, unresponsiveness
Underlying features of Borderline PD
- Fear of abandonment: mistrust due to abuse; feel as though defective
- Idealization followed by devaluation: attraction of new identity followed by boredom and waiting for betrayal by others
- Chronic emptiness: lack of stable identity
- Impulsivity: poor frustration tolerance and emotion regulation; lack of boundaries
- Mood lability: poor frustration tolerance
- Self-harm: maladaptive coping; pain distracts from negative affect
- Suicidal ideation/behavior: maladaptive coping, can be genuine desire to die
- Inappropriate anger: poor frustration tolerance and mood regulation
- Unstable but intense relationships: problems with boundaries; want stable, validating relationships; poor modeling from family
- View the world in black and white
Course of Borderline PD
- Worse in young adulthood, risk of suicide higher
- Therapy can improve symptoms
- Relationship and vocational stability for some during middle adulthood
- Symptoms “burn out” by 50s?
- Relatively high rate of suicide
- Commonly comorbid with other disorders
- Self-medication very common
Histrionic PD
Pervasive, excessive emotionality and attention seeking. 5+ of following:
- Uncomfortable when not the center of attention
- Interactions often include inappropriate sexually seductive/provocative behavior
- Rapidly shifting/shallow expressions of emotion
- Uses physical appearance to draw attention
- Speech is excessively impressionistic, lacking detail
- Self-dramatization, theatricality, exaggerated expression of emotion
- Easily suggestible
- Considers relationships more intimate than they really are
Narcissistic PD
Pervasive grandiosity, need for admiration, lack of empathy. 5+ of following:
- Grandiose sense of self-importance
- Fantasies of “unlimited success, power, brilliance, beauty, or ideal love”
- Believes s/he is special, unique, can only be understood by or associate with high-status people
- Requires excessive admiration
- Sense of entitlement
- Exploits others
- Lacks empathy
- Envious of others, believes others are envious of him/her
- Arrogant, haughty behaviors/attitudes
Cluster C Epidemiology
- Avoidant: 2.4%, equal men and women
- Dependent: .5-.6%, more common in women
- Obsessive-Compulsive: 2-8%, more common in men
Avoidant PD
Pervasive social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation. 4+ of following:
- Avoids jobs that require significant interpersonal contact
- Unwilling to get involved with someone unless certain of being liked
- Shows restraint in relationships because of fear of being shamed or ridiculed
- Preoccupation with being criticized/rejected in social situations
- Inhibited in interpersonal situations due to feelings of inadequacy
- Views self as socially inept, unappealing, inferior
- Reluctant to take risks due to fear of embarrassment
Avoidant PD and Social Anxiety Disorder
Some argue the same thing
Dependent PD
Pervasive/excessive need to be taken care of, leads to submissive, clinging behavior, fears of separation. 5+ of following:
- Difficulty making decisions without excessive advice/reassurance
- Needs others to assume major responsibilities
- Trouble expressing disagreement due to fear of loss of support/approval
- Trouble initiating/doing things on their own
- Goes to excessive lengths to obtain nurturance/support from others
- Feels uncomfortable/helpless when alone for fear of being unable to care for oneself
- Seeks new relationship as source of care/support when close relationship ends
- Unrealistically preoccupied with fears of being left to care for self
Obsessive-Compulsive PD
Pervasive preoccupation with orderliness, perfectionism, and mental/interpersonal control, at the expense of flexibility, openness, efficiency. 4+ of following:
- Preoccupied with details, rules, lists, order, organization, schedules (major point of activity is lost)
- Perfectionism interferes with task completion
- Devotion to work/productivity leads to exclusion of leisure, friendships
- Over conscientious, scrupulous, inflexible about matters of morality, ethics, values
- Unable to discard worn-out/worthless objects
- Reluctant to delegate tasks or work with others
- Miserly spending habits, money viewed as something to be hoarded for future catastrophes
- Rigid and stubborn
Etiology of Personality Disorders
- Temperament: genetics? family studies suggest low to moderate heritability
- Childhood abuse: disruption of attachment?
- Long-term, post-trauma reaction?
- Schizotypal: abnormalities in temporal lobe volume (but reductions in frontal lobe as in schizophrenia not seen)
- Borderline: Reduced hippocampus and amygdala size, heightened HPA axis activity?
- Antisocial: chronic underarousal? Higher fear detection threshold?
- Narcissistic: shield against low self-esteem and negative self-image
Section III Criteria
- General criteria for personality disorder are provided
- Criterion A: Level of personality functioning. Disturbances in self (identity, self-direction) and interpersonal functioning (empathy, intimacy)
- Criterion B: Pathological personality traits (each specific PD has a subset of traits from a group of 25 traits)
- Criteria C and D: traits are pervasive and stable
- Criteria E, F, and G: rule-out alternative explanations
Gore and Widiger article
- The DSM-5 maladaptive trait dimensional model proposal included 25 traits organized within five broad domain
- Domains: negative affectivity (neuroticism), detachment (introversion), antagonism (low agreeableness), disinhibition (low conscientiousness), and psychoticism (openness)
- Study tested the dimensional model proposed for DSM-V versus the five factor model
- The results provided support for the hypothesis that all five domains of the DSM-5 dimensional trait model are maladaptive variants of general personality structure
Zimmerman article
- Work Group recommended deleting 5 PD’s because too comorbid. Author argues that the core problem with DSM-IV PD’s is methodological, not inadequacies of the criteria themselves.
