Personality Disorders Flashcards
Boarderline Disturbance
On the “boarder” between neurotic and psychotic disturbances
•compared to psychotic disorders: more intact reality testing, better day to day functioning and independent living
•compared to neurotic disorders: less consistent reality testing, greater duration/pervasiveness of dysfunction
•characteristic pattern of many personality disorders (schizoaffective disorders, bipolar I, dissociative disorders, obsessive disorders, eating disorders)
Personality Disorders
Personality: pervasive, enduring pattern of inner experience and external behaviours, where patterns are consistent across situations and contexts
Personality disorders: experience and behavioural problems that deviate from the cultural expectations/what we would expect from them
•onset: adolescence/early adulthood
•stable over time and situations (inflexible)
*but personalities can change as we age (more agreeable, less neurotic)
•causes significant distress/impairment
DSM-5: proposed major revisions that weren’t approved because they were so controversial
•claimed that there is not enough research to support so main diagnostic categories remained similar
•some diagnoses are still too vague
Clusters of personality disorders
Cluster A (odd): paranoid, schizoid, schizotypal
•detached from society, behaviour doesn’t really make sense, schizophrenia like symptoms but not as severe
•prevalence: 5.7%
Cluster B (dramatic): antisocial, borderline, histrionic, narcissistic •fragmented sense of self, unstable, difficulty with empathy, interpersonal problems •prevalece: 1.5% (but seen a lot more in treatment)
Cluster C (fearful): avoidant, dependent, obsessive compulsive
•anxiety, OCD like symptoms
•prevalence 6.0%
Any PD prevalence: 9.1%
•comorbidities between PDs is common
•comorbidity with other disorders is common: anxiety, depression, substance use
General Diagnostic Criteria and Features
Enduring pattern of inner experiences and behaviour that deviate from cultural expectations:
•cognition, affect, interpersonal functioning, impulse control
•pattern is inflexible/pervasive across situations
•clinically significant distress/impairment
•stable, long duration, traced back to adolescence/early adulthood
Other features
•most people feel ego syntonic
•usually doesn’t seek help, only for more surface symptoms
•if do seek help, often blames others for problems
*keep in mind PDs are exaggerated and rigid manifestations of behaviours we all have to some extent
Paranoid personality disorder
Core idea: distrust of other people’s intentions with 4+ of the following
1. Suspect without evidence others are out to harm/deceive/exploit them
2. Preoccupied with doubt of trustworthiness of friends
3. Reluctant to confide in others
4. Sees hidden slights/threats in remarks
5. Persistent grudes
6. Sees attacks on their character others don’t see
7. Suspect without evidence of fidelity in romantic partners
Not due to another disorder
Other features
•difficult with compliments/constructive feedback
*perceived as attempts to manipulate/belittle
•persistently jealous (may gather convincing evidence to support their claims - presenting self as objective)
•Labile affect: hostile, stubborn, sarcastic
•Underlying concerns: power/status is very concerning but also very threatening (unrealistic fantasies enable feeling of self control because they don’t feel safe)
•negative stereotypes of outgroups, simplistic world view (good or bad) with low tolerance for ambiguity
Other disorders
•under stress, can show brief psychotic features
•premorbid signs of schizophrenia/other psychotic disorders
•overlap with delusional paranoia
•common comorbidity with depression, agoraphobia, substance use, and OCD
Prevalence: 2-5%
Schizoid Personality Disorder
Detachment from interpersonal interactions and doesn’t show expression with 4+
1. No desire for intimacy with others (including family)
2. Almost always chooses solitary activities
3. Little if any interest in sex
4. Little pleasure in most activities
5. Lack of close friends
6. Indifferent to praise of criticism
7. Flat affect, coldness, detachment
Not due to another disorder
Other features
•lifelong loners: prefer being alone
•oblivious/indifferent to social cues (seen as socially inept/self absorbed)
•doesn’t show feelings (no anger when evoked)
•very rarely will reveal significant inner pain around social interactions (lonely, anxiety, frustration, etc)
•may open up to people online
•rarely have intimate relationships
•life may seem directionless
•no clear work goals/impaired work functioning
- under stress may show brief psychotic features
- premorbid signs of schizophrenia and other psychotic disorders
- common comorbidity with depression
- schizoid: negative of schizophrenia
Prevalence
•3-5%
•slightly more diagnosed in men
Schizotypal personality disorder
Deviance from social norms of thinking and behaviour seen through pervasive social difficulties, and cognitive distortions or eccentric behaviour 5+
1. Ideas of reference (but not delusional intensity)
2. Odd beliefs/magical thinking influences behaviour
3. Unusual perceptual experiences
4. Odd thinking or speech
5. Suspicious, paranoid ideation
6. Inappropriate or blunted affect
7. Odd/eccentric behaviour or appearance
8. persistent social anxiety related to paranoia (not negative self evaluation) - won’t go away like SAD does
Not due to other disorder
Other features
- paranormal/superstitious phenomenon not consistent with culture (believes they’re magic)
- sub threshold experiences of delusions hallucinations and disorganization
- unusual mannerisms: stiff/inappropriate social interactions, appearance is weird
- considered positive symptoms of schizophrenia
- under stress can show brief psychotic features
- (high) premorbid signs of schizophrenia and other psychotic disorders
- more likely to seek treatment than previous two
- common comorbidity with depression, anxiety (may treat this initially then see the disorder later)
Prevalence:
0.4-5%
•slightly more common in men
•higher risk of schizophrenia than general population (but most don’t go on to develop schizophrenia)
*someone with schizophrenia is likely to have family member with schizotypal
Histrionic personality disorder
Pervasive excessive emotionality and attention seeking with 5+
- Uncomfortable when not centre of attention
- Inappropriate seductive behaviour
- Rapidly shifting/shallow emotions
- Consistently use physical appearance to draw attention to self
- Impressionist speech lacking detail
- Exaggerated emotions
- Suggestible
- Judges relationships to be more intimate than they are
Other features
•overly intimate in relationships (more about superficial speech not about valuing the relationship)
•suggestible: thinks other people can solve their problems
•inconsistent: jumps from idea to idea/doesnt complete things
•in close relationships, difficulties with dependency and control (manipulate/seduce partner to stay with them)
•wants to be close but often wears people out: constant need for attention, distrust with seductive behaviour, plays victim role, alienates friends (especially same sex)
•sensation seeking is high (gets bored in long term relationships)
•associations with somatic symptoms (symptoms that aren’t happening anymore), conversion disorder, depressive disorder (especially if can’t be centre of attention)
Prevalence
approx 1.8%
more prevalent in women in clinical settings, but uncertain
Narcissistic personality disorder
Pattern of grandiosity, need for admiration, lack of empathy with 5+
- Grandiosity
- Preoccupied with fantasies of power/success/brilliance/beauty
- Believes one is special and should only associate with high status people
- Requires excessive/total admiration
- Entitlement
- Interpersonally exploitative
- Lacks empathy
- Envious, or claims others are envious
- Arrogant behaviours and attitudes
Other features
•oversell abilities/achievements to others (believes to varying degrees but not delusional)
•entitled with little empathy for others
•little regard for how their actions impact others
•despite presentation, underlying self esteem is often very fragile
•narcissistic injury: criticism is very painful
•narcissistic rage: defence or withdrawal
•impaired relationship/work functioning (won’t take risks to advance career - can’t face mess ups, social isolation)
•comorbids with depression, hypomania when grandiose, eating disorders (anorexia) and cocaine use
Prevalence
0-6.2%
•majority diagnosed are male
Antisocial personality disorder (sociopathy, dissocial personality disorder)
Disregard for the rights and wellbeing of others with 3+
1. Fail to conform to norms and laws (repeated lawbreaking)
2. Impulsivity/can’t plan ahead
3. Deceitfulness
4. Irritability/aggression
5. Reckless disregard to safety of self or others
6. Consistent irresponsibility (work/finances)
7. Lack of remorse for hurting others
Must be atleast 18 (people conform more to society as they age), evidence of conduct disorder before 15 (need to demonstrate pervasive pattern), and not exclusively during schizophrenia or bipolar disorder
Other features
•manipulation to get things they want
•unreliable and irresponsible
•arrogant self appraisal
•superficial charm and cooperation (won’t follow through)
•explosive in close relationships
•difficulty supporting themselves resulting in poor psychosocial outcomes
•more likely to die violently
•underlying theme: I need to look out for myself first in this cruel world
•person can still experience tension, anxiety, boredom and distresses
Comorbids: anxiety, depression, substance use, impulse control disorders (gambling)
Prevalence
0.2-3.3%
more common in men 3:1 - 5:1
Chronic course but usually remits someone with age (especially criminal behaviour)
Antisocial personality disorder and psychopathy
Overlapping constructs but focus on different aspects
Dimensions of psychopathy
•Interpersonal (surface level): superficial charm, deceitfulness, grandiosity
•Affective (indifference to others): lack of guilt and responsibility
•Lifestyle: need stimulation, impulse control, irresponsible
•Antisocial: behavioural problems, delinquency, criminality
ASPD focus on behavioural, psychopath focuses on personality structure
•prison: 20-30% psychopathy, 70-80% (overlaps)
•psychopathy better predictor of long term violence
•psychopaths are higher functioning (show greater stress related heart reactivity)
•psychopaths can reach high status, but most are still more likely to end up in prison
*corporate settings 4%, community settings 1%, and prison settings 15%
Causal factors of both
•strong genetic component but specific genes are unclear
•parental impoverishment, abuse, neglect and inconsistent discipline (more common in low SES populations/immigrant population)
•impaired fear and distress reactivity (lack of guilt/empathy)
•poor impulse control (results in self and other destructive behaviours, comprbid ADHD predicts poorer outcomes - worse impulse control)
•presence of an dissocial phenotype (but socialization can impact how aggression is displayed)
Boarderline personality disorder
Instability in emotions, relationships, sense of self and behaviours 5+
- Frantic efforts to avoid abandonment
- Unstable/intense relationships with idealization and devaluation pattern
- Persistent unstable sense of self
- Self damaging impulsivity in 2+ areas (money, sex, drugs, driving)
- Recurrent suicidal behaviour or self harm behaviour
- Affective instability, marked mood reactivity
- Chronic feelings of emptiness
- Inappropriate, difficult to control anger
- Transient, self related paranoid ideation or severe dissociation
Other features
•poor integration (black and white thinking leads to splitting (all things are all good or all bad) perception can rapidly shift
•abandonment: self is bad and other is bad (cruel)
•can support others, but demands other person is always there for them
•emotions are overwhelming/unmanageable
•suicidality: 8-10% complete but many more attempts
•non suicidal self injury common for many reasons (emotional pain, manipulate, solicit care, ground self during dissociation, punish self for being bad)
•often undermines self before succeeding goals, disrupting careers, education, and clinical treatment (notoriously challenging to work with)
•stress can bring on dissociative features
•comorbids: depression, anxiety, substance use, eating disorders, PTSD, ADHD
•developmental history of abuse, neglect, hostility (parental loss common)
Prevalence
1-6%
•10% in outpatient mental health, 20% in inpatient psychiatry (well represented)
•more common in women 3:1
•chronic lifelong course, but will also remit somewhat with age (30s and 40s time when they attain more stability)
Conceptualization: orientations differ on primary concern of BPD
•psychodynamic: poorly integrated unstable sense of self (can’t integrate positive and negative emotions at the same time)
•CB: overly intense and poorly regulated emotions
•but both elements important, likely interactive
•DSM: focuses on impulsive self destructive behaviours, another variant focusing on chronic despair, inhibition, and schizoid features
Developmental factors
1. About 40% heritability: likely involves many genes (maybe serotonin system) and genes involved don’t seem specific to BPD (psychopathology in general
2. Childhood trauma, abuse, or severe hardship
•90% of BPD reported significant child abuse
•even higher levels than other PDs
3. Diathesis stress model
•biological: chronic stress impacts neurocognitive development
•psychological: person learns maladaptive ways of coping and obtaining care
Treatment
1. Dialectical behavioural therapy: derived from CBT, targets coping of difficult emotions
•distress tolerance, emotional regulation and interpersonal skills
•reinforcing adaptive behaviours, discussion of maladaptive behaviours
•expect more independence as patient progresses
•demanding on patient and therapist, but affective for reducing self harm behaviours
•less effective for feelings of emptiness/unstable sense of self
2. Psychodynamic therapy: more directive form targeting splitting
3. Metallization therapy: understanding own and others emotions
Avoidant personality disorder
Pervasive pattern of social inhibition and sensitivity to negative evaluation with 4+
- Avoids interpersonal tasks at work due to fear of criticism/rejection
- Unwilling to get involved with people unless certainty of being liked
- Show restraint in intimate relationships due to fear of shame/redicule
- Preoccupied with criticism and rejection in social situations
- Inhibited in new interpersonal situations due to fear of inadequacy
- Views self as socially inept, personally unappealing, or inferior
- Reluctant to take risks for fear of embarrassment
Other features
•avoids making new friends
•feels easily hurt ashamed or embarrassed
•exaggerates danger of social situations
•avoids speaking in social situations
•makes excuses to live avoiding lifestyle
Prevalence
approx 2.4%
Difference between this and SAD
•more likely to diagnose avoidant PD in more severe pervasive cases
•but SAD is more commonly used to diagnose
Dependent personality disorder
Excessive need to be taken care of resulting in submissive/clingy behaviour 5+
- Difficult making day to day decisions without excessive reassurance
- Needs others to assume responsibility for most things
- Difficulty expressing disapproval for fear and loss of support
- Lack of confidence in initiating own goals
- Excessive lengths to obtain support
- Feels uncomfortable/helpless when alone
- Urgently seeks new relationships when old ones end
- Preoccupied with fears of being left to take care of self
Other features
•needs reassurance for even minor choices (what to wear)
•very passive
•dependence on others to make pretty much all choices
•believes self is inept (can’t do things well)
•difficulty expressing disagreement (scared of being abandoned) can lead to abuse and self sacrificing
•pessimistic, very low self esteem
•don’t learn how to do important tasks (work, functional relationships)
Comorbid: anxiety, depression, adjustment disorders
•can have developmental experiences of chronic illness or other circumstances requiring significant care
Prevalence
0.5-0.6%
•more diagnosed in women in clinical settings
•cultural norms have big impact on what is appropriate vs excessive dependence
Obsessive compulsive personality disorder
Preoccupation with orderliness, control, and perfectionism with 4+
- Preoccupied with details/organization losing major point of tasks
- Perfectionism that interferes with task completion
- Excessive devotion to work/productivity (no leisure or friends)
- Overconscientious: right, fixated over values
- Unable to discard worthless items (no sentimental value)
- Reluctant to delegate, unless others can meet own standards
- Miserly towards money for self/others
- Rigid and stubborn in most contexts
Other features
•perfectionistic: never finishes tasks
•very high standards causing problems
•highly demanding of self and others
•unable to relax (time with friends must be productive)
•force self and others to follow strict rules, things must always be done correct way
•money must be saved for emergencies
•can’t compromise/understand others perspectives (even if it benefits them)
•anxiety if can’t make a decision or can’t control a situation
•excessive resistance to authority they don’t respect, but follows in commanding way to authority they do respect
•difficulty expressing affection (irrational)
Comorbidities: anxiety (SAD/GAD), depression, bipolar, eating disorders
•OCD common comorbidity, but most with OCD don’t display OCPD pattern
Prevalence
2-8% (one of the most common)
•2:1 ratio in men
•culture impacts whats considered excessive for these patterns
