Personality Disorders Flashcards
What was Livesely and Colleague’s perspective on normal personality and personality disorders?
- Normal personality is having adaptive solutions to life tasks
- Three life tasks:
1) To form stable, integrated and coherent representations of self and others (to see your self and others as they really are)
2) To develop capacity for intimacy (to have positive interrelationships)
3) To engage in pro-social and cooperative behaviours (to function adaptively in society) - Personality disorders occur when there is a failure to manage these life tasks
What was Millon’s perspective on normal personality and personality disorders?
- Criteria that distinguish ‘normal’ versus ‘disordered’ personality:
- Rigid and inflexible
- Self defeating, vicious cycle that perpetuate troubled ways of thinking and behaving
- Structural instability, fragility, ‘cracking’ under stress
What are personality traits?
- enduring 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 do personality traits constitute personality disorders?
- Only when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute PDs.
How are personality disorders viewed in the DSM-5?
- Eliminated Axis II (DSM-IV-TR)
- Maintained same categories as DSM-IV-TR
- Considered dimensional approach, which is described as an ‘alternative model’ (AMPD) in DSM-5 Section III
- Dimensional perspective: disordered personality reflects extreme levels of
tendencies (traits) - Not fully adopted in DSM-5, remains a proposal
What are the essential criteria for a personality disorder in the alternative model?
- Moderate or greater impairment in personality (self/interperonsal) functioning
- One or more pathological personality traits
- the impairment in personality functioning and the individual’s personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations
- the impairments in personality functioning and te individuals personality trait expression are relatively stable across time, wit onsets that can be traced back to at least adolescence or early adulthood
What are the 2 elements of personality functioning (criterion A) in the alternative model of personality disorder?
- Self: Identity and Self direction
- interpersonal: Empathy and intimacy
What are the 5 Dimensions of pathological traits in the AMPD?
- Negative affectivity (vs. emotional stability)
- Detachment (vs. extraversion)
- Antagonism (vs. agreeableness)
- Disinhibition (vs. conscientiousness)
- Psychoticism (vs. lucidity)
What is the current, main diagnostic criteria of general personality disorder?
- an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individal’s culture. this pattern is manifested in two (or more) of the following areas:
- cognition
- affectivity
- interpersonal functioning
- impulse control
- the enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
What are the DSM-V personality disorder clusters?
- Cluster A (odd/eccentric) : paranoid, schizoid, schizotypal
- Cluster B (Dramatic/Erratic): antisocial, borderline, histrionic, narcissistic
- Cluster C (anxious/fearful): avoidant, dependent, obsessive compulsive
What are the important diagnostic criteria for paranoid personality disorder?
- a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolvent, beginning by early adulthood and present in a variety of contexts, as indicated by four or more of the following
1. suspects, without sufficient basis, that others are exploiting, harming, or deceiving him/her
2. is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
3. is reluctant to confide in others bc of unwarranted fear that the information will be used maliciously against him/her
4. reads hidden demeaning or threatening meanings into benign remarks or events
5. Persistently bears grudges
6. perceives attacks on his/her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
7. has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
What is the key diagnostic criteria for Schizoid personality disorder?
- 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:
1. Neither desires nor enjoys close relationships, including being a part of a family
2. almost always chooses solitary activities
3. has little, if any, interest in having sexual experiences with another person
4. takes pleasure in few, if any, activities
5. lacks close friends or confidants other than first-degree relatives
6. appears indifferent to the praise or criticism of others.
7. Shows emotional coldness, detacment or flattened affectivity
What are the key diagnostic criteria of schizoptypal personality disorder?
- 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 four or more of the following:
1. ideas of reference
2. odd beliefs or magical thinking that influence behaviour and is inconsistent with subcultural norms
3. Unusual perceptual experiences, including bodily illusions
4. odd thinking and speech (e.g., vague, circumstantial, metaphorical etc.)
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 judgements about the self
What are the psychosocial risk factors that are believed to be the cause of schizotypal personality disorder?
- Compared to controls, individuals with SPD experienced higher rates of child abuse and early trauma
- Multiple forms of abuse, child maltreatment, and child neglect, are each associated with higher rates of symptoms
- Disturbances in early parental bonding is also associated with SPD: with both Anxious attachment and Avoidant attachment being associated with SPD symptoms
What are the behavioural genetic causes of schizotypal personality disorder?
- Evidence that SPD is genetically transmitted
- Also linked to schizophrenia
What are the molecular genetic causes of schizotypal personality disorder?
SPD has been linked to variations in 22q11 (a gene on chromosome 22) and to FMR-1 (a gene that codes for a protein involved in synaptic connections)
- take away message from this card: SPD has a genetic component, evidenced by it’s link to genes
What are the neurodevelopmental processes that seem to be related to the etiology of schizotypal personality disorder?
Evidence that SPD is related to prenatal and postnatal environmental influences (prenatal stress, exposure to influenza, birth complications, early nutrition)
What is the neurochemistry that is suspected to cause schizotypal personality disorder?
- Dopamine dysregulation has been associated with SPD
- Increased dopamine activity associated with positive symptoms and decreased dopamine activity associated with negative symptoms
What is Borderline personality disorder?
- A pervasive pattern of instability of interpersonal relationships, self image and affects and marked impulsivity (must have 5 of the 9 symptoms in DSM-5)
- Frantic efforts to avoid real or imagined abandonment
- a pattern of intense and unstable interpersonal relationships characterized by alternating extremes of idealization and devaluation
- identity disturbance: markedly and persistently unstable self image/sense of self
- impulsivity in at least 2 areas that are potentially self-damaging
- recurrent suicidal behaviour, gestures or threats or self-mutilating behaviour
- affective instability due to a marked reactivity of mood
- inappropriate, intense anger or difficulty controlling anger
- transient, stress-related paranoid ideation or severe dissociative symptoms
What is the mortality rate in BPD?
High rate of mortality – up to 10% of patients commit suicide.
What is the current consensus on the etiology of BPD?
currently believed to be a complex interaction between genetic factors and adverse childhood experiences
What has been suggested to be the core of borderline symptomatology and which biological factors underlie this?
- Affective dysregulation has been suggested to represent the core of borderline symptomatology
- Hypothesized that frontolimbic dysfunction (prefrontal cortex and limbic system) underlies affective dysregulation as well as other BPD symptoms.
- Structural & functional neuroimaging research has revealed a dysfunctional network of brain regions that seem to underlie much of the BPD symptomatology.
What is the relationship between BPD, PTSD and the brain?
- PTSD & BPD are suggested to be part of a trauma-related spectrum of psychiatric disorders.
- PTSD – related to a reduction in hippocampus volume (part of the limbic system)
- BPD – related to a reduction in volume in hippocampus and amygdala
Is BPD heritable?
Yes, BPD runs in families
What gene is considered a candidate gene for BPD
The serotonin transporter gene (5-HTT) is considered a candidate gene for BPD – because there are multiple lines of evidence suggesting that this gene plays a role in suicide, impulsive behaviour, and emotional instability
– Showed a significant association between the 5-HTT gene and BPD.
What is the object relations theory and how does it relate to BPD?
- Object Relations Theory: Personality disorders often involve maladaptive relations with others – possibly as a result of early relationships with parents and other adults.
- Research indicates that the internal “object world” of individuals with BPD contains malevolent object representations. Compared to controls, the object representations of individuals with BPD were more likely to contain themes of malevolence in relation to their “objects.”
- These kinds of object representations need to be considered in any explanation of the causes of BPD
What is the diathesis stress theory of BPD?
Vicious cycle between:
- emotional dysregulation in the child
- great demands on the family
- invalidation by parents through punishing or ignoring the demands
- emotional outbursts by child to which parents attend
What is histrionic personality disorder?
- a pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in 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 center of attention
2. interaction with others is often characterized by innapropriate sexually seductive or provocative behaviour
3. displays rapidly shifting and shallow expression of emotions
4. consistently uses physical appearance to draw attention to self
5. has a style of speech that is excessviely impressionistic and lacking in detail
6. shows self-dramatization, theatricality, and exaggerated expression of emotion
7. is suggestible (easily influenced by others)
8. Considers relationships to be more intimate than they actually are
What are the key diagnostic criteria of narcissistic personality disorder?
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
- Has a grandiose sense of self importance
- is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love
- 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
- requires excessive admiration
- has a sense of entitlement
- is interpersonally exploitative
- lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
- is often envious of others or believes that others are envious of him or her
- shows arrogant, haughty behaviours or attitudes
What is pathological narcissism?
- Pathological narcissism is a broader construct that includes NPD. There are two phenotypic themes:
- Narcissistic grandiosity (entitlement rage, exploitativeness, grandiose fantasy and self-entitlement)
- Narcissistic vulnerability (contingent self-esteem, hiding the self and devaluing)
What is the key diagnostic criteria for antisocial personality disorder?
- A pervasive pattern of disregard for and violation of the rights of others, occurring since 15 years of age as indicated by three or more of the 7 symptoms
- the individual must be at least 18 years of age
What is psychopathy and how is it different than APD?
Psychopathy is related to APD but emphasizes psychological (thoughts and feelings) not just behavioural aspects:
- lack of remorse (‘without conscience’)
- no sense of shame
- superficially charming
- manipulates others for own personal gain
- exploits people
- thrill seeking
Are all people who are diagnosed with APD also diagnosed with psychopathy
- All psychopaths are diagnosed with APD but many with APD do not
meet the criteria for psychopathy - Example from Hare (1996): killers who were not simply persistently antisocial; they were remorseless predators, used charm, intimidation and cold-blooded violence to achieve their ends
- 20% of people with APD score high on the Hare Psychopathy Checklist
- 75 to 80% of convicted felons meet criteria for APD but only 15 to 25% of convicted felons meet criteria for psychopathy
What is the role of family in the etiology of APD and psychopathy?
- Lack of affection
- Severe parental rejection
- Physical abuse
- Inconsistencies in disciplining
- Failure to teach child responsibility toward others
What are the limitations to research findings on family role in APD and psychopathy?
- Harsh or inconsistent disciplinary practices could be reactions to the child’s anti-social behaviour
- Many individuals who come from disturbed backgrounds do not become psychopaths
What are the genetic correlates of APD?
- Criminality and APD have heritable components
- higher concordance for MZ compared to DZ twin pairs
- Adoption studies also provide research evidence
What are the environmental influences of apd and psychopathy?
- higher parental conflict and higher negativity
- lower parental warmth predict antisocial behaviours
- Families without antisocial tendencies may become harsh in their disciplining in reaction to the child with antisocial tendencies
what is the relationship between emotion and psychopathy?
- Unresponsive to punishments / no conditioned fear responses
- lower skin conductance in resting situations
- skin conductance is less reactive when confronted or anticipate intense or aversive stimuli
- normal heart rate under resting conditions but increased heart rate when anticipating intense or aversive stimuli
What is the relationship between response modulation, impulsivity, and psychopathy?
- Slow brain waves and spikes in the temporal area
- Less activity in the amygdala /hippocampal formation
- Decreased prefrontal activity
What is the evil personality?
- The dark triad consists of the combination of narcissism, psychopathy, and Machiavellianism
- The dark tetrad includes sadism
- Evil = high narcissism + high psychopathy + high Machiavellianism + high sadism
What is the key diagnostic criteria of avoidant personality disorder?
- a pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation, beginning by early and present in a variety of contexts as indicated by four or more of the symptoms in the DSM-5
- is unwilling to get involved with people unless certain of being liked
- shows restraint with intimate relationships because of fear of being shamed or ridiculed
- is preoccupied with being criticized or rejected in social situations
- is inhibited in new interpersonal situations because of feelings of inadequacy
- views self as socially inept, personally unappealing, or inferior to others
- is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
What is dependent personality disorder?
- 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 symptoms in the DSM-5
What are the key diagnostic criteria of obsessive compulsive personality disorder?
- 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 8 symptoms in the DSM-5
What is the etiology of cluster C?
- Not much is known about causes for personality disorders in this cluster
- Speculation about causes has focused on parent child attachment relationships
- Psychoanalytic theories: OCPD traits due to fixation at anal stage of psychosexual development
What is schema therapy for PDs?
Schema therapy for PD uses CBT approach to examine logical errors and dysfunctional attitudes
What are the problems with providing therapy for people with BPD?
- Individuals with borderline personality disorder have troubles establishing trust
- Alternatively idealize then vilify therapist
What are the two main therapy approaches used for BPD?
- object-relation therapy for BPD
- Dialetical behaviour therapy (DBT) for BPD
What is object relation therapy for BPD?
- Strengthening client’s weak ego
- Reducing ‘splitting’
- Combines client-centred acceptance with a cognitive-behavioural focus
What is dialectical behaviour therapy for BPD?
- Challenge dichotomous (‘black and white’) thinking
- Teach assertiveness and emotion regulation
What is the Negative affectivity (vs. Emotional stability) pathological personality trait in AMPD in the DSM-5?
- Frequent and intense experiences of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt, shame, worry, anger) and their behavioural (e.g., self harm) and interpersonal (e.g., dependency) manifestations
- Examples of related symptoms: emotional liability, anxiousness
What is the detachment (vs. extraversion) pathological personality trait in AMPD in the DSM-5?
- Avoidance of socioemotional experience, including both withdrawal from interpersonal interactions (ranging from casual daily interaction to friendships/intimate relationships) and restricted affective experience and expression, particularly limited hedonic capacity
- Examples of related symptoms: Withdrawal, intimacy avoidance, anhedonia
What is antagonism (vs. agreeableness) pathological personality trait in AMPD in the DSM-5?
Behaviours that put the individual at odds with other people including an exaggerated sense of self importance and a concomitant expectation of special treatment, as well as a callous antipathy toward others, encompassing both an unawareness of others needs and feelings and a readiness to use others in the service of self-ehancement.
- Examples of related symptoms: Manipulativeness, grandiosity, deceitfulness
What is the Disinhibition (vs. conscientiousness) pathological personality trait in AMPD in the DSM-5?
- orientation toward immediate gratification leading to impulsive behaviour driven by current thoughts, feelings and external stimuli without regard for past learning or consideration of future consequences.
- Examples of related symptoms: Impulsivity, irresponsibility, risk taking
What is the psychoticism (vs. lucidity) pathological personality trait in AMPD in the DSM-5?
- exhibiting a wide range of culturally incongruent odd, eccentric or unusual behaviour and cognitions, including both process (e.g., perception, dissociation) and content (e.g., beliefs)
- Examples of related symptoms: unusual beliefs and experiences, eccentricity, cognitive and perceptual distortion
