Personality Disorders Flashcards
Four dimensions of temperament
- Behavioral inhibition / harm avoidance
- Behavioral activation / novelty seeking
- Social attachment / reward dependence
- Persistence
Categories of personality “style” or “trait”
- Obsessive-compulsive
- Histrionic
- Narcissistic
- Dependent
- Antisocial / sociopathic
DSM-V definition of a personality disorder
Key thing to listen for in interviewing someone with suspected personality disorder
- Sweeping statements and generaliations about themself or about everyone else in life
Only effective treatment for borderline personality disorder
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Dialectical behavioral therapy:
- Combination of CBT and Mindfulness approaches; combination of group and individual
- Therapist works with the patient to resolve contradictory ideas and emotions
- Therapy makes explicit the contradictions in the patient’s life through a series of structured approaches, including a protocol to address suicidal behaviors
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Effective in reducing self-harm and hospitalizations in pts with borderline PD
- Greatly decreases risk of suicide relative to other treatments
Genetic factors which predispose to personality disorders are most prominent for:
- Borderline personality disorder
- Schizotypal personality disorder
- Antisocial personality disorder
Diagnosis of personaliy disorders
- Not diagnosed from a single examination or from single presentation, but rather a diagnosis that pulls together a chronic history of events and series of presentations
- Personality change late in life is not personality disorder and should prompt a careful evaluation for CNS disease
Things to consider for diagnosis of antisocial personality disorder
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Be VERY cautious diagnosing in the context of opioid use disorder – opioid addiction can cause individuals to engage in criminal activity in order to obtain opioids and quell withdrawal symptoms.
- For that matter, be careful diagnosing in the context of any substance use disorder, and never diagnose based on only evaluating the patient when intoxicated or experiencing withdrawal
- Do NOT diagnose on the basis of a criminal record alone. A criminal record does not serve as sufficient evidence for antisocial behavior – a careful psychological analysis of motivations and baseline behavior is necessary to come to the conclusion that APD caused this behavior.
Cluster A personality disorders
- Paranoid - distrust and suspiciousness such that others’ motives are interpreted as malevolent. “Suspicious”
- Schizoid - detachment from social relationships and a restricted range of emotional expression. “Loner”
- Schizotypal - acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior. “Eccentric”
Cluster B personality disorders
- Antisocial – disregard for, and violation of, the rights of others. Often characterized by deceitfulness, impulsivity, aggression, lack of remorse, irresponsibility. “Exploitative”
- Borderline – instability in interpersonal relationships, self-image, and affects, and marked impulsivity. “Emotionally unstable”
- Histrionic –excessive emotionality, attention seeking, seductive. “Theatrical.”
- Narcissistic – grandiosity, need for admiration, and lack of empathy. “Egotistical.”
Cluster C personality disorders
- Avoidant - social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. “Fearful of rejection.”
- Dependent - submissive and clinging behavior related to an excessive need to be taken care of. “Dependent.”
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Obsessive-Compulsive - preoccupation with orderliness, perfectionism, and control. “Rigid.”
- Different than obsessive-compulsive disorder.
Obsessive-compulsive disorder vs Obsessive-compulsive personality disorder
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OCPD: Pattern of preoccupation with orderliness, perfectionism, and interpersonal control. Present in a variety of contexts. Preocupation with orders, lists, rules, organization, or schedules to the extent of impairment.
- No true obsession or compulsions!!! The name is bad.
- OCD: Specific obsession and compulsions are present. Significant associated anxiety.
- Usually people with OCD want to change, as they have good clinical insight and realize that their obsessions are unrealistic. People with OCPD by definition do not want change, they are rigid and have to have things a certain way.
Treating personality disorders
- Psychotherapy is the treatment of choice
- Medications are used to treat associated symptoms or comorbid psychiatric disorders
- DBT – Dialectical Behavior Therapy for Borderline PD
- For antisocial PD of significant severity, there is no known effective treatment
- Some people with less severe antisocial traits, in contrast, can improve with treatment.
Schizotypal PD is genetically associated with . . .
. . . schizophrenia
High adaptive level of defense mechanisms
This level of defensive functioning results in optimal adaptation in the handling of stressors. These defenses usually maximize gratification and allow the conscious awareness of feelings, ideas, and their consequences. They also promote an optimum balance among conflicting motives.
Mental inhibitions (compromise formation) level of defense mechanisms
Defensive functioning at this level keeps potentially threatening ideas, feelings, memories, wishes, or fears out of awareness
Minor image-distorting level defense mechanisms
This level is characterized by distortions in the image of the self, body, or others that may be employed to regulate self-esteem
Disavowal level defense mechanisms
. This level is characterized by keeping unpleasant or unacceptable stressors, impulses, ideas, affects, or responsibility out of awareness with or without a misattribution of these to external causes
Major image-distorting level defense mechanisms
This level is characterized by gross distortion or misattribution of the image of self or others
Action level defense mechanisms
This level is characterized by defensive functioning that deals with internal or external stressors by action or withdrawal.
Level of defensive dysregulation
This level is characterized by failure of defensive regulation to contain the individual’s reaction to stressors, leading to a pronounced break with objective reality
Affiliation
The individual deals with emotional conflict or internal or external stressors by turning to others for help or support. This involves sharing problems with others but does not imply trying to make someone else responsible for them.
Altruism
The individual deals with emotional conflict or internal or external stressors by dedication to meeting the needs of others. Unlike the self-sacrifice sometimes characteristic of reaction formation, the individual receives gratification either vicariously or from the response of others.
Anticipation
The individual deals with emotional conflict or internal or external stressors by experiencing emotional reactions in advance of, or anticipating consequences of, possible future events and considering realistic, alternative responses or solutions
Autistic fantasy
The individual deals with emotional conflict or internal or external stressors by excessive daydreaming as a substitute for human relationships, more effective action, or problem solving.
Devaluation
The individual deals with emotional conflict or internal or external stressors by attributing exaggerated negative qualities to self or others.
Displacement
The individual deals with emotional conflict or internal or external stressors by transferring a feeling about, or a response to, one object onto another (usually less threatening) substitute object.
Dissociation
The individual deals with emotional conflict or internal or external stressors with a breakdown in the usually integrated functions of consciousness, memory, perception of self or the environment, or sensory/motor behavior
As in dissociative-predominant PTSD
Help-rejecting complaining
The individual deals with emotional conflict or internal or external stressors by complaining or making repetitious requests for help that disguise covert feelings of hostility or reproach toward others, which are then expressed by rejecting the suggestions, advice, or help that others offer. The complaints or requests may involve physical or psychological symptoms or life problems
Idealization
The individual deals with emotional conflict or internal or external stressors by attributing exaggerated positive qualities to others
Intellectualization
The individual deals with emotional conflict or internal or external stressors by the excessive use of abstract thinking or the making of generalizations to control or minimize disturbing feelings
Isolation of affect
The individual deals with emotional conflict or internal or external stressors by the separation of ideas from the feelings originally associated with them. The individual loses touch with the feelings associated with a given idea (e.g., a traumatic event) while remaining aware of the cognitive elements of it (e.g., descriptive details).
Omnipotence
The individual deals with emotional conflict or internal or external stressors by feeling or acting as if he or she possesses special powers or abilities and is superior to others.
Projection
The individual deals with emotional conflict or internal or external stressors by falsely attributing to another his or her own unacceptable feelings, impulses, or thoughts.
Projective identification
As in projection, the individual deals with emotional conflict or internal or external stressors by falsely attributing to another his or her own unacceptable feelings, impulses, or thoughts.
Unlike simple projection, the individual does not fully disavow what is projected. Instead, the individual remains aware of his or her own affects or impulses but misattributes them as justifiable reactions to the other person. Not infrequently, the individual induces the very feelings in others that were first mistakenly believed to be there, making it difficult to clarify who did what to whom first.
Rationalization
The individual deals with emotional conflict or internal or external stressors by concealing the true motivations for his or her own thoughts, actions, or feelings through the elaboration of reassuring or self-serving but incorrect explanations.
Reaction formation
The individual deals with emotional conflict or internal or external stressors by substituting behavior, thoughts, or feelings that are diametrically opposed to his or her own unacceptable thoughts or feelings (this usually occurs in conjunction with their repression).
Self-assertion
The individual deals with emotional conflict or stressors by expressing his or her feelings and thoughts directly in a way that is not coercive or manipulative
Self-observation
The individual deals with emotional conflict or stressors by reflecting on his or her own thoughts, feelings, motivation, and behavior, and responding appropriately.
Splitting
The individual deals with emotional conflict or internal or external stressors by compartmentalizing opposite affect states and failing to integrate the positive and negative qualities of the self or others into cohesive images.
Because ambivalent affects cannot be experienced simultaneously, more balanced views and expectations of self or others are excluded from emotional awareness. Self and object images tend to alternate between polar opposites: exclusively loving, powerful, worthy, nurturant, and kind—or exclusively bad, hateful, angry, destructive, rejecting, or worthless.
Sublimation
The individual deals with emotional conflict or internal or external stressors by channeling potentially maladaptive feelings or impulses into socially acceptable behavior (e.g., contact sports to channel angry impulses).
Undoing
The individual deals with emotional conflict or internal or external stressors by words or behavior designed to negate or to make amends symbolically for unacceptable thoughts, feelings, or actions
Phases of psychotherapy
Transference in psychotherapy
The reactivation, in a later stage of life, of a person’s feelings, attitudes, or behavior patterns that were first established in response to parents or other early caretaking figures.
Transference is usually unconscious. Manifests as emotional expectations. The positive transference consists of hopeful expectations and positive feelings toward the physician. The negative transference consists of feelings of mistrust and anger
Countertransference in psychotherapy
The therapist’s response to the patient or to the patient’s transference.
Also usually unconscious. A well-trained therapist does not act on such feelings but, instead, becomes aware of them and uses them to learn something about the way in which the patient affects other people
Corrective Emotional Experience in psychotherapy
The new emotional experience the patient has with the therapist in which the therapist behaves differently from the patient’s parents.
The contrast between the patient’s expectation and the therapist’s actual behavior is a powerful force for change. By contradicting the expectations, the therapist’s responses lead the patient to new views of reality and, ultimately, to a new concept of self.
Emotional Intensity in psychotherapy
Therapy is seldom beneficial when the patient is not engaged emotionally. Effective therapy also requires that the therapist be emotionally engaged and have an active attitude.
Resistance in psychotherapy
Reluctance to change may emerge as overt interference, such as missing sessions, refusing to be open with the therapist, forgetting to do homework assignments, or rejecting interpretations or suggestions.
At times a therapy will fail when resistance is too strong. Most therapies have ways of confronting this defensive behavior as part of the process of engaging the patient.
Repetition compulsion in psychotherapy
Refers to a person’s tendency to repeat patterns. The pattern that underlies the repetition may be completely unconscious, necessitating much work for the person to see how it affects current life experience
“Principles” of CBT
- close correlations exist between a patient’s mood and the patient’s patterns of conscious thought
- certain habits of thought can cause and maintain a patient’s depressed state
Who is CBT effective for?
- CBT is well suited for patients who suffer from:
- Alone, for mild to a moderate degree of MDD, dysthymia, or depressed mood due to an adjustment disorder
- In combination with pharmacotherapy, for patients who have anxiety disorders or severe MDD, bipolar disorder, or psychotic symptoms
Typical course of CBT
- The treatment is usually brief, consisting of one session a week for 15–30 weeks
- Goal is to help the patient achieve relief from and resolution of a specific concern
- Does this by uncovering pathological patterns of thought and develop ways to control them
- To this end, the therapist has the patient complete homework assignments that usually involve recording in a journal conscious thoughts and feelings in reaction to certain events
Group Therapy
- In group therapy, patients are taught new coping skills in a didactic format using a skills training manual
- Trains patients in mindfulness techniques, self-observational skills, distress tolerance, emotional regulation, and interpersonal effectiveness
Individual Therapy
Individual sessions provide a nonjudgmental and supportive environment for the focus on developing behavioral change. Sessions are structured to avert states of high arousal that may interfere with attention required for learning.
Behavioral analysis is used to help identify antecedents and consequences of disruptive behaviors, as well as thoughts and feelings that add to distress and trigger problematic behaviors.
