Personality disorders I

Question 1

Fridell and Hesse (2006)

Answer 1

Aim: To assess the diagnostic concordance of SCID-II and clinicians’ estimation of DSM-III-R personality disorders of substance abusers. Method: Clinical diagnoses of substance abusers in inpatient treatment were compared with SCID-II diagnoses (N = 138). Findings: The overall prevalence of personality disorder was 79% for clinical diagnosis and 80% for SCID-II diagnosis. Substantial agreement was found for borderline personality disorder, and moderate agreement was found for presence of any personality disorder, and antisocial personality disorder. All other disorders had slight to fair agreement. Antisocial personality disorder was overdiagnosed by clinical diagnosis but schizotypal, obsessive-compulsive, passive-aggressive, and masochistic personality disorders were reported more often by SCID-II. Selecting only the primary clinical diagnosis and omitting additional clinical diagnoses, reduced agreement with SCID-II diagnoses. Implications: Clinical diagnosis and structured interviews are not interchangeable, and produce somewhat different profiles of diagnoses for a group of substance abusers, but the two methods for diagnosing personality disorders converge for the two most common personality disorders in substance abusers. Rare and less-known diagnoses tend to be underreported whereas common and well-known disorders tend to be slightly overdiagnosed by clinical diagnosis as compared with a semistructured interview, especially if only one clinical diagnosis is noted.

Question 2

First et al. (1995)

Answer 2

The history and description of the Structured Clinical Interview for DSM-HI-R Personality Disorders (SCID-II) is presented. The SCID-II is a clinician-administered semistructured interview for diagnosing the 11 Axis II personality disorders of the Diagnostic and Statistical Menual of Mental Disorders (3rd ed., rev.), plus the Appendix category self-defeating personality disorder. The SCID-II is unique in that it was designed with the primary goal of providing a rapid clinical assessment of personality disorders without sacrificing reliability or validity. It can be used in conjunction with a self-report personality questionnaire, which allows the interview to focus only on the items corresponding to positively endorsed questions on the questionnaire, thus shortening the administration time of the interview.

A test-retest reliability study of the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) was conducted on 284 subjects in four psychiatric patient sites and two nonpsychiatric patient sites. For the patient sites, kappas ranged from .24 for obsessive—compulsive personality disorder to .74 for histrionic personality disorder, with an overall weighted kappa of .53. For the nonpatients, however, agreement was considerably lower, with an overall weighted kappa of .38. Mean duration of administration time was 36 minutes. Results of this study and other studies using the SCID-II suggest that the reliability and validity of the SCID-II are comparable with other instruments that diagnose Axis II disorders of the Diagnostic and Statistical Manual of Mental Disorders, but this new instrument has the advantage of a shorter time of administration.

Question 3

Maffei et al. (1997)

Answer 3

Interrater reliability and internal consistency of the SCID-II 2.0 was assessed in a sample of 231 consecutively admitted in-and outpatients using a pairwise interview design, with randomized rater pairing and blind interview assessment. Inter-rater reliability coefficients ranged from 48 to .98 for categorical diagnosis (Cohen κ), and from .90 to .98 for dimensional judgements (Intraclass correlation coefficient). Internal consistency coefficients were satisfactory (.71-.94). The results suggest that the SCID-II 2.0 has adequate interrater and internal consistency reliability.

Question 4

Somma et al. (2017)

Answer 4

Results
In the present study, intraclass correlation coefficient (ICC) values ranged from .88 (Dependent PD
and Histrionic PD) to .94 (Avoidant PD) for dimensional SCID-5-PD interview dimensional ratings
(median ICC value = .94). Adequate Cohen k values were observed for SCID-5-PD dichotomous
ratings of presence of clinically significant subthreshold features (median k value = .78, SD = .06),
as well as for SCID-5-PD interview categorical PD diagnoses (median k value = .89, SD = .11).
Conclusions
The present study findings suggest that the Italian translation of the SCID-5-PD is likely to
yield reliable assessment of both dimensional and categorical PD diagnoses, at least in a
sample of clinical adults who volunteered to ask for psychotherapy treatment.

Question 5

Sass et al. (1996)

Answer 5

Categorical and dimensional models of personality, personality disorders (PO) and their interrelation will be discussed under the hypothetical perspectives, that higher order personality factors structure the personality of normal persons as well as of the mentally ill, and that no fundamental, but only a gradual difference exists
between normal personalities and PDs. The relationship between this categorical conceptualization of the PDs and the dimensional factor model of personality was examined by using the Aachen Inventory for the Assessment of Personality Disorders (AIPD) that provides a typological assessment of 11 abnormal personalities covering all
criteria of OSM-ill-R and ICO-IO, and the self report scale “Sechs Faktoren Test” (SFT) to measure higher order factors of personality as neuroticism, aggressiveness, conscientiousness, openness to ellperience, extraversion and religious attitude. The following relations were expected: I) Personality disorders can be suitably assigned
to superordinated clusters of personality factors. 2) Personality disorders can be appropriately explained in terms of the “big five” personality disorders. 3) “Neuroticism” will be a common factor closely related to all personality disorders.

Question 6

Leichsenring et al. (2019)

Answer 6

Objective: Patients with mental disorders do not only show specific symptoms but also impairments in personality functioning, especially those with personality disorders. Recent developments in DSM-5 and ICD-11 suggest a dimensional approach to personality disorders. Few studies, however, have examined changes in personality functioning.

Methods: In a large sample of 2,596 patients treated by inpatient psychodynamic therapy, changes in personality functioning were studied. Two patient groups were examined, one with (N = 1152, BPO) and one without a presumptive diagnosis of a borderline personality organization (N = 1444, NBPO). For the assessment of personality functioning, the Borderline-Personality Inventory (BPI) was used. The BPI taps personality functioning as defined by Kernberg’s structural criteria of personality organization. Symptom distress and interpersonal problems were examined with the Symptom Checklist SCL-90-R and the Inventory of Interpersonal Problems (IIP). Patients were assessed at admission and discharge.

Results: In the BPO sample significant and substantial pre-post effect sizes in overall personality functioning, identity integration, and defense mechanisms/object relations were found (d = 0.68, 0.60, 0.78). In addition, large improvements in symptoms (SCL-90-R) were achieved (d = 0.97). For interpersonal problems effect sizes were medium (0.56). At discharge 36% of the BPO patients scored below the BPI-Cut-Off score for a BPO (remission). Pre-post effect sizes in the NPBO sample (N = 1444) were significant but small for changes in personality functioning (d = 0.31–0.46) and substantial for improvements in symptoms (d = 0.77).

Conclusions: Both personality functioning and symptom distress can be substantially improved by inpatient psychodynamic therapy. Future research is recommended to study both improvements in symptoms and personality functioning.

Question 7

Bowins (2010)

Answer 7

Categorical disease models of personality disorder currently dominate in the DSM-IV-TR and ICD-10 diagnostic systems. In preparation for DSM-V, these models have been questioned in light of evidence and widely held beliefs that disorders of personality are extreme variants of normal personality. Unfortunately, problems arise in trying to produce a dimensional model of abnormal and normal personality, such as how aspects of normal personality can be applied to personality disorders, and the all-important issue of precisely what aspect of normal personality is overextended in these disorders. In contrast to other approaches, a dimensional model based on defense mechanisms is easily applied to personality disorders, eliminates the need for complex scales, retains the notion of entities with which clinicians are familiar, provide useful therapeutic strategies, and clearly specify what aspect of normal personality is overextended. It also allows for the addition of new personality disorders

Question 8

Trull and Durrett (2005)

Answer 8

We review major categorical and dimensional models of personality pathology, highlighting advantages and disadvantages of these approaches. Several analytic and methodological approaches to the question of the categorical versus dimensional status of constructs are discussed, including taxometric analyses, latent class analyses, and multivariate genetic analyses. Based on our review, we advocate a dimensional approach to classifying personality pathology. There is converging evidence that four major domains of personality are relevant to personality pathology: neuroticism/negative affectivity/emotional dysregulation; extraversion/positive emotionality; dissocial/antagonistic behavior; and constraint/compulsivity/conscientiousness. Finally, we discuss how dimensional approaches might be integrated into the diagnostic system, as well as some of the major issues that must be addressed in order for dimensional approaches to gain wide acceptance.

Question 9

Bornstein (2019)

Answer 9

The current debate regarding how best to conceptualize, operationalize, and assess personality pathology is often framed as a choice between categorical (“type”) and dimensional (“trait”) models, but when viewed from the perspective of the diagnostician, these two approaches actually have much in common. It is not possible to assign symptom ratings in any categorical personality disorder framework without first evaluating the severity of each symptom on a continuum, nor to implement dimensional personality disorder assessments in clinical settings without using thresholds that demarcate the presence of personality pathology, or severity of personality dysfunction. Although recent discussions of these two frameworks have focused primarily on issues regarding construct validity (and to a lesser extent, clinical utility), it is important to consider the impact of the diagnostic process as well. When considered within this broader context, the advantages and limitations of each perspective are illuminated, and it becomes clear that the categorical and dimensional frameworks represent an evolving dialectic that will continue into the future, as new and better models alter the focus of these debates

Question 10

what is abnormal?

Answer 10

There are many ways to define abnormal.

Need to be careful how we use the terminology

broader approach is needed.

The definition of abnormal behaviour takes into account various other psychological criteria in addition to the statistical and social aspects including:
- levels of distress, impairment to functioning, subjective feelings, emotional affect and thought patterns

Question 11

statistical definitions of abnormality

Answer 11

most simplistic - whatever is different from normal is abnormal.

• It can be statistically determined how often something occurs and when it is rare it can be called abnormal.
• Rarely is associated with abnormality

Statistical definitions need further caution as ‘rare’ is not necessarily ‘abnormal’

• Consider intelligence: very high IQ is statistically rare and could be classified as ‘abnormal’ but it is actually a desirable trait.
• Can be problematic as well
• Social - ideas around homosexuality – still illegal in many societies

Question 12

social definitions of abnormality

Answer 12

define abnormal according to what society tolerates. Behaviours deemed unacceptable by society are labelled as abnormal

• But what is deemed unacceptable in one society might be perfectly acceptable in another and simply reflect a different way of life and different orientation.
• Judgements of people based on their lifestyle
• Abnormal label may be inappropriate

Question 13

ways of defining abnormality

Answer 13

statistical

social

The statistical and social approaches to defining abnormality both suffer from changing social and cultural norms over time and between cultures – some are slower at evolving than others
- Behaviours thought offensive or socially inappropriate in the past might be acceptable today (e.g., homosexuality was considered socially unacceptable, a form of abnormal behaviour or mental illness).

Question 14

methods of assessing personality disorder

Answer 14

Diagnosis involves various sources of information including:

• Clinical assessment by a qualified mental health professional:
  
  1. Clinician’s observations
  2. The Structured Clinical Interview (SCID) - designed for making DSM-V diagnoses. Two versions are available:
     - SCID-1 for diagnosing DSM-V Axis 1 clinical disorders
     - SCID-II for diagnosing DSM-V Axis II Personality Disorders
  3. The SCID-5-PD can be used to make personality disorder diagnoses, either categorically (present or absent) or dimensionally
• The SCID-5-PD is the updated

Question 15

clinical assessment

Answer 15

might be corroborated by additional information from:

• Self-reported experiences and behaviours.
• Observations by family, friends and sometimes co-workers.
• Less clear onset

Question 16

self-report scales

Answer 16

also used to diagnose personality disorder:

• Minnesota Multiphasic Personality Inventory (MMPI).
• Personality Diagnostic Questionnaire – Revised (PDQ-R).
  
  • These questionnaires ask people whether they are experiencing any signs of the various disorders

Question 17

categories or dimensions?

Answer 17

Diagnostic systems tend to use disorder categories to describe people but evidence suggests that a dimensional approach to personality disorders is more appropriate (e.g., Livesley et al., 1998 and several other papers)

Overlap between categories

Question 18

categorical approach

Answer 18

a person is either diagnosed with the disorder or they are not.
- There is a qualitative break between people who have a personality disorder and people who do not.

Question 19

dimensional approach

Answer 19

each disorder is viewed as a continuum which ranges from normality at one end to severe disturbance at the other end.
- People with a disorder differ in degree only from those without a disorder.

Research using a diverse range of methodologies provides considerable support for the dimensional conceptualisation of personality disorders (e.g., Livesley et al., 1992, 1994; Morey et al, 2000) – DSM5 did not adopt this but does have an appendix

Personality disorder lies at the extreme end of a continuum and normal personality lies along the same continuum (for a review see Trull & Durrett, 2005).

• Personality disorders can be construed as the extremes of characteristics we all possess (Flett, 2007).
• There is one exception. Research indicates that psychopathy may represent a discrete category (Skilling et al, 2002) – alongside narcissism

Question 20

what is a personality disorder?

Answer 20

A personality disorder is an extreme or severe disturbance in the overall character and behaviours of an individual that affects various aspects of their personality.

• It will always involve a lot of personal and social disruption which not only affects the person themselves but also those around them (Maltlby et al., 2010).
• Some less treatable than others

This disruption in personality and behaviour will be present over the course of the person’s life and some symptoms will emerge during childhood (Paris, 2003) – apparent across the course of the life – present but not diagnosed in childhood – reluctance to diagnose in childhood

Question 21

personality disorder

Answer 21

onset early in life and remains lifelong problem.

• Most people with PD reluctant to ask for or accept any form of help. Typically challenging to therapist and not responsive to therapeutic input – at the rough end of the spectrum
• Usually referred by family, friends or work colleagues.
• Difficult to treat – personality – with us throughout the whole life and is influenced by environmental impact as well
• No clear start, progression, end and cause

Question 22

psychological disorder

Answer 22

Clear start/onset and clear trajectory for recovery.

Often associated with a cause in the person’s environment (e.g., bereavement, job loss, etc).

Seek therapy and work with therapist to recover.

Question 23

Kendell (2002)

Answer 23

Ongoing debate

The distinction between PD and Mental Illness is increasingly being challenged.

The divide is often tenuous and there is much overlap between symptoms of some PDs and some mental illnesses.

Recent moves towards a trait approach recognises that PD lie on a continuum and represent extreme ends of common traits.

DSM-IV was revised and DSM-V does recognise the need for further research examining PDs as continuous traits rather than absolute categories. (Hierarchical model, Axis 3 – to drive research not diagnosis)

Psychological disorder is not lifelong and doesn’t cause the same types of problems as a PD

Question 24

labelling and personality disorder

Answer 24

Mentioning a personality disorder diagnosis has a powerful effect on clinicians views.

Vital that personality disorder concepts refer to real entities and identifiable

Question 25

Lewis and Appleby (1988)

Answer 25

The effect of receiving a personality diagnosis label on the way patients are perceived by psychiatrists.

One of six vignettes sent to 240 practising psychiatrists.

• One vignette mentioned the patient had been diagnosed with a personality disorder.
• Rate the ‘patient’ against a number of statements.
• There was a large effect of mentioning personality disorder.
  
  • Judgements of the patient were always less favourable.

Lewis and Appleby (1988) showed that just the mention of a personality disorder diagnosis had a powerful effect on clinicians’ views.

The pervasive nature of personality disorders and the widely accepted belief in the limited effectiveness of most treatments has led to an emphasis on
- ‘development’ and ‘management’ rather than ‘aetiology’ and ‘treatment’ (Holmes, 2010).

Question 26

according to the psychiatrists, patients with PD were

Answer 26

Likely to manipulate admission

Likely to take an overdose to seek attention

Not a suicide risk

Unwanted in the doctors clinic

Likely to annoy

Unlikely to improve

Not mentally ill and unlikely to warrant NHS time

Not suitable for anti-depressants

Unlikely to comply with treatment

In debt due to their own fault

A management problem

Question 27

labelling and perceptions of crime and justice

Answer 27

The stigma and discrimination that can result from being diagnosed with a Personality Disorder or other psychological disorder highlights the importance of evidence based diagnosis.

Have to be careful

This is further highlighted because there is evidence suggesting relationships between some personality disorders and some criminal behaviour.

• Extreme psychopathic killer for example
• Very limited evidence

Question 28

classifying a personality disorder

Answer 28

DSM-V lists over 250 different disorders.
- Personality disorders represent a small number of the many possible psychopathologies detailed in DSM-V.

Ten different personality disorders are included and they are grouped into three clusters (returning to this later).

DSM-V recognises the considerable overlap between PDs and psychological disorders.

Question 29

APA definition

Answer 29

“an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it .” (DSM-V).

If lived in different culture might not be classified

The DSM-V detail several general criteria in addition to the specific criteria given for each particular personality disorder.

Question 30

DSM-V general criteria for diagnosing PDs

Answer 30

deviation from expectations needs to be manifested in at least two of the following ways:

• Cognitions (e.g., ways of thinking, perceiving and interpreting things, events, situations and people).
• Affect (e.g., the emotions of the individual) this might include the range and intensity of the emotions, emotional lability (change) and the appropriateness of these emotional responses).
• Interpersonal functioning – how an individual relates to and interacts with other people.
• Impulse control – lack of control over impulses and the gratification of needs.

Question 31

additional criteria

Answer 31

pattern of experiences and behaviours:

• must be enduring, inflexible, maladaptive or dysfunctional and be constant across a broad range of personal and social situations (e.g., it is not limited to one specific “triggering” stimulus or situation).
• leads to personal distress or clinically significant impairment to the individual’s personal, social or occupational life.
• is stable and present over long periods of time. The onset can be traced back to adolescence or early adulthood – short periods is more likely to be a psychological disorder
• cannot be explained as a manifestation or consequence of other adult mental disorders.
• cannot be attributed to the physiological effects of a particular substance (e.g., a drug) or to a medical condition (e.g., head injury).

Question 32

10 PDs

Answer 32

Cluster A:

Cluster B:

Cluster C:

Question 33

cluster A

Answer 33

Schizoid, schizotypal and paranoid PDs.

Common theme - a tendency to be odd or eccentric. Most of the ‘oddness’ has to do with interaction with others.

Schizotypal disorders are not the same as the abnormal psychological state of schizophrenia.
- Although there are clearly overlaps between these disorders in their symptoms and causes, schizophrenia reflects a clinical and psychological diagnosis.

Schizophrenia is a serious mental illness that involves hallucinations, delusions and perceptual aberrations.

The personality disorders of schizoid and schizotypal exhibit some low-grade nonpsychotic symptoms of schizophrenia.

People with schizotypal disorders are likely to possess the genotype that makes them more vulnerable to schizophrenia (Larson & Buss, 2010).

Question 34

cluster B

Answer 34

Antisocial, borderline, histrionic and narcissistic PDs.

Common theme - they represent dramatic, emotional or erratic disorders.

Where psychopathy would sit if it becomes formalised

As a group they exhibit hostile interpersonal beliefs, viewing others as

• existing primarily to be used and taken advantage of (antisocial and borderline personality disorders)
• as admirers to give attention and adoration to the self (narcissistic and histrionic personality disorders).

Psychopathy is a concept related to antisocial personality disorder but it is not the same.

• Only a subset of people with antisocial personality disorder will meet criteria for a diagnosis of psychopathy.
• We shall be looking more closely at psychopathy in lecture 17.

Question 35

cluster C

Answer 35

Avoidant, dependent and obsessive-compulsive PDs.

Common theme - they all represent anxious or fearful disorders.

• Reasons for fearfulness vary across the disorders e.g.,
  
  • fear of rejection for the avoidant PD
  • fear of being alone for the dependent personality

Personality disorder symptoms in this cluster are linked with an anxious, fearful or preoccupied attachment style (Brennan & Shaver, 1998).

• Patterns of behaviours are aimed at avoiding anxiety and fear.
  
  • Paradoxically although certain behaviour patterns might solve particular problems they also create other equally severe problems (e.g., avoidant behaviour can lead to isolation and increasing fear of social situations).
  • Can only get over fear by exposure

May be caused by childhood trauma in the brain

Question 36

paranoid PD (cluster A)

Answer 36

characterised by extreme distrust and irrational suspicions of other people. Prevalence 0.5% – 2.5% of the general population (e.g., Torgersen et al., 2001).

Four or more of the following are required for a diagnosis (DSM-V):

• Suspicious that others are exploiting or deceiving them.
• Preoccupied with unjustified doubts about the trustworthiness of others including friends and family
• Pathological jealousy. Recurring suspicions about the fidelity of partners.
• Reluctance to confide in others as concerned the information would be used in a malicious way.
• Misinterprets social events. Perceive innocent or benign remarks as threatening or demeaning.
• Persistently holds grudges against certain people. Quite rigid in their views and be unforgiving of others who are perceived to have insulted or hurt them.
• Hypersensitive - will often perceive that innocent comments from others are attacks on their character and will react angrily in response.

Typical thoughts and beliefs: “Get them before they get you”. “Others always have ulterior motives”. “Don’t trust them with anything”

Question 37

schizoid PD (A) characterised by

Answer 37

A pattern of detachment, disconnection or indifference to interpersonal and social relationships

Restricted emotions.

Does not respond to social cues so might appear inept or socially clumsy.
- Present in about 1.7% of the general population (e.g., Torgersen et al., 2001).

Question 38

required for diagnosis (schizoid PD)

Answer 38

Will not seek out or enjoy close personal relationships including family relationships.

Will nearly always choose solitary pursuits and jobs.

Little or no interest in sexual experiences.

Few or no close friends.
Indifferent to the praise or criticism of others.

Flattened emotions, emotionally cold, shows low levels of attachment or no attachment to others.

Typical thoughts or beliefs:
“I hate being tied to other people”. “My privacy is more important to me than being close to others”.

Question 39

schizotypical PD (A) characterised by

Answer 39

extreme discomfort with close relationships

distortions in thinking, feelings and perceptions

sometimes displaying eccentric behaviour.
- Present in about 0.6% of the general population (e.g., Torgersen et al., 2001).

Question 40

schizotypical PD (A) diagnosis

Answer 40

Ideas of reference – believing that everyday events refer to them.

Magical thinking or odd beliefs. (e.g., beliefs in clairvoyance or telepathy or other fantasies that lie outside cultural norms).

Unusual perceptions, distortions or experiences of bodily feelings.

Odd thinking and speech (e.g., might use metaphors a lot and come across as confusing and abstract).

Suspicious and paranoid ideas about the world.

Inappropriate emotional expression or lacking in emotional expression.

Extreme discomfort in social situations, lacking close friends and intimate relationships.

General social anxiety because of paranoid fears about other people and events.

Question 41

APD (B) characterised by

Answer 41

general disregard for others and little care for the feelings, rights or happiness of others.
- Prevalence of APD is estimated to be between 0.7%-3% of the population (e.g., Torgersen et al., 2001).

Question 42

APD (B) diagnosis

Answer 42

Failure to conform to social norms (e.g., repeatedly breaking the law).

Repeatedly lying and conning others for profit or pleasure.

Impulsivity and repeated failures to plan ahead.

Irritability and aggressive behaviour (e.g., repeatedly getting into fights).

Reckless disregard for the safety of others and of the self.

Repeated acts of irresponsibility (failure to hold down a job or meet financial obligations or frequent truanting from school).

Lack of remorse (indifferent to the pain of others and rationalising hurting or mistreating others).

Additionally, to be diagnosed with APD the behaviour shown must not be a consequence of another disorder such as schizophrenia.

Typical thoughts:
“I’m different and laws don’t apply to me”. She/He had it coming, they were asking for it”. I’ll say anything to get what I want”.

Question 43

borderline PD (B) characterised by

Answer 43

instability in relationships, behaviour, emotions and self-image.
- Estimates indicate it affects between 0.7% - 2% of the population (e.g., Torgersen et al., 2001).

Question 44

borderline (PD) diagnosis

Answer 44

Repeated suicidal behaviour or threats, or self-harm or self-mutilating behaviour.

Fear of abandonment.

Impulsivity in at least two areas that are potentially damaging (e.g., financial behaviour, sexual behaviours, substance use or abuse, dangerous driving).

Unstable, intense relationships (idealisation and devaluation).

Disturbances in identity characterised by a persistent, unstable self-image.

Unstable emotions and feelings, marked changes in mood, irritability and anxiety.

Persistent feelings of emptiness or worthlessness.

Aggressiveness or great difficulty in controlling anger (frequent fights, temper displays).

When under stress may exhibit paranoid ideas and delusions or dissociation.

Typical thoughts and beliefs:
“If you leave me I’ll kill myself”. “I’m nothing without you, I’ll die if you go”. “I hate and detest you”.

Question 45

histrionic PD (B) characterised by

Answer 45

attention seeking behaviour, the need to be centre of attention, overly dramatic mood swings, excessive need for approval.

Question 46

histrionic PD (B) diagnosis

Answer 46

Excessive attention seeking.

Constant need to be the centre of everyone’s attention.

Interactions with others are often sexually provocative or seductive.

Excessive, exaggerated emotions, changeable and lacking depth.

Physical appearance is used to draw attention to oneself.

Prefer impressions to facts (impressionistic thinking rather than rational). Shallow opinions, dramatically expressed but very suggestible and easily changed.

Over dramatic about themselves.

Exaggerates the intimacy of personal relationships.

Typical thoughts and beliefs:
“I’m so interesting and attractive everyone likes me”. “I’m at my happiest when I’m the centre of attention”. “I hate being bored”.

Question 47

narcissistic PD (B) characterised by

Answer 47

strong need to be admired, a pervasive pattern of grandiosity (inflated sense of self-importance), a lack of empathy.
- Narcissists have high self-esteem but it’s fragile in the face of criticism and they can exhibit rage when they believe they are not getting the admiration they deserve.

Question 48

narcissistic PD (B) diagnosis

Answer 48

Excessive need to be admired.

Inflated sense of self-importance (grandiosity).

Believes themselves to be unique and ‘special’.

Preoccupied with daydreams about prosperity, power, influence and adoration from others.

Has a strong sense of entitlement.

Exploitative in intimate relationships.

Lacks insight in the needs and feelings of others (lacks empathy).

Tends to be envious of others or to believe that others are envious of them.

Sense of superiority and tendency to be arrogant in attitudes and behaviours.

Typical thoughts and beliefs:
“I’m special and I deserve special treatment”. “I don’t need to listen to you as I’m so much more important than you are”.

Question 49

avoidant PD (C) characterised by

Answer 49

social inhibition, feelings of inadequacy and fear about being criticised or negatively judged by others.

• Low self esteem and a tendency to be shy and to avoid situations that might bring criticism.
  
  • Affects around 0.8% of the population (e.g., Torgersen et al., 2001).

Question 50

avoidant PD (C) diagnosis

Answer 50

Restricts activities in personal and occupational life to avoid criticism and negative appraisal.

Feelings of inadequacy or inferiority in social situations – avoidance of social situations.

Fear of rejection and feelings of inadequacy restrain individuals from starting new relationships.

Avoids new activities for fear of embarrassment or criticism.

Preoccupied with fear of rejection or criticism in social situations.

Typical thoughts and believes:
“I’m going to avoid situations that attract attention to me”. “I hate being criticised it makes me feel so bad”. “I wish you would like me but I’m sure you don’t because I’m so inept”.

Question 51

dependent PD (C) characterised by

Answer 51

pervasive psychological dependence on other people. Lack of confidence in themselves and let others take responsibility for major aspects of their life.
- Affects around 1.5% of the population (e.g., Torgersen et al., 2001).

Question 52

dependent PD (C) diagnosis

Answer 52

Pervasive need to be taken care of due to extreme concern about being unable to take care of self.

Great difficulty making normal everyday decisions and seeks out lots of reassurance from others.

Needs others to take responsibility for major areas of their life.

Will rarely take the initiative or disagree with others for fear of losing their support or approval.

Finds it difficult to work independently due to a lack of confidence.

Will go to excessive lengths to gain support from others to the extent of taking on horrible tasks.

Does not like being alone due to extreme fear of not being able to cope. Preoccupied with fears about being left alone and unable to cope.

Following a relationship break up will quickly seek out another relationship for support.

Typical thoughts and beliefs:
“I need someone to tell me what to do”. “My worst nightmare is to be abandoned and alone”. “I mustn’t upset him/her because I depend on them”.

Question 53

OCPD (C) characterised by

Answer 53

preoccupation with order and seeking perfectionism, strong conformity to rules and moral codes.
- Affects around 2.0% of the population (e.g., Torgersen et al., 2001).

Question 54

OCPD (C) diagnosis

Answer 54

Preoccupation with details and rules can overshadow the purpose of a task.

Perfectionism is so high that it interferes with task completion.

Excessive devotion to work leaving little time for a personal or social life.

Inflexible beliefs, values and morals.

Things must be done the way they want to do them.

Often miserly with money.

Holds rigid and stubborn attitudes and behaviours.

Typical thoughts and beliefs:
“The only right way to do things is my way”. “It’s vital to follow the rules and to get it perfect”. “I can only rely on myself, others are too casual and irresponsible”.

Question 55

OCPD and OCD

Answer 55

OCD is an anxiety disorder that can be more debilitating than OCPD both in its symptoms and consequences.

• OCD is characterised by a pattern of intrusive thoughts that are persistent and troubling to the person. In addition ritualistic behaviours are present such as frequent hand washing or repeating actions a particular number of times such as checking the doors are locked again and again.
• OCPD is characterised by a collection of traits including a very strong need for order, high conformity and high conscientiousness – less likely to cause high levels of stress – ritualistic behaviours present but less severe

Individuals with OCPD are at a raised level of risk for developing OCD along with some other types of anxiety disorders (e.g., Oltmanns & Emery, 2004).