Session-13 Personality Disorders (Cluster C) Flashcards
How does DSM-IV-TR describe Personality Disorders?
A Personality Disorder is an enduring pattern of inner experience and behavior that deviates from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment (APA, 2000, p. 686)
DSM-IV-TR: What are personality disorders based in?
Based in personality development rather than as a specific disease entity
DSM-IV-TR: Do personality disorders have periods of remission?
No periods of significant remission, change in severity of symptoms or improvement over time
How does DSM-IV-TR view personality disorders?
Notion of personality disorders as organizational clusters of personality traits (or dimensions) that exist on a continuum between normal and abnormal
DSM-IV-TR: What is the categorical perspective for PDs?
Diagnostic approach: categorical perspective that PDs are qualitatively distinct clinical syndromes.
DSM-IV-TR: What is the dimensional perspective for PDs?
Alternative: Dimensional Perspective (Willa): PDs “represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another” (p. 689)
note:
Many attempts to identify fundamental traits or dimensions “that underlie the entire domain of normal and pathological personality functioning” (p. 689).
DSM-IV-TR: PDs Models to find underlying traits/ dimensions.
What is the “Five Dimensions” model?
Five dimensions:
Neuroticism
Introversion vs. Extroversion
Closedness vs. Openness to Experience
Antagonism vs. Agreeableness
Conscientiousness
DSM-IV-TR: PDs Models to find underlying traits/ dimensions.
What is the “Specific areas of personality dysfunction (15-40 dimensions)?
Specific areas of personality dysfunction (15-40 dimensions):
Affective Reactivity
Social Apprehensiveness
Cognitive Distortion
Impulsivity
Self-Centeredness
Etc.
DSM-IV-TR: PDs Models to find underlying traits/ dimensions.
What is the “proposed traits”?
Harm avoidance
Persistence
Cooperativeness
Etc.
How are Personality Disorders Organized in DSM-IV-TR?
Cluster A (odd-eccentric)
Paranoid
Schizoid
Schizotypal
Cluster B (dramatic-emotional) Antisocial Borderline Histrionic Narcissistic
Cluster C (anxious-fearful)
Avoidant (#1)
Dependent (#2)
Obsessive-Compulsive (#3)
How are the Personality Disorder DSM-IV-TR clusters viewed?
These clusters may “be viewed as dimensions representing spectra of personality dysfunction on a continuum with Axis I mental disorders” (p. 690)
What is DSM-IV-TR: Personality Disorders: Cluster C?
Cluster C (anxious-fearful)
Avoidant (#1)
Dependent (#2)
Obsessive-Compulsive (#3)
What is DSM-IV-TR: C: Avoidant PD (#1)?
Characterized by social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation
Avoidance of work or school activities involving interpersonal contact for fear of criticism, disapproval or rejection
Unwillingness to make new friends unless certain that they will be liked and accepted without criticism
Avoidance of intimate relationships for fear of being shamed or ridiculed
Preoccupation with criticism or rejection in social situations
Inhibition in new interpersonal situations due to feelings of inadequacy
View of self as inept and inferior
Reluctant to engage in new activities that may cause embarrassment
Hypervigilant of behaviors of others, carefully reading body language and facial expressions and easily personalizing them
Their anxious presentation may elicit criticism from others, which only serves to confirm their self-doubts
Anxious about reacting to criticism with blushing or crying and the additional criticism that those reactions may elicit
Present as shy, timid, withdrawn, isolated
Few social supports
Significant impact on occupational functioning
What are DSM-IV-TR: Avoidant PD (#1): Differential Considerations?
Social Phobia, Generalized Type:
-High degree of overlap (so much so that it’s not clear dividing them up into these two disorders is conceptually or clinically useful)
Panic Disorder with Agoraphobia:
- In Panic Disorder, the onset of avoidance is usually in response to panic attacks
- In Avoidant PD, the onset is early with an absence of clear precipitants and a stable course
Schizoid/Schizotypal PD:
-People with Avoidant PD want relationships, but avoid them for fear of rejection, whereas people with Schizoid or Schizotypal PD do not desire relationships and the social isolation is not distressing to them.
Paranoid PD:
-Reluctance to confide in others is predicated on fear of others’ malicious intent, whereas in Avoidant PD that reluctance results from fear of being embarrassed or found to be inadequate
What is Avoidant PD (#1): Etiology?
Temperamental shyness
Shame:
- Extreme sensitivity to shame and feelings of vulnerability
- Developmental experiences
- Disruption in early attachment relationships, causing shame to emerge as a result of being rebuffed and invalidated by parents (and, in response, the development of a sense that their needs are excessive or inappropriate)
Shyness or avoidance as a defense (at first reactionary, then preemptive) against embarrassment, humiliation, rejection and failure
DSM-IV-TR: Psychodynamic View
What are “characterological features” associated with PDs?
Core conflict
Defenses
Object Relations
Self Functions
What is “core conflict”?
the main cause of anxiety in the mind, often due to early developmental/relational trauma that has not been resolved.
What is “defenses”?
adaptations created by the ego that become well-patterned and rigidify across the life span.
What is “object relations”?
how the “introject” (internal model of self, other, and self in relation to other) influences present-day events and relational experiences
What is “self functions”?
the characteristic way one relates to oneself and maintains mental “cohesion” in the face of narcissistic injury and stress; self-object vs. self-self relational tendency.
What are the Avoidant PD (#1): Characterological Features?
Core conflict: “If I have a need and express it, I will be rejected and feel shame”
Defenses and ego functioning: Blend of mature and primitive defenses
Object relations:
Themes of shame, inadequacy
Avoidance of situations (relationships) that might lead to shame and humiliation
Self functions:
Poor
Sense of self as inadequate
Depressive/masochistic self-states common; may also present as perfectionistic
What are Avoidant PD (#1): Treatment Considerations?
Hx. of neglect of early caregivers-insecure attachment style in childhood. Example of early schema- “I am too needy and people cannot handle this”.
Fear of forming intimate relationships in adulthood.
Shame is central feature and hide out to avoid shameful affect.
Fear of situation where they feel they cannot measure up to per an ego-ideal (internal standard) and they are vulnerable. Hence, avoidance behavior.
Central theme in treatment is exposure to what client is fearful of and challenge old maladaptive schemas.
What is DSM-IV-TR: Dependent PD (#2)?
Characterized by a “pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation” (APA, 2000, p. 721).
The behaviors arise from a fear of being unable to function adequately without the care of others and are intended to elicit caregiving from others.
What is DSM-IV-TR: Dependent PD (#2) Criteria?
Diagnostic criteria:
Difficulty making everyday decisions without excessive advice and reassurance from others
Needing others to assume responsibility for most major areas of their lives
Difficulty disagreeing with others for fear of loss of approval
Difficulty initiating projects alone
Going to excessive lengths to obtain nurturance and support from others
Feeling uncomfortable or helpless when alone
Urgently seeking replacement relationship when one ends
Preoccupied with fears of being left to take care of self
Tend to minimize or belittle their own positive qualities or abilities – “I’m so stupid”
Criticism or disapproval viewed as proof of worthlessness, which further undermines self-esteem and self-efficacy
Impairment in occupational functioning if tasks require initiative (or limited to jobs that don’t require initiative)
Relationships limited to those on whom the individual is dependent
What are DSM-IV-TR: Dependent PD (#2): Differential Considerations?
In general, the early onset, chronic pattern of dependency must be distinguished from dependency that arises from an Axis I disorder or as the result of GMC
Borderline PD:
Both characterized by fears of abandonment; however, in BPD, those fears are managed by acting out, rage, entitled demands, whereas in DPD fears are managed by becoming overly appeasing and submissive and seeking replacement relationships
Histrionic PD:
Both characterized by need for reassurance and approval, but in HPD, the attention-seeking behavior is dramatic and flamboyant, whereas in DPD it is self-effacing and docile
Avoidant PD:
Both Avoidant PD and DPD are characterized by feeling of inadequacy and fears of rejection; however, in Avoidant PD, the person reacts to the fear by avoiding relationships, whereas in DPD, the person actively seeks relationships
What is DSM-IV-TR Dependent PD (#2): Etiology?
Psychodynamic understanding of etiology:
Pervasive pattern of parental reinforcement for dependency
Families with low expressiveness and high control
Enmeshed attachment relationships in which independence was discouraged
What are DSM-IV-TR Avoidant PD (#2): Characterological Features?
Core conflict: separation/individuation is bad and may destroy the object.
Defenses and ego functioning:
Mature and primitive defenses
-reaction formation/compromise formation: dependent clinging may mask resistance to the expression of aggression
Self functions:
Poor: neediness of others for selfobject functions
Sadomasochistic relationships function to soothe the self
Object relations:
Neediness, dependency, submissiveness
What is DSM-IV-TR: Obsessive-Compulsive PD (#3)?
Characterized by a “preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency” (APA, 2000, p. 725).
Attempts to maintain a sense of control (and self-cohesion) by way of excessive attention to rules, perfectionism, excessive devotion to work, and over-conscientiousness.
Preoccupation with orderliness, perfection, and mental and interpersonal control.
Characteristics of OCPD tend to be reinforced in situations that reward high performance
-It becomes a disorder when these features are inflexible, maladaptive or persistent across a range of contexts
Difficulties with decision-making, particularly if there are no clear rules or procedures
-So much so that they may never begin tasks
Become upset in situations where they are not able to maintain control, although they do not directly express their dissatisfaction; e.g., travel delays and ruminating about the letter they will write to the airline
Highly controlled emotions undermine intimate relationships
Occupational difficulties arise when they encounter situations in which flexibility or compromise are required
What is Criteria for DSM-IV-TR: Obsessive-Compulsive PD (#3)?
Diagnostic criteria:
Excessive preoccupation with details, rules, lists, organization or schedules to the detriment of the major point of any activity
Perfectionism that interferes with task completion
Excessive devotion to work and productivity to the exclusion of leisure and relationships
Over-conscientiousness and inflexibility about ethics, morality or values
Inability to discard worn-out or worthless objects even when they have no sentimental value
Reluctance to delegate tasks due to concern that they won’t be completed exactly as desired
Excessive frugality
Rigidity and stubbornness
What are DSM-IV-TR: Obsessive-Compulsive PD: Differential Considerations?
Obsessive-Compulsive Disorder:
People with OCD have true obsessions and/or compulsions, whereas people with OCPD do not
Extreme hoarding: OCD should be considered
Narcissistic PD:
Also perfectionistic, but usually think they are superior and have achieved perfection, whereas people with OCPD are self-critical
What is DSM-IV-TR Obsessive-Compulsive PD: Etiology?
Psychodynamic view of etiology:
Centrality of issues associated with the anal stage
Anger and aggression that arise in response to the experience of being controlled are introjected (instead of turned vs. the object)
- The need to feel in control becomes important to the maintenance of self-esteem
- Not feeling loved by parents gives rise to self-doubt
- Understanding an excessive need for orderliness as reaction formation against the out-of-control feelings of aggression
What are DSM-IV-TR Obsessive-Compulsive PD: Characterological Features?
Core Conflict: rage at being controlled vs. fear of being punished
Defenses and ego functioning:
-Punitive superego and demands for perfection
-Primarily mature defenses
-Organizing defenses
Obsessive: Isolation of affect (if higher functioning, more mature versions like rationalization, compartmentalization, intellectualization)
Compulsive: Undoing
Obsessive and compulsive: both isolation and undoing
Displacement (particularly of anger) onto a legitimate target reduces feelings of shame associated with anger
-Overvaluation of cognition and mentation
Feelings are viewed as indicative of weakness, childishness, loss of control and are excessively avoided
Fear of shame associated with revealing vulnerability results in an overly cognitive and rational approach to relationships
This significantly undermines relationships, including the therapeutic one
Questions about emotional responses are met with exceedingly rationale , emotionally distancing or impassive responses
-Behavioral defenses (a/w compulsive personalities)
Undoing:
Compulsive actions aimed at undoing a thought or action
Compulsions are defined by their drivenness – the sense that they MUST be performed in order to maintain control
Sense of omnipotent control in compulsions – overestimation of the degree to which the person’s actions defined the outcome
-Reaction formation
Overcontrolled conscientiousness and excessive need for orderliness represents a reaction formation against wishes to be messy, rebellious and aggressive
Object relations:
-Control is a central issue in families of origin:
Caregivers who were rigid, controlling: Control expressed through induction of guilt: I expected more from a smart kid like you.” :Modeling of moralization: “It hurts me to do this, but it’s for your own good”
High standards of behavior and expectations of conformity by parents or caregivers result in the development of harsh superego
Wish to gain love by perfection
Need to control others in relationships and fear of getting out of control
Counter-dependency evident in excessive individualism
Self functions:
- Profound concern with control and morality
- Themes of dependency and aggression:
Righteous behavior is equated with keeping aggressive and needy parts of the self contained
- Self-esteem is maintained by meeting the demands of a internalized objects who have high standards for behavior
- Paralyzing fear of making the wrong choice and things turning out badly as a result
Limited insight into the extent to which, by trying to keep all their options open (and, in so doing, to maintain control over all possible outcomes, with the goal of the perfect solution), they end up undermining their options, which results in a forced outcome that was not necessarily their choice
What is DSM-IV-TR OCPD: Treatment?
Good patients – conscientious, hard-working, motivated
Rambling speech pattern with frequent retraction of thoughts or feelings that have been verbalized
Transference:
- May perceive therapist as the demanding and judgmental parent resulting in conscious compliance and unconscious oppositionality
- Critical, overcontrolling
- Great difficulty acknowledging feeling irritated or unsatisfied with the therapist – we create the space for it to exist and help hold it until they are able to hold it themselves
Countertransference:
Irritated
Discouraged
Bored or distanced by intellectualizing defense
Were there changes to DSM-5: Personality Disorders?
No Change:
Cluster A: odd or eccentric
Paranoid
Schizoid
Schizotypal
Cluster B: dramatic, erratic and emotional antisocial borderline histrionic narcissistic
Cluster C: anxious or fearful
avoidant (#1)
dependent (#2)
obsessive compulsive (#3)
What is the DSM-5: General View of Personality Disorder?
A. An enduring pattern of inner experience and behavior that deviates markedly from person’s culture. Pattern demonstrated in two or more of the following:
- cognition
- affectivity.
- interpersonal functioning
- impulse control
B. Inflexible and pervasive pattern
C. Clinically sig. distress and disability
D. Pattern stable and long duration and onset can be traced to adolessence or early adulthood.
E. Not explained by another mental dx.
F. Not accounted by substance or GMC
What is DSM-5: Avoidant PD (#1)?
A. Pervasive pattern of social inhibition , feelings f inadequacy, and hypersensitivity to negative evaluation, beginning from early adulthood. Four or more of the following:
- avoids occupational activity that involve sig. interpersonal contact because of fears of criticism etc.
- unwilling to get involved with people unless certain of being liked.
- restrained in intimate relationships bc. Of being shamed or ridiculed
- preoccup. With rejection or criticism in social sit.
- inhibition in new social sit. Because of feeling inadequate.
- views self as socially inept and inferior to others
- reluctant to take personal risks or engage in new activities because of fears of possible embarrassment.
What is DSM-5: Dependent PD (#2)?
A. Pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood. Five or more of the following:
- difficulty making everyday decisions without excessive amount of advice and reassurance from others
- needs others to assume responsibility for most major areas of his or her life
- difficulty expressing disagreement with others because of fear of loss of support or approval (note: Do not include realistic fears of retribution).
- difficulty initiating projects or doing things on own bc. Of lack of self-confidence in judgment or abilities rather then lack of motivation or energy
- excessive lengths to obtain support from others to the point of doing unpleasant things
- uncomfortable or helpless when alone bc. Of fears of unable to take care of self
- seeks another relationships as support or care if one relationship ends
- unrealistically preoccupied with fears of being left to take care of self
What is DSM-5: Obsessive-Compulsive PD (#3)?
A. Preoccupation with orderliness, perfection and control at the expense of flexibility or openness and efficiency, beginning from early adulthood. Four or more of the following:
- preoccupied with details, rules, lists to the extent that major point of the activity is lost.
- perfectionism interferes with task completion
- excessive devotion to work etc. to the exclusion of leisure (not accounted by obvious eco. Reasons)
- inflexibility about morality ad ethics (e.g. not accounted by cultural or religious values)
- unable to discard worthless objects even when they have no sentimental value
- difficulty delegating tasks
- miserly spending style towards self and others; money hoarded for future catastrophes
- rigid or stubborn
