Week 1 Flashcards
DSM Def. Personality Disorder
= an enduring pattern of inner experience and behavior that deviates markedly 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
Cluster A Characteristics
Cluster A
- Incl. paranoid, schizoid, and schizotypal PDs
- Appear odd or eccentric
- Prevalence estimates: ~ 5.7%
Cluster B Characteristics
Cluster B
- Incl. antisocial, borderline, histrionic, and narcissistic PDs
- Appear emotional, dramatic, or erratic
- Prevalence estimates: ~1.5%
Cluster C Characteristics
Cluster C
- Incl. avoidant, dependent, and obsessive-compulsive PDs
- Appear anxious or fearful
- Prevalence estimates: ~ 6.0%
Overall prevalence of PD
~ 9.1% for any PD, indicating frequent co-occurrence of disorders from different clusters
General Personality Disorder - Diagnostic Criteria
A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
- Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
- Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
- Interpersonal functioning
- Impulse Control
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and Its onset can be traced back at least to adolescence or early adulthood.
E. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
F. The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).
General Personality Disorder - Development and Course
Stable over time (though some become less evident or remit with age)
If the patient is under 18, features must’ve been present for at least 1 year
Antisocial PD cannot be diagnosed in patients under 18
General Personality Disorder - Culture-Related Diagnostic Issues
Take ethnic, cultural, and social background into account
PDs should not be confused with problems assoc. with acculturation
General Personality Disorder - Gender-Related Diagnostic Issues
Some PDs are more prevalent in females/ males
Caution: do not over or underdiagnose certain PDs because of social stereotypes about typical gender roles and behaviors
General Personality Disorder - Differential Diagnosis
- Other mental disorders and personality traits
- Psychotic disorders
- Anxiety and depressive disorders
- PTSD
- Substance Use Disorder
- Personality changes due to another medical condition
Paranoid Personality Disorder - Diagnostic Criteria
A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of con texts, as indicated by four (or more) of the following:
- Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
- Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
- Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
- Reads hidden demeaning or threatening meanings into benign remarks or events.
- Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
- Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
- Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.
Paranoid Personality Disorder - Development and Course
- May be first apparent in childhood/ adolescence
- These children appear to be “odd” or “eccentric”
- More commonly diagnosed in males
Paranoid Personality Disorder - Prevalence
~ 2.3 – 4.4%
Paranoid Personality Disorder - Associated features supporting diagnosis
- Difficult to get along with
- Problems with close relationships
- Overt argumentativeness
- Recurrent complaining
- Excessive need to be self-sufficient and autonomous
- Difficulty accepting criticism
- Seek to confirm their preconceived negatives notions regarding people/ situations
- May experience brief psychotic episodes in response to stress
- Most common co-occurring PDs: schizotypal, schizoid, narcissistic, avoidant, and borderline
Paranoid Personality Disorder - Culture-related Diagnostic Issues
Members of minority groups, immigrants, refugees, or from diff. ethnic backgrounds may display guarded or defensive behaviors because of unfamiliarity or in response to perceived neglect of the majority society
Some ethnic groups display culturally related behaviors that can be misinterpreted as paranoid
Paranoid Personality Disorder - Differential Diagnosis
- Must be distinguished from:
- personality changes due to another medical condition
- symptoms that may develop in assoc. with persistent substance use
- traits associated with the development of physical handicaps
Schizoid Personality Disorder - Diagnostic Criteria
A. 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:
- Neither desires nor enjoys close relationships, including being part of a family.
- Almost always chooses solitary activities.
- Has little, if any, interest in having sexual experiences with another person.
- Takes pleasure in few, if any, activities.
- Lacks close friends or confidants other than first-degree relatives.
- Appears indifferent to the praise or criticism of others.
- Shows emotional coldness, detachment, or flattened affectivity.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition.
Schizoid Personality Disorder - Development and Course
may be first apparent in childhood and adolescence
Schizoid Personality Disorder - Prevalence
~ 3.1% - 4.9%
Schizoid Personality Disorder - Associated features Supporting Diagnosis
- give the impression that they lack emotion
- difficulty responding appropriately to important life events
- few friendships, date infrequently, often do not marry
Schizoid Personality Disorder - Culture-Related Diagnostic Issues
- defensive behaviors of people from a variety of cultural backgrounds may be erroneously labeled as schizoid
Schizoid Personality Disorder - Gender-Related Diagnostic Issues
- slightly more common in males & may cause more impairments in them
Schizoid Personality Disorder - Differential Diagnosis
- to give additional diagnosis, the disorder must have been present before the onset of psychotic symptoms and must persist when the psychotic symptoms are in remission
- difficult to distinguish from indiv. With milder form of autism spectrum disorder
- must be distinguished from changes due to other medical conditions & changes associated with persistent substance use
Schizotypal Personality Disorder - Diagnostic Criteria
A. 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 behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
- Ideas of reference (excluding delusions of reference).
- Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”: in children and adolescents, bizarre fantasies, or preoccupations).
- Unusual perceptual experiences, including bodily illusions.
- Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
- Suspiciousness or paranoid ideation.
- Inappropriate or constricted affect.
- Behavior or appearance that is odd, eccentric, or peculiar.
- Lack of close friends or confidants other than first-degree relatives.
- Excessive social anxiety that does not diminish with familiarity and tends to be as¬sociated with paranoid fears rather than negative judgments about self.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.
Schizotypal Personality Disorder - Associated Features Supporting Diagnosis
- may experience transient psychotic episodes (particularly in response to stress)
- 30-50% have a concurrent diagnosis of major depressive disorder
Schizotypal Personality Disorder - Prevalence
~ 0.6%-4.6%
Schizotypal Personality Disorder - Development and Course
- relatively stable course
- may be first apparent in childhood and adolescence
Schizotypal Personality Disorder - Cultural-Related Diagnostic Issues
- pervasive culturally determined characteristics (particularly those regarding religious beliefs or rituals) can appear schizotypal
Schizotypal Personality Disorder - Gender-Related Diagnostic Issues
- slightly more common in males
Antisocial Personality Disorder - Diagnostic Criteria
A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:
- Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
- Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
- Impulsivity or failure to plan ahead.
- Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
- Reckless disregard for the safety of self or others.
- Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
- Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of schizo¬phrenia or bipolar disorder.
Antisocial Personality Disorder - Associated Features Supporting Diagnosis
- tend to be callous, cynical, and contemptuous of the feelings, rights, and suffering of others
- inflated and arrogant self-appraisal
- lack of empathy
- may have history of many sexual partners and may never sustain a monogamous relationship
- may be irresponsible as parents
- may fail to be self-supporting, may become impoverished or even homeless, or may spend many years in penal institutions
Antisocial Personality Disorder - Prevalence
~ .2%-3.3%
Antisocial Personality Disorder - Development and Course
- chronic course
- may become less evident or remit as they grow older
- cannot be diagnosed before age 18
Antisocial Personality Disorder - Culture-Related Diagnostic Issues
- consider SES, as antisocial behavior may be part of protective survival strategies
Antisocial Personality Disorder - Gender-Related Diagnostic Issues
- much more common in males
- might be underdiagnosed in females
Antisocial Personality Disorder - Differential Diagnosis
- when SUD is present, antisocial PD is only diagnosed when signs of it were already present in childhood/ adolescence
- should not be diagnosed if it only occurs in the course of schizophrenia or a bipolar disorder
- must be distinguished from criminal behavior undertaken for gain
Borderline Personality Disorder - Diagnostic Criteria
Diagnostic Criteria
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
2. A pattern of unstable and intense interpersonal relationships characterized by alternat¬ing between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self- mutilating behavior covered in Criterion 5.)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
Borderline Personality Disorder - Associated features Supporting Diagnosis
- Pattern of undermining themselves at the moment a goal is about to be realized
- Some have Psychotic symptoms in response to stress
- May feel more secure with transitional objects
- Suicide is more common
- Recurrent job losses, interrupted education, and separation/ divorce is common
- Physical and sexual abuse, neglect, hostile conflict, and early parental loss are more common in their childhood histories
Borderline Personality Disorder - Prevalence
~ 1.6%-5.9%
Prevalence may increase in older age groups
Borderline Personality Disorder - Development and Course
- Most common pattern: chronic instability in early adulthood
- Impairment from disorder and risk of suicide wane with advancing age
- During 30s and 40s the majority attains greater stability in their relationships and vocational functioning
Borderline Personality Disorder - Gender-Related Diagnostic Issues
Predominantly diagnosed in females (~75%)
Histrionic Personality Disorder - Diagnostic Criteria
A pervasive pattern of excessive emotionality and attention-seeking, beginning by early adult¬ hood and present in a variety of contexts, as indicated by five (or more) of the following:
- Is uncomfortable in situations in which he or she is not the center of attention.
- Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
- Displays rapidly shifting and shallow expressions of emotions.
- Consistently uses physical appearance to draw attention to self.
- Has a style of speech that is excessively impressionistic and lacking in detail.
- Shows self-dramatization, theatricality, and exaggerated expression of emotion.
- Is suggestible (i.e., easily influenced by others or circumstances).
- Considers relationships to be more intimate than they actually are.
Histrionic Personality Disorder - Associated Features Supporting Diagnosis
- Diff. achieving emotional intimacy in romantic relationships
- Often act out a role (e.g., victim or princess)
- Seek to control their partner while displaying marked dependency on them
- Problems with same-sex friends due to their sexually provocative interpersonal style
- Upset when they aren’t the center of attention
- Become bored with their usual routine
Histrionic Personality Disorder - Prevalence
~ 1.84%
Histrionic Personality Disorder - Gender-Related Diagnostic Issues
- In clinical settings more often diagnosed in females
- But some studies suggest the same ratio in males and females
Narcissistic Personality Disorder - Diagnostic Criteria
A pervasive pattern of grandiosity (in fantasy or behavior), 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 (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
- 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 (or institutions).
- Requires excessive admiration.
- Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
- Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
- 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 behaviors or attitudes.
Narcissistic Personality Disorder - Associated Features Supporting Diagnosis
- Sensitive to criticism
- May lead to feeling humiliated, degraded, or empty
- May cause social withdrawal
- May disrupt Performance
- Impaired interpersonal relationships due to their problems with entitlement, need for admiration, and the disregard for sensitivities of others
Narcissistic Personality Disorder - Prevalence
~0-6.2%
Narcissistic Personality Disorder - Development and Course
- Narcissist traits may be common in adolescents but do not necessarily lead to a narcissistic personality disorder
- Narcissists may have problems facing their own aging process
Narcissistic Personality Disorder - Gender-Related Diagnostic Issues
50-75% of those diagnosed are male
Narcissistic Personality Disorder - Differential Diagnosis
- most useful feature in discriminating a narcissistic PD from other disorders is the grandiosity characteristic
- grandiosity can also emerge as part of manic or hypomanic episodes: the assoc. with mood change or functional impairments helps to distinguish
Narcissistic Personality Disorder - Which cluster?
Cluster B
Histrionic Personality Disorder - Which cluster?
Cluster B
Borderline Personality Disorder - Which cluster?
Cluster B
Antisocial Personality Disorder - Which cluster?
Cluster B
Paranoid Personality Disorder - Which cluster?
Cluster A
Schizoid Personality Disorder - Which cluster?
Cluster A
Schizotypal Personality Disorder - Which cluster?
Cluster A
Avoidant Personality Disorder - Which cluster?
Cluster C
Obsessive-compulsive Personality Disorder - Which cluster?
Cluster C
Dependent Personality Disorder - Which cluster?
Cluster C
Avoidant Personality Disorder - Diagnostic Criteria
A. A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to neg¬ative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
- Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
- Is unwilling to get involved with people unless certain of being liked.
- Shows restraint within intimate relationships because of the 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.
Avoidant Personality Disorder - Associated Features Supporting Diagnosis
- Major problems in social and occupational functioning
- Low self-esteem and hypersensitivity to rejection: restricted interpersonal contacts
- May avoid situations which would be important for their jobs demand
- Often diagnosed with dependent personality, borderline, and Cluster A PDs
Avoidant Personality Disorder - Prevalence
~ 2.4%
Avoidant Personality Disorder - Development and Course
- Often starts in infancy or childhood with shyness, isolation, and fear of strangers/ new situations
- Become increasingly shy and avoidant during adolescence
- Some studies suggest that this may remit with age
Avoidant Personality Disorder - Culture-Related Diagnostic Issues
- Some variation between cultures
- Most avoidant behavior due to problems in acculturation after immigration
Avoidant Personality Disorder - Gender-Related Diagnostic Issues
- Equally frequent in males and females
Dependent Personality Disorder - Diagnostic Criteria
A. 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 and present in a variety of contexts, as indicated by five (or more) of the following:
- Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
- Needs others to assume responsibility for most major areas of his or her life.
- Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include realistic fears of retribution.)
- Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).
- Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
- Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.
- Urgently seeks another relationship as a source of care and support when a close re¬lationship ends.
- Is unrealistically preoccupied with fears of being left to take care of himself or herself.
Dependent Personality Disorder - Associated Features Supporting Diagnosis
- Characterized by pessimism and self-doubt
- Tend to belittle their abilities
- Seek overprotection and dominance from others
- Avoid positions of responsibility
Dependent Personality Disorder - Prevalence
~ 0.49% - 0.6%
Dependent Personality Disorder - Gender-Related Diagnostic Issues
Gender-Related Diagnostic Issues
- In clinical settings, more frequent in females
- Some studies suggest the same rates among males
Dependent Personality Disorder - Differential Diagnosis
- Must be distinguished from dependency arising due to another mental/ medical condition
Dependent Personality Disorder - Culture-Related Diagnostic Issues
- Age and cultural factors need to be considered
Obsessive-Compulsive Personality Disorder - Diagnostic Criteria
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 following:
- Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
- Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).
- Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
- Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
- Is unable to discard worn-out or worthless objects even when they have no sentimental value.
- Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
- Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
- Shows rigidity and stubbornness.
Obsessive-Compulsive Personality Disorder - Associated Features Supporting Diagnosis
- Difficulty to prioritize tasks
- Become angry/ upset when unable to maintain control of their physical or interpersonal environment
- Attentive to their relative status in dominance-submission relationships
- Everyday relationships have a formal and serious quality
Obsessive-Compulsive Personality Disorder - Prevalence
~ 2.1% - 7.9%
Obsessive-Compulsive Personality Disorder - Gender-Related Diagnostic Issues
- Studies: about twice as often diagnosed in males
Obsessive-Compulsive Personality Disorder - Differential Diagnosis
- OCD can be distinguished from OCPD by the presence of true obsessions and compulsions in OCD
Personality Change Due to Another Medical Condition - Diagnostic Criteria
A. A persistent personality disturbance that represents a change from the individual’s pre¬vious characteristic personality pattern.
Note: In children, the disturbance involves a marked deviation from normal development or a significant change in the child’s usual behavior patterns, lasting at least 1 year
B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder (including another mental disorder due to another medical condition).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa¬tional, or other important areas of functioning.
Personality Change Due to Another Medical Condition - Specify whether…
Which type:
Labile type: If the predominant feature is affective lability.
Disinhibited type: If the predominant feature is poor impulse control as evidenced by sexual indiscretions, etc.
Aggressive type: If the predominant feature is aggressive behavior.
Apathetic type: If the predominant feature is marked apathy and indifference.
Paranoid type: If the predominant feature is suspiciousness or paranoid ideation.
Other type: If the presentation is not characterized by any of the above subtypes.
Combined type: If more than one feature predominates in the clinical picture.
Unspecified type
Other Specified Personality Disorder
- Symptoms are characteristic of a PD but do not meet the full criteria of a PD
- Used when a clinician chooses to communicate the specific reason why criteria are not met
Unspecified Personality Disorder
- Symptoms are characteristic of a PD but do not meet the full criteria of a PD
- Used when a clinician chooses NOT to communicate the specific reason why criteria are not met and when there is insufficient information to make a more specific diagnosis
Granieri et al. (2017) - Summary
Aim:
- investigate the relationship between DMs and DSM-5 maladaptive personality domains among adults
Methods:
- 328 adults aged between 18 and 64 years old
- completed measures on DMs and maladaptive personality domains
Results:
- immature defenses positively predicted maladaptive personality domain scores
- mature defenses were related to better personality functioning
- different defense patterns emerged as significant predictors of the maladaptive personality domains comprised in the alternative DSM-5 model for personality disorder
Discussion:
- defense patterns represent core components of personality and its disorders
- suggest that increased use of immature defenses and reduced use of mature defenses have a negative impact on the development of personality
Defense Mechanisms (DM) - Def.
- by Sigmund Freud (1894, 1896)
- concept of a menta operation, usually unconscious, directed against the expression of drives and impulses
Defense Mechanisms (DM) - Characteristics
- DMs may be defined as unconscious mental mechanisms that are directed against both internal drive pressures and external pressures, especially those threatening self-esteem or structure and integration of the self
- Develop according to predictable sequences with the maturation of the child
- are part of normal personality functioning
- can lead to psychopathology, if one or more are used excessively
- are distinguishable from one another
Defense Mechanisms (DM) - Function
to protect the self from anxiety, conflict, shame, loss of self-esteem, or other unexpectable feelings and negative thoughts
Defense Mechanisms (DM) - Degree of maturity
Mature:
- imply a greater ability to adapt to reality, so that they can effectively distance threatening feelings without distorting the reality
- e.g., sublimation, humor, suppression, altruism
Immature or even primitive:
- characterized by severe alteration of painful mental contents and/or radical distortion of external reality
- e.g., projection, splitting, acting out, and autistic fantasy
Defense Mechanisms (DM) - Sex differences
both in use of specific DMs and in overall defensive styles adopted by individuals
Women:
- tend to use more internalizing DMs (such as somatization)
- find it more difficult to express aggression outwardly and are more likely to turn it against themselves by relying on defenses that modify inner thoughts and feelings
Men:
- men tend to use more externalizing defenses (such as acting out)
- depend more on defenses that locate conflict in the external world, and tend to turn against the object
Defense Mechanisms (DM) - Psychological health
- related to mature DMs
- especially to the ability to appropriately use a variety of DMs in different contexts
- exclusive use of immature defense is a risk factor for the development of different forms of psychopathology
Personality Organization - Def.
reflect the individual’s predominant psychological characteristics that are based on the individual’s identity integration, DMs, and reality testing
Neurotic organization of personality - Def.
characterized by identity integration (object constancy), a conserved capacity for reality testing, and prevalent use of mature and neurotic DMs
Borderline personality organization - Def.
characterized by a failure in identity integration (identity diffusion), a conserved reality testing when not in a condition of distress, and use of immature DMs
Psychotic organization of personality - Def.
characterized by lack of ego boundaries, loss of reality testing, and use of immature and primitive DMs
Five domains of personality
- negative affectivity (which includes personality features such as emotional lability and hostility)
- detachment (which includes personality features such as intimacy avoidance and suspiciousness)
- antagonism (which includes personality features such as grandiosity and manipulativeness)
- disinhibition (which includes personality features such as impulsivity and risk-taking)
- psychoticism (which includes personality features such as cognitive-perceptual dysregulation, unusual beliefs, and experiences)
Neurotic-Level Personality Structure - Def.
denotes a high level of capacity to function despite emotional suffering
Neurotic-Level Personality Structure - Defences used
- Rely primarily on the more mature or second-order defenses
- Presence of primary defenses does not rule out a diagnosis
- Absence of mature defenses does rule out a diagnosis
Neurotic-Level Personality Structure - Characteristics in Therapy
transference neurosis = neurotic-level client maintains some more rational, objective capacities in the middle of whatever emotional storms and associated distortions occur
- Strangers to hallucinatory or delusional misinterpretations of experiences
- Much of their psychopathology is ego alien or capable of being addressed so that it becomes so
- Neurotic-level people are ordinarily in solid touch with what most of the world calls “reality”
- Patient and therapist live subjectively in more or less the same world
- capacity for the “therapeutic split” between the observing and the experiencing parts of the self
Psychotic-level personality structure - Def.
function but strike one as confused and deeply terrified, and their thinking feels disorganized or paranoid
Psychotic-level personality structure - Characteristics in Therapy
- people are much more internally desperate and disorganized
- It is not difficult to diagnose patients who are in an overt state of psychosis, they express hallucinations, delusions, and ideas of reference, and their thinking strikes the listener are illogical
- Psychotic breaks (by therapist) prevent suicides and homicides and keep people out of hospitals
– Not anchored in reality
Psychotic-level personality structure - Defences used
- Withdrawal
- Denial
- Omnipotent control
- Primitive idealization and devaluation
- Primitive forms of projection and introjection
- Splitting
- Extreme dissociation
- Acting out
- Somatization
Borderline personality organization - Defence used
use of primitive defenses
- Denial
- Projective identification
- Splitting
Borderline personality organization - difference to PPO
- when the therapist confronts a borderline patient on using a primitive mode of experiencing, the patient will show at least a temporary responsiveness
- when the therapist makes a similar comment to a psychotically organized person
- will become further agitated (internal terror)
Borderline personality organization - Difference to PPO
- when the therapist confronts a borderline patient on using a primitive mode of experiencing, the patient will show at least a temporary responsiveness
- when the therapist makes a similar comment to a psychotically organized person
- will become further agitated (internal terror)
Borderline personality organization - Identity integration
- Their experience of self is likely to be full of inconsistency and discontinuity (like psychotic-level)
- Unlike patients with psychotic-level - rarely sound concrete or tangential to the point of being bizarre, but they tend to dismiss the therapist’s interest in the complexities of themselves and others
- Insecurely attached and lack the “reflective function” that finds meaning in their own behavior and that of others
- They cannot “mentalize” (cannot appreciate the separate subjectivities of other people, lack theory of mind)
Borderline personality organization - Reality Testing
Borderline clients, when interview thoughtfully, demonstrate an appreciation of reality no matter how crazy or florid their symptoms are
Neurotic-Level Personality Structure - Summary
People whose personalities are organized at the neurotic level have:
1) intact reality testing,
2) a consistent sense of self and of other people,
3) generally rely on mature defense mechanisms when stressed
People with a neurotic level of personality organization have a good sense of reality, so they can distinguish between what is real from what is not. For instance, they don’t hear voices that are not there or believe other people are trying to harm them when this is not the case. They have a good sense of their own strengths and weaknesses. They know what their values are. They have a pretty consistent sense of purpose, direction, and life goals. They are able to deeply commit to, and care about, other people and view other people accurately, taking into account both their strengths and weaknesses. They successfully cope with stress in an effective and adaptive manner.
Psychotic-Level Personality Structure - Summary
People with this level of personality organization have:
1) severely compromised reality testing,
2) an inconsistent sense of self and others,
3) utilize immature defenses
Because their reality testing is compromised these people might hear or see things that are not really there, or have delusions, such as being convinced that they have special powers (for instance, the ability to read other people’s minds or to fly). They may believe they receive special messages through the television (a phenomenon known as “Ideas of Reference” or “Delusions of Reference”). They don’t have a clear sense of themselves and the boundary between themselves and other people is often blurred. As such, they have great difficulty distinguishing between experiences and perceptions that originate within their own mind, from those that originate in the real world. Their ability to cope with stress is extremely poor and they do not function well in society.
Borderline-Level Personality Structure
Along the middle of this dimension are personalities organized at the borderline level. At this level, reality testing is generally intact (unlike the more severe psychotic level). However, people with a borderline level of personality organization have a fragmented sense of self and others (unlike the less severe neurotic organization with an integrated self). Because they possess a fragmented sense of self they don’t have a consistent view of themselves or others, over time and across situations. This fragmented sense of self is the most significant and defining feature of the borderline level and results in severe and repetitive problems with interpersonal relationships.
In addition, people with a borderline level of personality organization tend to rely on primitive defense mechanisms. Therefore, they don’t manage stressful situations very well. One of the main primitive defense mechanisms used by people with borderline personality organization is called “splitting.” This defense mechanism is characterized by a tendency to view the world and other people in a polarized manner, as “all good” or “all bad,” flipping back and forth between these two extremes based on moment-to-moment perceptions.
