Week 21: Psychopathology and Therapeutic Orientations Flashcards
Learning Objectives:
Define what is meant by a personality disorder.
Identify the five domains of general personality.
Identify the six personality disorders proposed for retention in DSM-5.
Summarize the etiology for antisocial and borderline personality disorder.
Identify the treatment for borderline personality disorder.
Personality
Characteristic, routine ways of thinking, feeling, and relating to others.
*Personality traits are integral to each person’s sense of self, as they involve what people value, how they think and feel about things, what they like to do, and, basically, what they are like most every day throughout much of their lives.
Personality - Five Factor Model
Five broad domains or dimensions are used to describe human personality.
- Neuroticism or Emotional Stability
- Extraversion or Introversion
- Openness or Closedness
- Agreeableness or Antagonism
- Conscientiousness or Disinhibition
Neuroticism (Emotional Instability)
or
Emotional Stability
Neuroticism:
- fearful
- apprehensive
- angry
- bitter
- pessimistic
- glum
- timid
- embarrassed
- tempted
- urgency
- helpless
- fragile
Emotional Stability:
- relaxed
- unconcerned
- cool
- even-tempered
- optimistic
- self-assured
- glib
- shameless
- controlled
- restrained
- clear-thinking
- fearless
- unflappable
Extraversion
or
Introversion
Extraversion:
- cordial
- affectionate
- attached
- sociable
- outgoing
- dominant
- forceful
- vigorous
- energetic
- active
- reckless
- daring
- high-spirited
- excitement-seeking
Introversion:
- cold
- aloof
- indifferent
- withdrawn
- isolated
- unassuming
- quiet
- resigned
- passive,
- lethargic
- cautious
- monotonous
- dull
- placid
- anhedonic
Openness (unconventionality)
or
Closedness (conventionality)
Openness (unconventionality) :
- dreamer
- unrealistic
- imaginative
- aberrant
- aesthetic
- self-aware
- eccentric
- strange
- odd
- peculiar
- creative
- permissive
- broad-minded
Closedness (conventionality) :
- practical
- concrete
- uninvolved
- no aesthetic interest
- constricted
- unaware
- alexythymic
- routine
- predictable
- habitual
- stubborn
- pragmatic
- rigid, traditional
- inflexible
- dogmatic
Agreeableness
or
Antagonism
Agreeableness:
- gullible
- naive
- trusting
- confiding
- honest
- sacrificial
- giving
- docile
- cooperative
- meek
- self-effacing
- humble
- soft
- empathetic
Antagonism
- skeptical
- cynical
- suspicious
- paranoid
- cunning
- manipulative
- deceptive
- stingy
- selfish
- greedy
- exploitative
- oppositional
- combative
- aggressive
- confident
- boastful
- arrogant
- tough
- callous
- ruthless
Conscientiousness
or
Disinhibition
Conscientiousness:
- perfectionistic
- efficient
- ordered
- methodical
- organized
- rigid
- reliable
- dependable
- workaholic
- ambitious
- dogged
- devoted
- cautious
- ruminative
- reflective
Disinhibition:
- lad
- negligent
- haphazard
- disorganized
- sloppy
- casual
- undependable
- unethical
- aimless
- desultory
- hedonistic
- negligent
- hasty
- careless
- rash
Personality Disorders
Definition
+
Examples (10)
When personality traits result in significant distress, social impairment, and/or occupational impairment.
1 - antisocial
2 - avoidant
3 - borderline
4 - dependent
5 - histrionic
6 - narcissistic
7 - obsessive-compulsive
8 - paranoid
9 - schizoid
10 - schizotypal
When personality disorders are syndromes
When personality disorders is a constellation of maladaptive personality traits, rather than just one particular personality trait
Avoidant personality disorder as a syndrome
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
combination of traits from:
- introversion (e.g., socially withdrawn, passive, and cautious)
- neuroticism (e.g., self-consciousness, apprehensiveness, anxiousness, and worrisome)
Dependant personality disorder as a syndrome
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation.
combination of traits of:
- neuroticism (anxious, uncertain, pessimistic, and helpless)
- maladaptive agreeableness (e.g., gullible, guileless, meek, subservient, and self-effacing).
Antisocial personality disorder as a syndrome
A pervasive pattern of disregard and violation of the rights of others. These behaviors may be aggressive or destructive and may involve breaking laws or rules, deceit or theft.
combination of traits from:
- antagonism (e.g., dishonest, manipulative, exploitative, callous, and merciless)
- low conscientiousness (e.g., irresponsible, immoral, lax, hedonistic, and rash).
Obsessive-Compulsive Personality Disroder
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency.
*largely a disorder of maladaptive conscientiousness, including such traits as workaholism, perfectionism, punctilious, ruminative, and dogged
Schizoid Personality DIsorder
A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings.
*is confined largely to traits of introversion (e.g., withdrawn, cold, isolated, placid, and anhedonic)
Borderline Personality Disorder
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity.
*largely a disorder of neuroticism, including such traits as emotionally unstable, vulnerable, overwhelmed, rageful, depressive, and self-destructive
Histrionic Personality Disorder
A pervasive pattern of excessive emotionality and attention seeking.
- largely a disorder of maladaptive extraversion, including such traits as attention-seeking, seductiveness, melodramatic emotionality, and strong attachment needs
Narcissistic personality disorder
(Syndrome)
A pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy.
*includes traits from:
- neuroticism (e.g., reactive anger, reactive shame, and need for admiration)
- extraversion (e.g., exhibitionism and authoritativeness)
- antagonism (e.g., arrogance, entitlement, and lack of empathy)
- conscientiousness (e.g., acclaim-seeking)
Schizotypal personality disorder
(Syndrome)
A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as perceptual distortions and eccentricities of behavior.
*includes traits from:
- neuroticism (e.g., social anxiousness and social discomfort)
- introversion (e.g., social withdrawal), unconventionality (e.g., odd, eccentric, peculiar, and aberrant ideas)
- antagonism (e.g., suspiciousness).
Depressive Episode Criteria:
- 2+ weeks
- Interfere with daily functioning
- Core symptom: depressed mood AND/OR anhedonia
- What is depressed mood?
- Emptiness
- Hopelessness
- Irritability
- Guilt
- Pessimism
- Emotional numbness 3
Major Depressive Episode (MDE) Criteria:
- Weight changes
- Sleep disturbance
- Psychomotor changes
- e.g. slowing of thinking, movement
- Feeling worthless, inappropriately guilty
- Indecisive, confused, inability to concentrate
- Loss of energy
- Suicidal ideation
Major Depressive Disorder (MDD) Criteria:
Aka Clinical Depression:
- 1 or more MDEs
- But no mania/hypomania
- Episodes are separated by at least 2 months
- Symptoms need to cause significant distress
- Impairment and cannot be due to the effects of a substance or a general medical condition
Persistent Depressive disorder
Previously known as: dysthymia, chronic major
depression
- Same as MDD, but lasts 2+ years
- Lifetime prevalence: 3%
Must have 2 of:
- poor appetite or overeating
- insomnia or hypersomnia
- low energy or fatigue
- low self-esteem
- poor concentration or difficulty making decisions
- feelings of hopelessness
Depressive Disorders Stats
- Lifetime prevalence = 16.6%
- Women > men, but only among adults
- Before puberty: males > females
- Average age of onset = mid-20s
- But earlier onset in more recent generations
- Predicts worse outcome
- Around half of those who have one MDE will have another
- 5-10% will subsequently experience a manic episode
- Highly comorbid
- E.g. Anxiety disorders: 59%
Implicated & associated factors
GENETICS STATS
- 30-50%
- > 100 genetic risk loci
- > 200 potential genes
Implicated & associated factors
ENVIRONMENTAL STRESSORS STATS
- Loss of loved one: death, divorce, breakup
- Lost job, money problems
- Traumatic events
- Serious illness
Implicated & associated Factors
BRAIN FUNCTION
- Greater neural sensitivity in response to negative stimuli
- Brain areas involved in stress response & positively motivated behaviours
Implicated & associated Factors
COGNITION
- Pessimistic attributional styles
- Internal, global, stable
Depressive Disorders:
Medications
- SSRIs, SNRIs
- Act on serotonin and norepinephrine
- Fewer side effects & risks than older MAOIs & Tricyclics
- BUT, still enough to increase risk of noncompliance
- Finding the right one can take time, trial & error
- Those that work the best not necessarily the most tolerable
- E.g. Venlafaxine one of the most effective, but also with some of the highest dropout rates
Depressive Disorders: Therapies
Electroconvulsive therapy
- Induced seizure with electric currents under general anesthetic
- For severe, treatment resistant depression
- High efficacy (80% benefit)
- BUT potential for long-term memory loss
Depressive Disorders: Therapies
Transcranial magnetic stimulation
- Magnetic fields targets mood-regulatory regions of the prefrontal cortex
- Non-invasive, no anesthesia
- Effective for 50-60% of patients when other treatments have failed
- Side effects are often minor (headache) or rare (seizure)
Depressive Disorders: Treatment
Therapies
* Deep Brain Stimulation
- Permanently implanted electrode stimulates brain
- For severe, treatment resistant depression
- Comes with the same risks as major surgery, plus additional side effects of stimulation
- Experimental treatment
Depressive Disorders: Treatment
Psychosocial Approaches
- Time limited: 12-20 weeks for MDD
- Work best in combination with medication
E.g.
Cognitive Behavioural Therapy
* Identify & address cognitive distortions and maladaptive behaviours
Interpersonal Therapy
* Focus on improving interpersonal relationships, based on a reciprocal mood-relationship model
Mania vs. hypomania
Mania vs. hypomania
* Neither explained by other substances
* Both include a distinct period of markedly changed behaviour
Mania
* 1+ wk
* Causes major impairments to daily functioning
* Psychotic features common: delusions, hallucinations
Hypomania
* 4 days+
* Does not cause major impairment, hospitalization, or psychotic features
Bipolar I
- Single or recurrent manic episode
- More intense “highs”
- May/may not also have MDE (not required for diagnosis)
Criteria - 3 of the following if euphoric, 4 if
irritable:
* inflated self-esteem or grandiosity
* increase in goal-directed activity/psychomotor agitation
* decrease need for sleep
* racing thoughts or flight of ideas
* distractibility
* increased talkativeness
* risky behaviour
Bipolar II
- Single or recurrent hypomanic episodes & MDE
*No manic episode
- Less intense “highs”, but with definite depressive episodes
Cyclothymic disorder
- Many alternating periods of hypomanic &
depressive episodes over 2 years or more - Significant distress/impairment
- Less than 2mns between episodes
Bipolar mood disorders Stats
- Prevalence: 4.4%
- BD I: 1%
- Women = men
- BD II: 0.5%
- Women > men
- Cyclothymia: 0.4-1%
- Women = men
- Age of onset:
- BPD I: 14-21 yrs
- BPD II: 18-29
- Cyclothymia: adolescence-early adulthood
- Comorbidity: 65%
- Anxiety & substance use disorders
Bipolar mood disorders:
Factors
- Highly heritable
- 44-90%
- Considered one of the “most heritable”
- High heterogeneity
- High variation in clinical presentation, time courses, responses to treatment
- Psychosocial stressors likely important
- Up to ~50% experience early & severe physical & sexual abuse
Bipolar mood disorders:
Treatment
Medications
- Lithium
- Reduces dopamine (excitatory) and increases GABA (inhibitory)
- Effective, BUT many cognitive & physical side effects increase risk of noncompliance
Anticonvulsants
* Alone or with lithium
* Functionally mood stabilizers aimed at reducing mania
Interpersonal and social rhythm therapy (IPSRT)
* Psychosocial approach
* Focus on stabilizing circadian rhythm
* Disruptions common in ppl w/BPD
* Emphasizes importance of daily routine
* Based on the concept of “zeitgebers” (time givers)
* Cues in the environment that synchronize circadian rhythm
* E.g. sunlight, eating, sleeping, social relationships
Define Paranoid
A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent.
The personality disorders that were slated for deletion were ______ , ________ , _______ , and_________ (APA, 2012).
histrionic
schizoid
paranoid
dependent
*The rationale for the proposed deletions was in large part because they are said to have less empirical support than the diagnoses that were at the time being retained
Antisocial personality disorder, for instance, is generally considered to be the result of an interaction of genetic dispositions for low anxiousness, aggressiveness, impulsivity, and/or callousness, with a tough, urban environment, inconsistent parenting, poor parental role modeling, and/or peer support
Borderline personality disorder is generally considered to be the result of an interaction of a genetic disposition to negative affectivity interacting with a malevolent, abusive, and/or invalidating family environment
To the extent that one considers the DSM-5 personality disorders to be maladaptive variants of general personality structure, as described, for instance, within the Five-Factor Model, there would be a considerable body of research to support the validity for all of the personality disorders, including even the histrionic, schizoid, and paranoid. There is compelling multivariate behavior genetic support with respect to the precise structure of the Five-Factor Model (e.g., Yamagata et al., 2006), childhood antecedents (Caspi, Roberts, & Shiner, 2005), universality (Allik, 2005), temporal stability across the lifespan (Roberts & DelVecchio, 2000), ties with brain structure (DeYoung, Hirsh, Shane, Papademetris, Rajeevan, & Gray, 2010), and even molecular genetic support for neuroticism (Widiger, 2009).
Egosyntonic
most people are largely comfortable with their selves, with their characteristic manner of behaving, feeling, and relating to others
Who seeks treatment for Personality disorder?
People with personality disorders tend not to seek help because they are egosyntonic (comfortable with themselves and their behaviour)
*Exception:
Borderline Personality Disorder
& Avoidant Personality Disorder
Why?
High Neuroticism and experience life as one of pain and suffering
*Narcacists rarely seek help to reduce arogance
*Paranoid people rarely for suspiciousness
*Antisocial rarely for criminality, aggression, or irresponsibility
Neuroticism
Domain of general personality structure that concerns inherent feelings of emotional pain and suffering, including feelings of distress, anxiety, depression, self-consciousness, helplessness, and vulnerability.
Many of the people with a substance use disorder will have __________ personality traits
antisocial
Prevalence of personality disorders within clinical settings
The prevalence of personality disorders within clinical settings is estimated to be well above 50%. As many as 60% of inpatients within some clinical settings are diagnosed with borderline personality disorder. Antisocial personality disorder may be diagnosed in as many as 50% of inmates within a correctional setting. It is estimated that 10% to 15% of the general population meets criteria for at least one of the 10 DSM-IV-TR personality disorders
People with personality disorders and responsiveness to therapy & treatment
Antisocial persons will tend to be irresponsible and negligent
Borderline persons can form intensely manipulative attachments to their therapists
Paranoid patients will be unduly suspicious and accusatory; narcissistic patients can be dismissive and denigrating
Dependent patients can become overly attached to and feel helpless without their therapists.
Why are personality disorders so hard to treat?
Because they involve well-established behaviors that can be integral to a client’s self-image,
*moderate adjustments in personality functioning can represent quite significant and meaningful change to patients
Treatment of Borderline Personality Disorder
Dialectical behavior therapy
Cognitive-behavior therapy that draws on principles from Zen Buddhism, dialectical philosophy, and behavioral science.
Four components
- individual therapy
- group skills training
- telephone coaching
- A therapist consultation team
typically last a full year
expensive form of treatment
Research has indicated that its benefits far outweighs its costs, both financially and socially
ALSO
mentalization therapy
Why are there no manuals in other personality disorders other than Borderline?
Unclear why specific and explicit treatment manuals have not been developed for the other personality disorders. This may reflect a regrettable assumption that personality disorders are unresponsive to treatment. It may also reflect the complexity of their treatment.
SO MANY OVERLAPPING SYMPTOMS that can be diognosed with different things
Not much effort into making treatment because people tend to not seek treatment for their personality disorder
______personality disorder combines the Five Factor traits of neuroticism and maladaptive agreeableness.
Dependant
Marcus is dishonest, and does not often care about the hurt or pain he causes others. Marcus may suffer from ______personality disorder.
Antisocial
nucleus accumbens
A structure in the brain associated with liking
Why are personality disorders traditionally so difficult to treat?
a. Personality disorders reflect a “different” kind of personality rather than one that is pathological, and thus treatment is not needed..
b. Insurance companies do not consider these conditions serious, and thus refuse to pay for the needed therapy..
c. There is no research into what treatments may be effective to help such clients..
d. Many people with such conditions end up in prison, where treatment is not offered..
e. The disorders involve well-established behaviors that are integral to a person’s self-image.
e. The disorders involve well-established behaviors that are integral to a person’s self-image.
For which personality disorder has a manualized and empirically validated treatment protocol been developed?
borderline
______best describes the expert opinion of how personality disorders arise.
a. “They arise when a disorder like depression lasts too long”.
b. “They are genetic in origin”.
c. “Nothing is known about their origins”.
d. “They likely involve genetic and environmental factors”.
e. “They arise due to abuse, harsh parenting, and similar environmental factors”
d. “They likely involve genetic and environmental factors”.
Learning Objectives:
Learn about Cleckley’s classic account of psychopathy, presented in his book The Mask of Sanity, along with other historic conceptions.
Compare and contrast differing inventories currently in use for assessing psychopathy in differing samples (e.g., adults and younger individuals, within clinical-forensic and community settings).
Become familiar with the Triarchic model of psychopathy and its constituent constructs of boldness, meanness, and disinhibition.
Learn about alternative theories regarding the causal origins of psychopathy.
Consider how longstanding matters of debate regarding the nature, definition, and origins of psychopathy can be addressed from the perspective of the Triarchic model.
high-profile Psychopath criminals
Charles Manson
Jeffrey Dahmer
Bernie Madoff.
Psychopathy
Synonymous with psychopathic personality, the term used by Cleckley (1941/1976), and adapted from the term psychopathic introduced by German psychiatrist Julius Koch (1888) to designate mental disorders presumed to be heritable.
French physician Philippe Pinel
1806/1962
documented cases of what he called manie sans delire (“insanity without delirium”), in which dramatic episodes of recklessness and aggression occurred in individuals not suffering from obvious clouding of the mind.
German psychiatrist Julius Koch (1888)
introduced the disease-oriented term psychopathic to convey the idea that conditions of this type had a strong constitutional-heritable basis.
American psychiatrist Hervey Cleckley (1941/1976)
book - The Mask of Sanity
described psychopathy as a deep-rooted emotional pathology concealed by an outward appearance of good mental health.
How do psychopathic individuals present?
Present as confident, sociable, and well adjusted.
However, their underlying disorder reveals itself over time through their actions and attitudes.
Cleckley 16 diagnostic criteria for a psychopathic individual using:
indicators of apparent psychological stability
&
symptoms of behavioral deviancy
Note: Cleckley does not include cruel, violent, or dangerous like many others during her time
Cleckley also touches on “successful psychopaths”
- superficial charm
- absence of delusions
- absence of “nervousness”
- unreliability
- untruthfulness
- lack of remorse and shame
- antisocial behavior
- poor judgement and failure to learn by experience
- pathological egocentricity
- poverty in affective reactions
- loss of insight
- unresponsiveness in interpersonal relations
- fantastic and uninviting behavior
- rare suicidal behavior
- impersonal sex life
- failure to follow any life plan.
*Cleckley’s conception served as a referent for the diagnosis of psychopathy in the first two editions of the official American psychiatric nosology, the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Hervey Cleckley
Man who devised the original tests for psychopathy, asserted that some psychopaths may appear as well-adjusted, successful people who maintain respectable careers in fields like business and medicine.
Anti-social Personality Disorder
*Replaced the Cleckley-oriented conception of psychopathy
Counterpart diagnosis to psychopathy included in the third through fifth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM; APA, 2000). Defined by specific symptoms of behavioral deviancy in childhood (e.g., fighting, lying, stealing, truancy) continuing into adulthood (manifested as repeated rule-breaking, impulsiveness, irresponsibility, aggressiveness, etc.).
*Concerns with this new conception were expressed by psychopathy experts, who noted that ASPD provided limited coverage of interpersonal-affective symptoms considered essential to psychopathy (e.g., charm, deceitfulness, selfishness, shallow affect)
Assessment for Psychopathic individuals
rating instruments and self-report scales
Most widely used Instrument: PCL-R
Psychopathy Checklist-Revised
- comprises 20 items rated on the basis of interview and file-record information
- includes interpersonal-affective deficits and behavioral deviance from Ceckley
- still limited, indirect coverage of positive adjustment features
The manual for the PCL-R recommends the use of a cutoff score of 30 out of 40
High scores = impulsive and aggressive tendencies, low empathy, Machiavellianism, lack of social connectedness, and persistent violent offending.
Two important factors from Subdimensions in the Psychopathy Checklist-Revised (PCL-R)
- interpersonal-affective
relates to indices of narcissism, low empathy, and proactive aggression and to some extent (after controlling for its overlap with the antisocial factor) adaptive tendencies such as high social assertiveness and low fear, distress, and depression
- antisocial deviance
associated mainly with maladaptive tendencies and behaviors, including impulsiveness, sensation seeking, alienation and mistrust, reactive aggression, early and persistent antisocial deviance, and substance-related problems.
Psychopathy in noncriminal adults
Individuals mostly found through self-report-based measures.
Two important factors from Psychopathic Personality Inventory - Revised
PPI - R
contains 154 items, organized into eight facet scales.
Two important factors
- Fearless Dominance (FD)
factor reflecting social potency, stress immunity, and fearlessness - Self-centered impulsivity (SCI)
factor reflecting egocentricity, exploitativeness, hostile rebelliousness, and lack of planning.
Scores on PPI-SCI, like Factor 2 of the PCL-R, are associated with multiple indicators of deviancy—including impulsivity and aggressiveness, child and adult antisocial behavior, substance abuse problems, heightened distress and dysphoria, and suicidal ideation.
Difference between factors from PCL-R and PPI
In PPI, factors are uncorrelated, and thus even more distinct in their external correlates.
Scores on PPI-FD are associated with indices of positive psychological adjustment (e.g., higher well-being; lower anxiety and depression) and measures of narcissism (low) empathy, and thrill/adventure seeking (Benning, Patrick, Blonigen, Hicks, & Iacono, 2005). Given this, PPI-FD has been interpreted as capturing a more adaptive expression of dispositional fearlessness (i.e., boldness; see below) than the interpersonal-affective factor of the PCL-R—which can be viewed as tapping a more pathologic (antagonistic or “mean”) expression of fearlessness.
Two important factors from Antisocial Process Screening Device (APSD)
includes 20 items completed by parents or teachers.
Measure for psychopathic tendencies in youth
*ages 6 through 13
- Callous-Unemotional (CU)
- reflecting emotional insensitivity and disregard for others - Impulsive/Conduct Problems (I/CP)
- reflecting impulsivity, behavioral deviancy, and inflated self-importance.
High in only I/CP
- low intelligence
- heightened emotional responsiveness to stressors
- higher aggression
High in both CU & I/CP
- average to above average intelligence
- low reported levels of anxiety and nervousness
- reduced reactivity to stressful events
- preference for activities entailing novelty and risk.
* learn less readily from punishment
* engage in high levels of premeditated as well as reactive aggression and exhibit more persistent violent behavior across time
Triarchic model
Patrick, Fowles, & Krueger
Model formulated to reconcile alternative historic conceptions of psychopathy and differing methods for assessing it. Conceives of psychopathy as encompassing three symptomatic components: boldness, involving social efficacy, emotional resiliency, and venturesomeness; meanness, entailing lack of empathy/emotional-sensitivity and exploitative behavior toward others; and disinhibition, entailing deficient behavioral restraint and lack of control over urges/emotional reactions.
- disinhibition
- tendencies toward impulsiveness, weak behavioral restraint, hostility and mistrust, and difficulties in regulating emotion. - boldness
- dominance, social assurance, emotional resiliency, and venturesomeness. - meanness
- deficient empathy, lack of affiliative capacity, contempt toward others, predatory exploitativeness, and empowerment through cruelty and destructiveness.
- According to the model, individuals high in disinhibitory tendencies would warrant a diagnosis of psychopathy if also high in boldness or meanness (or both), but individuals high on only one of these tendencies would not.
- Individuals with differing relative elevations on these three symptomatic components would account for contrasting variants (subtypes) of psychopathy as described in the literature
Triarchic Psychopathy Measure (TriPM)
contains 58 items comprising three subscales that correspond to the constructs of the model
inventory designed specifically to operationalize Triarchic model
TriPM Subscale - disinhibition
- I often act on immediate needs
(true) - I have good control over myself
(false) - I have had problems at work because I was irresponsible
(true)
TriPM Subscale - boldness
- I can get over things that traumatize others
(true) - I can convince people to do what I want
(true) - I stay away from physical danger as much as I can
(false)
TriPM Subscale - meanness
- How other people are important to me
(false) - I enjoy pushing people around sometimes
(true) - I’ve injured people before to see them in pain
(true)
Two theories on the cause of psychopathic individuals
*neuroimaging has demonstrated deficits in basic subcortical (amygdala) reactivity to interpersonal distress cues (e.g., fearful human faces) in high-psychopathic individuals
(1) theories emphasizing core deficits in emotional sensitivity or responsiveness
(2) theories positing basic impairments in cognitive-attentional processing
Debated issues regarding psychopathy
- is psychological/emotional stability a characteristic of psychopathy or not?
- is lack of anxiety central to psychopathy?
- Are violent/aggressive tendencies typical of psychopathic individuals and should this be included in the definition of the disorder?
- Does criminal or antisocial behaviour more broadly represent a defining feature of psychopathy or a secondary manifestation?
- Do differing subtypes of psychopathy exist?
- Does psychopathy differ in men and women?
- Do “successful” psychopaths exist?
(how does their behaviour contribute to this?)
Some aspects of the psychopathic personality could be beneficial in certain professions requiring leadership and courage
*higher estimated levels of PPI-FD (boldness) predicted higher ratings of presidential performance, persuasiveness, leadership, and crisis management ability, whereas higher estimated levels of SCI predicted adverse outcomes such as documented abuses of power and impeachment proceedings. Further research on outcomes associated with high levels of boldness and/or meanness in the absence of high disinhibition should yield valuable new insights into dispositional factors underlying psychopathy and alternative ways psychopathic tendencies can be expressed.
The dark triad
- Narcissism
- Psychopathy
- Machiavellianism
In the Third Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), psychopathy was replaced with ______.
Antisocial Disorder
How does the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classify childhood psychopathology?
As a conduct disorder
Criminal psychopathology has recently been characterized into two variants: primary (bold-disinhibited) and secondary (disinhibited-mean), based on ______.
anxiety levels
Learning Objectives:
Become familiar with the most widely practiced approaches to psychotherapy.
For each therapeutic approach, consider: history, goals, key techniques, and empirical support.
Consider the impact of emerging treatment strategies in mental health.
Today, nearly_____ of all Americans will experience mental illness at some point in their lives, and mental health problems affect more than _______ of the population in any given year
half
a quarter
Cognitive Behavioral Therapy (CBT)
most effective approach in the schools of thought of therapy
involves work with a therapist as well as homework assignments between sessions. It has proven to be very effective for virtually all psychiatric illnesses.
Psychoanalysis and Psychodynamic Therapy
psychoanalysis - earliest therapy
*popularized by Sigmund Freud
- mental health problems form due to unconscious conflicts and desires that must be identified and addressed accordingly
- often explore childhood experiences
- meet longterm for many years
Freud - mental health problems stem from our sexual urges
Freud later said conflict between Id, Ego, Superego
Freud’s structural model
Id
- pleasure-driven unconscious urges (e.g., our animalistic desires for sex and aggression)
Superego
- the semi-conscious part of the mind where morals and societal judgment are internalized (e.g., the part of you that automatically knows how society expects you to behave)
Ego
- also partly conscious
- mediates between the id and superego. Freud believed that bringing unconscious struggles like these (where the id demands one thing and the superego another) into conscious awareness would relieve the stress of the conflict
psychoanalytic therapy
&
psychodynamic therapy
Psychoanalytic therapy
Sigmund Freud’s therapeutic approach focusing on resolving unconscious conflicts
*Goal is to balance Id and Superego desires
Psychodynamic therapy
Treatment applying psychoanalytic principles in a briefer, more individualized format.
*Same basic tenets as psychoanalysis
*More focus on social and interpersonal context
*focuses more on relieving psychological distress than on changing the person.
Free association
In psychodynamic therapy, a process in which the patient reports all thoughts that come to mind without censorship, and these thoughts are interpreted by the therapist.
*Also often look into childhood experiences
*When difficult to explore deep memories, we also explore dreams with manifest and latent content
Act of transference during psychodynamic therapy
a patient begins to express unjustified anger toward the therapist during therapy
*the patient may be displacing feelings for people in their life (e.g., anger toward a parent) onto the therapist.
countertransference
the therapist has to be aware of their own thoughts and emotions so they do not displace their own emotions onto the patient
What is the key to psychoanalytic theory?
The key to psychoanalytic theory is to have patients uncover the buried, conflicting content of their mind, and therapists use various tactics—such as seating patients to face away from them—to promote a freer self-disclosure.
As a therapist spends more time with a patient, the therapist can come to view their relationship with the patient as another reflection of the patient’s mind.
Advantages Disadvantages of Psychoanalytic Therapy
Advantage
- Psychoanalytic theory was history’s first attempt at formal treatment of mental illness, setting the stage for the more modern approaches used today.
Disadvantages
- # of therapists decreasing worldwide
- Not appropriate for all patients; those with severe psychopathology or intellectual disabilities
- Expensive because treatment can last years
- lack of empirical support for effectiveness
- limited research that has been done states Psychoanalytic Therapy does not lead to better mental health outcomes
humanistic or person-centered therapy (PCT)
Developed by Carl Rogers
*believed that all people have the potential to change and improve, and that the role of therapists is to foster self-understanding in an environment where adaptive change is most likely to occur
The quality of the relationship between therapist and patient is of great importance in person-centered therapy
* patient must engage in a genuine, egalitarian relationship
- nonjudgmental and empathetic
Belief is that mental health problems result from an inconsistency between patients’ behavior and their true personal identity.
- based on the idea that humans have an inherent drive to realize and express their own capabilities and creativity.
Goal:
Create conditions under which patients can discover their self-worth, feel comfortable exploring their own identity, and alter their behavior to better reflect this identity.
* patient should experience both a vulnerability to anxiety, which motivates the desire to change, and an appreciation for the therapist’s support.
Techniques in Person-Centered Therapy
Largely unstructured conversation between the therapist and the patient.
Rogers’s original name for PCT was non-directive therapy, and this notion is reflected in the flexibility found in PCT. Therapists do not try to change patients’ thoughts or behaviors directly. Rather, their role is to provide the therapeutic relationship as a platform for personal growth.
In these kinds of sessions, the therapist tends only to ask questions and doesn’t provide any judgment or interpretation of what the patient says. Instead, the therapist is present to provide a safe and encouraging environment for the person to explore these issues for themself.
unconditional positive regard in Person-Centered Therapy
In person-centered therapy, an attitude of warmth, empathy and acceptance adopted by the therapist in order to foster feelings of inherent worth in the patient.
the therapist is never to condemn or criticize the patient for what s/he has done or thought
This creates an environment free of approval or disapproval
Advantages and Disadvantages of Person-Centered Therapy
benefits
- highly acceptable paitents
- supportive, flexible environmentals very rewarding
- clients also tend to respond well to being treated with nonjudgmental empathy outside of therapy
Disadvantages
- Mixed findings about effectiveness
- Unspecific treatment factors
- the therapy focuses on techniques that can be applied to anyone so none specific to patients individual needs (one size fits all)
Cognitive Behavioural Therapy (CBT)
A family of approaches with the goal of changing the thoughts and behaviors that influence psychopathology.
The premise of CBT is that thoughts, behaviors, and emotions interact and contribute to various mental disorders.
Present-focused therapy (i.e., focused on the “now” rather than causes from the past, such as childhood relationships) that uses behavioral goals to improve one’s mental illness. Often, these behavioral goals involve between-session homework assignments.
When the patient has their next therapy session, the patient and the therapist review the patient’s “homework” together. CBT is a relatively brief intervention of 12 to 16 weekly sessions, closely tailored to the nature of the psychopathology and treatment of the specific mental disorder.
Empirical data shows, CBT has proven to be highly efficacious for virtually all psychiatric illnesses
Pattern of thoughts, feelings, and behaviors addressed through cognitive-behavioral therapy.
CYCLE:
Thoughts create feelings
Feelings create behaviours
Behaviours reinforce thoughts
Dr. Aaron T. Beck & Albert Ellis
Automatic thoughts
& three belief systems, or schemas
Thoughts that occur spontaneously; often used to describe problematic thoughts that maintain mental disorders.
schema: A mental representation or set of beliefs about something.
- beliefs about the self
- beliefs about the world
- beliefs about the future
CBT is used to rewrite these schemas
If I don’t wash my hands constantly, I’ll get a disease
BECOMES
Washing my hands three times a day is sufficient to prevent a disease
rational-emotive-behavioral therapy (REBT) uses really similar concept encouraging patients to evaluate their own thoughts about situations
Techniques in CBT
Reappraisal, or cognitive restructuring
CBT is targets maladaptive behavior not just thoughts
exposure therapy
Reappraisal, or cognitive restructuring:
- The process of identifying, evaluating, and changing maladaptive thoughts in psychotherapy.
Exposure therapy:
- A form of intervention in which the patient engages with a problematic (usually feared) situation without avoidance or escape.
- extinction learning - patient “unlearns” the irrational fear
Advantages and Disadvantages of CBT
advantages:
- brief
- cost-effective for average customer
- intuitive and logical for patients
- adapted to suit needs of different populations
- empirical support for its effectiveness
- equally or more effective than other forms of treatment, including medication and other therapy
disadvantages
- involve significant effort on the patient’s part
- homework
Pioneers of CBT
Idea that a person’s behavioral and emotional responses are causally influenced by one’s thinking.
- Greek philosopher Epictetus is quoted as saying, “men are not moved by things, but by the view they take of them.”
- how one percieves an event creates more of a response than the actual event itself
Beck: automatic thoughts
Ellis: self-statements
Ellis’s ABC model and CBT (cognitive behaviour therapy)
A - antecedent event
B - belief
C - consequence
During CBT, the person is encouraged to carefully observe the sequence of events and the response to them, and then explore the validity of the underlying beliefs through behavioral experiments and reasoning, much like a detective or scientist.
mindfulness-based therapy (MBT)
advantages and disadvantages
A form of psychotherapy grounded in mindfulness theory and practice, often involving meditation, yoga, body scan, and other features of mindfulness exercises.
*level of accessibility to patients highly important
Increasing in popularity:
- mindfulness-based stress reduction (MBSR)
- mindfulness-based cognitive therapy (MBCT)
Advantages
- acceptability and accessibility to patients
- yoga and meditation already popular
*people have more of an interest in related psychological therapies
- evidence for helping mood and anxiety disorders
Disadvantages
- Efficacy of MBT has not reached a consensus between researchers
-
Mindfulness-based stress reduction (MBSR)
Use of
- meditation
- yoga
- attention to physical experiences
Goal:
- reduce stress
- allow for better objective evaluation of thoughts
Mindfulness-based cognitive therapy (MBCT)
(meta)
- less focus on general stress reduction
- more focus on one’s thoughts and their associated emotions
*helps prevent relapses in depression
- encourages patients to evaluate their thoughts objectively, without judgment
Help address:
- depression
- anxiety
- chronic pain
- coronary artery disease
- fibromyalgia
Mindfulness-based cognitive therapy (MBCT)
VS
Cognitive Behaviour Therapy (CBT)
CBT
Focus: changing negative or maladaptive thought
- treat depression
MBCT
Focus: use mindfulness and cognitive therapy to be more aware of thoughts
- avoiding relapse in depression
Dialectical behavior therapy (DBT)
(can be quick fix)
A treatment often used for borderline personality disorder that incorporates both cognitive-behavioral and mindfulness elements.
*often used to treat borderline personality disorder
*focus on skills training
ex. distress tolerance - ways to cope with maladaptive thoughts and emotions in the moment.
Dialectical behavior therapy (DBT)
vs.
Cognitive Behaviour Therapy (CBT)
DBT employs techniques that address the symptoms of the problem (e.g., cutting oneself)
CBT addresses the problem itself (e.g., understanding the psychological motivation to cut oneself)
*CBT does not teach skills training ‘quick fixes’ because of the concern that the skills—even though they may help in the short-term—may be harmful in the long-term, by maintaining maladaptive thoughts and behaviors.
Dialectical Worldview
A perspective in DBT that emphasizes the joint importance of change and acceptance.
not black and white
*in the grey
*good and bad
DBT tries to help patients be less judgmental of their thoughts using mindfulness-based therapy and encourages change through therapeutic progress, using cognitive-behavioural techniques as well as mindfulness exercises.
acceptance and commitment therapy (ACT)
A therapeutic approach designed to foster nonjudgmental observation of one’s own mental processes.
*In this treatment, patients are taught to observe their thoughts from a detached perspective
ACT encourages patients not to attempt to change or avoid thoughts and emotions they observe in themselves
Goal:
recognize which thoughts are beneficial and which are harmful
internet-and mobile-delivered therapies
make psychological treatments more available and accessable
ex. smartphones, lap tops, computers
cognitive bias modification
Using exercises (e.g., computer games) to change problematic thinking habits.
CBT-enhancing pharmaceutical agents
drugs used to improve the effects of therapeutic interventions (we know this through animal testing)
*certain drugs influence the biological processes known to be involved in learning
- if people take these drugs while going through psychotherapy, they are better able to “learn” the techniques for improvement.
Pharmacological Treatments for mental disorders
Psychiatric drugs = public use by general medical practitioners
*frequently used to treat mental disorders, including schizophrenia, bipolar disorder, depression, and anxiety disorders.
*further research needed to prove the efficacy of Psychiatric drugs
Psychotherapy = qualified psychologist
comorbidity
Describes a state of having more than one psychological or physical disorder at a given time
Integrative or eclectic psychotherapy
(integrative psychotherapy)
this term refers to approaches combining multiple orientations (e.g., CBT with psychoanalytic elements).
EX. a therapist may employ distress tolerance skills from DBT (to resolve short-term problems), cognitive reappraisal from CBT (to address long-standing issues), and mindfulness-based meditation from MBCT (to reduce overall stress). And, in fact, between 13% and 42% of therapists have identified their own approaches as integrative or eclectic
According to research evidence, ______therapy is the most effective contemporary approach to providing psychotherapy services to people in need.
cognitive behavioral
During a session, Dr. Davidson asks his client, Jorge, to lay back on the sofa and close his eyes. “Just say anything that comes into your mind, and don’t worry at all about what it means,” he instructs Jorge. This technique is called:
free association
Why has it been difficult for research to establish a solid answer to the question of whether person-centered therapy (PCT) is, overall, an effective approach to treating clients?
PCT is based on nonspecific treatment factors, without considering specific treatment factors to directly target a given mental problem.
The foundational premise of cognitive behavioral therapy (CBT) is that:
Thoughts, actions, and emotions interact and contribute to psychopathology.
Cognitive ______refers to the process of identifying, evaluating, and changing maladaptive thoughts in psychotherapy.
restructuring
Which therapeutic strategy, that emphasizes simultaneous acceptance and change, is often used for the treatment of borderline personality disorder?
Dialectical behavior therapy
