Week 9 Personality Disorders

Question 1

What is personality?

Answer 1

Global term describing how we cope
with and adapt and respond to a range
of life experiences

Inwardly experienced, outwardly projected

Main features tend to be relatively enduring
Most people evolve through experiences and learn more effective ways of behaving

Question 2

What are personality disorders?

Answer 2

Fixed, ingrained and unchanging way of dealing with life experience

Enduring patterns of behaviour that deviates
markedly from expectations within the culture

Associated with unusual ways of interpreting events, unpredictable mood swings or impulsive behaviour

Stable patterns of behaving can be traced
back to adolescence or early childhood

Long-standing, pervasive and inflexible

Rarely learn to adapt responses

Ability to learn new responses lacking

Introduce disruption and hardship into lives of others

Frequently cause emotional distress to themselves and those they interact with

Question 3

Cluster A: Odd or eccentric

Answer 3

Schizotypal:
* Acute discomfort in close relationships
* Cognitive or perceptual distortions
* Eccentricities of beh

Paranoid:
* Distrust
* Suspiciousness

Schizoid:
* Detachment from social relationships
* Restricted range of emotional
expression

Question 4

Cluster B: Dramatic, Emotional, or Erratic

Answer 4

Antisocial:
* Disregard for rights of others
* Violation of rights of others

Borderline:
* Instability of:
* Interpersonal relationships
* Self-image
* Affects
* Marked impulsivity

Histronic:
* Excessive emotionality
* Attention seeking

Narcissistic:
* Grandiosity
* Need for admiration
* Lack of empathy

Question 5

Cluster C: Anxious or Fearful

Answer 5

Avoidant:
* Social inhibition
* Feelings of inadequacy
* Hypersensitivity to negative evaluation

Dependent:
* Submissive
* Clingy
* Excessive need to be taken care of

Obsessive-compulsive:
* Preoccupation with:
* Orderliness
* Perfectionism
* Control

Question 6

Borderline Personality Disorder: Aetiological Considerations

Answer 6

Diverse range of symptoms for a single
theory to encompass – quite often focus
on particular characteristics:
– Risk Factors
– Biological Explanations
* Genetics, neurotransmitters, neuroimaging
– Psychological Theories
* Object relations theory/Splitting
* Diathesis-Stress Theory

Question 7

Risk factors for BPD

Answer 7

Childhood physical, verbal and sexual abuse
– Herman, Perry & vander Kolk (989); Zanarini et al. (1997)

Childhood neglect or rejection
– Zanarini et al. (2000); Guttman (2002)

Inconsistent or loveless parenting
– Kernberg (1985)

Parental substance and alcohol abuse, promiscuity
– Graybar & Boutilir (2002)

Environmental instability and paternal
psychopathology, academic underachievement, low intelligence and artistic skills
– Helgeland & Torgersen (2004)

Question 8

Genetic Influence for BPD

Answer 8

• Modest evidence for genetic component
• Appears to run in families (Baron et al.,
  1985)

– Twin studies report concordance rates:
* 35% (MZ) and 7% (DZ) twins (Torgersen et al., 2000)

– Traits common in BPD have a strong inherited
component
* E.g., neuroticism, emotional dysregulation (Nigg & Goldsmith, 1994)

Question 9

Neurotransmitter Activity

Answer 9

Low levels of serotonin
(Norra et al., 2003)

Dysfunction in brain
dopamine activity
(Friedel, 2004)

Explain symptoms e.g., impulsivity/cognition
– Evidence remains circumstantial (Davey,
2008)

Question 10

Neuroimaging Techniques

Answer 10

Abnormalities in a
number of brain areas:
– Frontal lobe
– Hippocampus
– Amygdala (Juengling et al., 2003; Soloff et al.,
2003)

Cause or consequence ?
(Leib et al., 2004)

Question 11

Object Relations Theory

Answer 11

• People are motivated to respond to the world through perspectives learnt from important people in their developmental past

Experience: Neglect or abuse in infancy
->
Expectation: Similar behaviour from others
who remind them of the neglectful or abusive person from their past

These images of people and events turn into Objects in the subconscious

Objects carried into adulthood

Used by the subconscious to predict people’s behaviour in their social relationships and interactions

Question 12

Object Relations Theory cont.

Answer 12

Inadequate or abusive experiences lead
child to develop an insecure ego
– Lack of self-esteem
– Increase dependence
– Fear of separation and rejection
(Bartholomew, Kwong & Hart, 2001; Kernberg,
1985)

Question 13

Splitting

Answer 13

Weak ego -> Defence mechanism

Evaluations of people, events or things
- The division or polarisation of beliefs, actions, objects, or persons by focusing selectively on their positive or negative attributes

• Diffuses anxiety
• Reinforces sense of self
• Distorted picture of reality
• Restricted range of thoughts and emotions
• Impact on interpersonal relating

Question 14

Diathesis-Stress Theory (Linehan, M, 1987)

Answer 14

Parenting can amplify
vulnerabilities of some children
– Biological diathesis (possibly genetic) –
difficult in controlling emotions
– Invalidating family
environment

Question 15

BPD drug treatments

Answer 15

Clients with comorbid AN and DP
– Anxiolytic and antidepressant drugs

Antipsychotic drugs
– Can be effective in reducing symptoms of
Cluster A personality disorders

Atypical antipsychotic drugs
– Used to reduce impulsivity, hostility,
aggressiveness, irritability and rage outbursts
(Walker et al., 2003)

Question 16

Object Relations Psychotherapy

Answer 16

The self as self developing and
existing within the context of
relationship

Therapist interacts with client, supporting in the resolution of pathological constructs through the active experience of the
real relationship between the therapist and the client
–Opportunity to re-experience relational issues as loss, intimacy, control, dependency, autonomy, trust etc.

Question 17

Object Relations Psychotherapy cont.

Answer 17

Though interpretation and confrontation may be involved, the primary objective is the
working through original pathological components of the client’s emotional world
Therapist offers a safe, caring
relational environment
–Is aware of the client’s unconscious attempts to involve the therapist in the same patterns of relationship as those that constitute the client’s
distorted dynamic interactions with
significant others

Found to be effective in changing internal representations of relationships with impt
others (Clarkin et al., 2004; Levy et al., 2006)

Question 18

Dialectical Behaviour Therapy (Marsha Linehan, 1987)

Answer 18

Client-centered empathy
Behavioural problem-solving

Therapist is fully accepting of client
– A dialectical of the goal of bringing about change

Over time, goal is to move client towards
change while maintaining empathic validation
of them

Question 19

Marsha Linehan (1987)

Answer 19

Behavioural aspect aids in acquiring
– More effective and socially acceptable ways of handling daily living
– Emotion regulation
– Interpersonal effectiveness
– Core mindfulness
– Distress tolerance

Compared to treatment as usual, effective in decreasing self-harm, suicide attempts,
treatment dropout, inpatient hospital days
At 1 year following treatment (Linehan et al., 1991; Linehan, Heard & Armstrong, 1993)

Question 20

Amanda: conceptualisation and treatment

Answer 20

Lack of direction or goals
->General Equivalency Diploma Examination

Feelings of depression
Mood diary 3 x a day incl. thoughts
– Tendency to make negative predictions about events leading to sadness and
depression

Anxiety-provoking situations
– Worst, best and most likely scenario, compare with actual outcome

Helped control negative thoughts and replace them with more adaptive and realistic ways of thinking based on experience

Question 21

Cognitive Therapy Example

Answer 21

Amanda held a number of part-time jobs, typically lasted 1-2 months before she quit or was sacked for not turning up to work

‘my supervisors don’t like me and are looking for an excuse to sack me’
->
a small negative interaction at work
->
‘I’m about to be fired’
->
stopped showing up for work
->
self-fulfilling prophecy

Question 22

Cognitive Therapy Example cont.

Answer 22

Amanda obtained a part-time job in a supermarket

mentally rehearse most likely scenario daily -kept job for 18 months:

Most Likely:
I’m new at work, but everyone else was new at one time, too. Some people may like me, and some may not, but that’s the way it is with everyone. Some conflict with other people is inevitable. I can still do my job even if everyone does not like me. One bad day at work does not mean I have to quit.

Question 23

Amanda: Conceptualisation and treatment 2

Answer 23

3. poor impulse control
4. Excessive and poorly controlled anger
   *‘Time-delay’ procedures

Impulse
(to use drugs, self-harm, express anger)

Telephone therapist/friend
Go to A&E if not control impulse on own

During waiting period intensity of emotion declines

Question 24

Amanda: Outcome

Answer 24

Noticeable progress in first few months following therapy

None of the therapeutic interventions had a
lasting impact

Amanda had a poor employment history
– Little evidence she could support herself in the foreseeable future

Concern that she might continue to deteriorate
and end up in hospital on a long-term basis

Question 25

Section III and Personality Disorder

Answer 25

Impairments in personality FUNCTIONING

Impairments in pathological personality TRAITS

Six specific personality disorder types
– Antisocial
– Avoidant
– Borderline
– Narcissistic
– Obsessive-compulsive
– Schizotypal