XI - Personality Disorders

Question 1

Definition of Personality Disorder

Answer 1

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

Question 2

Clinical feature of personality disorder

Answer 2

Pervasive, clinically significant distress, manifest in at least two areas: cognition, affectivity, interpersonal functioning, or impulse control. Often involves problems with one’s identity/sense of self, may cause as much difficulty in own lives as those of others, challenges with therapist/patient dyad

Question 3

“Character disorders”

Answer 3

Personality disorders formerly known as “character disorders” but too much stigma involved

Question 4

Personality disorders - coding in DSM-IV

Answer 4

Were formerly coded in Axis II but now no axes in DSM-V

Question 5

Problems with estimating prevalence

Answer 5

Generally underestimated as it takes a long time for evaluation, and they are often not coded because insurance companies consider them untreatable. There is also stigma to having personality disorders.

Question 6

Difficulties with diagnosis

Answer 6

Criteria not as sharply defined as for other disorders, diagnostic categories not mutually exclusive, personality is dimensional in nature so a matter of degree - may represent extreme levels of normal traits.

Question 7

Five-Factor Model (FFM) of personality

Answer 7

Openness to experience, conscientiousness, extraversion, agreeableness, neuroticism. PDs may involve high levels of these normal traits. Ex: histrionic - high extraversion and neuroticism, dependent - high agreeableness and neuroticism

Question 8

Difficulties in understanding etiology of personality disorders

Answer 8

Lack of research, comorbidity, new area of study, most studies to date are retrospective

Question 9

Clusters of Personality Disorders

Answer 9

Cluster A - Odd/Eccentric
Cluster B - Dramatic/Emotional/Erratic
Cluster C - Anxious/Fearful

Question 10

Cluster A Disorders

Answer 10

Odd/Eccentric Disorders.

• Paranoid
• Schizoid
• Schizotypal

Question 11

Cluster B Disorders

Answer 11

Dramatic/Emotional/Erratic Disorders

• Histrionic
• Narcissistic
• Antisocial
• Borderline

Question 12

Cluster C Disorders

Answer 12

Anxious/Fearful Disorders.

• Avoidant
• Dependent
• Obsessive Compulsive

Question 13

Paranoid Personality Disorder

Answer 13

Cluster A. Core Feature: Suspiciousness and distrust. Suspects others are exploiting, harming, deceiving him/her without sufficient basis. Preoccupied with doubts about trustworthiness. Reluctant to confide. Reads demeaning content into benign remarks or events. Tends to see self as blameless. On guard for perceived attacks, reacts with counterattacks. Grudges, unforgiving, sometimes violent. May have transient psychotic symptoms under stress.

Question 14

Schizoid Personality Disorder

Answer 14

Cluster A. Core feature: Detachment. Inability and lack of desire for attachments. Doesn’t desire or enjoy relationships. Likes solitary activities, but takes pleasure in few things. Lacks close relationships; may be viewed as cold, distant, introverted. Appears indifferent to praise/criticism - non-reactive and apathetic. FFM: introversion, low openness.

Question 15

Schizotypal Personality Disorder

Answer 15

Cluster A. Core feature: Eccentricity in cognition, perception, behavior; pervasive interpersonal deficits. Introverted, peculiar thought patterns, cognitive/perceptual distortions, oddities of perception and speech that interfere with interpersonal relationships, may have transient psychotic symptoms, personalized and superstitious thinking, may believe they have magic powers.

Causal factors: some biological associations with schizophrenia.
Possible subtypes: one genetically linked to schizophrenia and one linked to abuse and early trauma

Question 16

Histrionic Personality Disorder

Answer 16

Cluster B. Core Feature: Emotionality and Attention-Seeking. Concern with attractiveness, attention. Very emotional, self-dramatizing. Angry if attention not given. May be inappropriately provocative. Considered self centered, vain, approval-seeking. Easily influenced by others. Considers relationships to be more intimate than they really are.

Question 17

Narcissistic Personality Disorder

Answer 17

Cluster B. Core Features: Grandiosity, Need for Admiration, Lack of Empathy. Preoccupation with receiving admiration, self-promoting, fantasies of unlimited success/power/beauty/love. Believes that he/she is unique and understood only by high-status people. Entitled, lack of empathy, retaliatory if not validated.

Subtypes: Grandiose (aggression and dominance) and Vulnerable (fragile, sensitive to rejection and criticism, low self-esteem)

Question 18

Antisocial Personality Disorder

Answer 18

Cluster B. Core Feature: Disregard for and violation of rights of others. Failure to conform to social norms and laws, deceitfulness, impulsivity, disregard for safety of self and others, irresponsibility, lack of morals, manipulation, lack of empathy, superficial charm. Must be at least 18 with a history of Conduct Disorder before age of 15.

Question 19

Borderline Personality Disorder

Answer 19

Cluster B. Core Feature: Affective instability. Unstable self-image, relationships. Impulsivity and self-injury. 75% experience cognitive symptoms like transient psychotic episodes. Lots of stigma.

Question 20

Borderline Personality Disorder DSM-V Diagnostic Criteria

Answer 20

Pervasive pattern of instability regarding relationships, self-image, affect; impulsivity beginning by early adulthood. 5+ of following:

(1) Frantic efforts to avoid real or imagined abandonment
(2) Unstable and intense interpersonal relationships characterized by alternating between idealization and devaluation
(3) Identity disturbance/unstable self-image
(4) Impulsivity in at least two areas that are self-damaging
(5) Recurrent suicidal behavior or self-mutilation, or threats
(6) Affective instability
(7) Chronic feelings of emptiness
(8) Inappropriate, intense anger or difficulty controlling anger
(9) Transient stress-related paranoia or dissociative symptoms

Question 21

History of BPD

Answer 21

Late 19th C - “Borderland” between sanity and insanity
Mid 20th - Middle ground between neurosis and psychosis
1950s - Previous assumptions questioned as some patients were rarely/never psychotic but also lacked stability of neurotic-level patients
1980 - DSM III coined BPD for first time

Now, it is the most frequently diagnosed and studied PD

Question 22

BPD and Psychodynamic Theory

Answer 22

All involve parenting issues
Stern - Theory that BPD secondary to narcissism that came from dysfunctional mother-child dyad (object relations theory)
Mahler - Fixation in phase of separation - need to separate from parent yet fear of abandonment
Kernberg - Theory of caregiver-child interactions that alternate between rejection and smothering. Result is insecure ego typified by all-good or all-bad

Question 23

Linehan’s’ Biosocial Theory

Answer 23

BPD results from interaction between biological and environmental factors. Invalidating environment: private experiences like emotional experiences are invalidated, punished, negated, responded erratically to, trivialized, or attributed to socially unacceptable personal characteristics such as over-reactivity, inability to see things realistically, lack of motivation or discipline, bad attitude.

Question 24

Invalidating environment

Answer 24

Environment where communication of private experience indiscriminately rejected. Punishment of emotional displays. Oversimplify ease of problem solving and meeting goals for an individual

Question 25

Multidimensional Diathesis-Stress Theory of BPD

Answer 25

Genetic vulnerabilities -> affective instability and impulsivity. This + trauma, parental problems, or loss/rejection -> emotional lability, chaotic relationships, impulsive behavior -> Borderline personality disorder

Question 26

Dialectical behavior therapy (DBT)

Answer 26

Unique kind of cognitive/behavioral therapy adapted specifically for BPD - supported by research.

Question 27

Avoidant Personality Disorder

Answer 27

Cluster C. Core Features: Social Inhibition, Inadequacy. Extreme insecurity in interactions and relationships. Feelings of ineptness, hypersensitivity to criticism, shyness. Deficits in ability to experience pleasure. Want interpersonal contact but avoid. Causal factor: behavioral inhibition

Question 28

Avoidant Personality Disorder vs. Schizoid Personality Disorder

Answer 28

Avoidant: want relationships. Schizoid: do not want relationships. Question: is being content without relationships an indicator of abnormality?

Question 29

Dependent Personality Disorder

Answer 29

Cluster C. Core Feature: Helplessness, Self-Doubt. Extreme need to be taken care of, difficulty separating, discomfort with being alone, subordination of needs to keep others involved with them, lack of anger, indecisiveness. Causal factor: high neuroticism and agreeableness

Question 30

Obsessive-Compulsive Personality Disorder

Answer 30

Cluster C. Core Feature: Preoccupation with control. Excessive concern with order, rules, trivial details. Overly conscientious, highly neurotic, inflexible, perfectionism. Lack of expressiveness, difficulties relaxing and having fun. No true obsessions or compulsions like OCD

Question 31

OCD vs Obsessive-Compulsive Personality Disorder

Answer 31

OCD has obsessions paired with compulsions to neutralize. Obsessive-Compulsive Personality Disorder does not have true obsessions or compulsive rituals.

Question 32

Treatment of Personality Disorders

Answer 32

Very challenging to treat. People may believe there is no need to change, and that their traits are not indicative of a disorder. In addition, client-therapist relationships may be particularly difficult to form.