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PSYC*3390 Ch 11.doc

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PSYC 3390
Mary Manson

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Tuesday, November 6, 2012 Chapter 11: Personality Disorders - a person’s broadly characteristic traits, coping styles, and ways of interacting in the social environment emerge during childhood and normally crystallize into established patterns by the end of adolescence or early adulthood - these patterns constitute the individual’s personality- the set of unique traits and be- haviours that characterize the individual - the five-factor model of personality traits include neuroticism, extroversion/introversion, openness to experience, agreeableness/antagonism, and conscientiousness Clinical Features of Personality Disorders - for most of us, our adult personality is attuned to the demands of society, in other words, we readily comply with most societal explanations Personality Disorder - certain traits that are so inflexible and maladaptive that these people are unable to perform adequately at least some of the varied roles expected of them by society - personality disorders were formerly known by psychodynamic theorists as characteris- tics disorders - criteria for diagnosing a personality disorders are that the person’s enduring pattern of behaviour must be pervasive and inflexible, as well as stable and of long duration - it must also cause wither clinically significant distress or impairment in functioning and be manifested in at least 2 of the following areas: cognition, affectivity, interpersonal functioning or impulse control - people with personality disorders often cause at least as much difficulty in the lives of others as in their own lives - other people tend to find the behaviour of individuals with personality disorders confus- ing, exasperating, unpredictable and to varying degrees, unacceptable - in milder cases, we find people who generally function adequately but who would be described by their relatives, friends or associates as troublesome, eccentric, or hard to get to know - personality disorders typically do not stem from debilitating reactions to stress in the recent past, as in posttraumatic stress disorder or many cases of major depression - these disorders stem largely from the gradual development of inflexible and distorted personality and behavioural patterns that result in persistently maladaptive ways of per- ceiving, thinking about, and relating to the world Tuesday, November 6, 2012 - in many cases, major stressful life event aery in life also help set the stage for develop- ment of these inflexible and distorted personality patterns - epidemiological studies on the prevalence of personality disorders in Canada are few - 9.1% of individuals were found to suffer from a personality disorder, earlier studies found 13% - 67% of people with a personality disorder were found to also suffer at least one anxiety disorder, mood disorder, impulse control disorder, or substance-use disorder Difficulties Doing Research on Personality Disorders - there are 2 main categories of difficulties Difficulties in Diagnosing Personality Disorders - more misdiagnoses probably occur here than in any other category of disorder - one problem is that diagnostic criteria for personality disorders are not as sharply de- fined as for most Axis 1 diagnostic categories - because the criteria for personality disorder are defined by inferred traits or consistent patterns of behaviour rather than by more objective behavioural standards, the clinician must exercise more judgment in making the diagnosis - semistructured interview and self-report inventories have improved diagnosis\because - because the agreement between the diagnoses made on the basis of different struc- tured interviews or self-report inventories is often rather low, there are still substantial problem with the reliability and validity of these diagnoses - a second problem is that the diagnostic categories are not mutually exclusive - people often show characteristics of more than one personality disorder - the Dimensional Assessment of Personality Pathology (DAPP) is a dimensional sys- tem of assessment for symptoms and traits involved in personality disorders - the five-factor model has been the most influential - it is necessary also to measure the six different facets or components of each of the 5 basic personality traits e.g. neuroticism is comprised of anxiety, angry-hostility, depres- sion, self-consciousness, impulsiveness, and vulnerability Difficulties is Studying the Causes of Personality Disorders - on major problem in studying the causes of personality disorders stems from the high level of commodity among them - another problem occurs because researchers have more confidence in prospective studies, in which groups of people are observed before a disorder appears and are fol- Tuesday, November 6, 2012 lowed over a period of time to see which individuals develop problems and what casual factors have been present - very little prospective research has yet been conducted with personality disorders - the majority of research is conducted on people who already have the disorders, some relies on retrospective recall of prior events, and some relies on observing current bio- logical, cognitive, emotional and interpersonal functioning - of possible biological factors, it has been suggested that infants’ temperament may predispose them to the development of particular personality traits and disorders - negative emotionality, sociability vs social inhibition or shyness and activity level are several of the most important dimensions - most temperament and personality traits have been found to be moderately heritable so it is not surprising that there is increasing evidence for genetic contributions to certain personality disorders - some progress is also being made in understanding the psychobiological substrate of at least some of the traits prominently involved in the personality disorders - psychodynamic theorists originally attributed great importance in the development of character disorders to an infant’s getting excessive vs insufficient gratification of his or her impulses in the first few years of life - learning-based habit patterns and maladaptive cognitive styles have received attention - many of these maladaptive habits and cognitive styles have been hypothesized to play important roles for certain disorders may originate in disturbed parent-child attachment relationships - parents psychopathology and ineffective parenting practices have also been implicated - emotional, physical, and sexual abuse may be important factors - social stressors, societal changes and cultural values have also been implicated as so- ciocultural causal factors Categories of Personality Disorders - grouped into 3 clusters: - Cluster A: people with these disorders often seem odd or eccentric, with unusual be- haviour ranging from distrust and suspiciousness to social detachment e.g. paranoid, schizoid, schizotypal - Cluster B: individuals with these disorders share a tendency to be dramatic, emotional and erratic e.g. histrionic, narcissistic, antisocial, and borderline personality disorder Tuesday, November 6, 2012 - Cluster C: in contrast to the other 2 clusters, anxiety and fearfulness are often part of these disorders e.g. avoidant, dependent, and obsessive-compulsive personality disor- ders - 2 additional personality disorders (depressive and passive-aggressive personality dis- order) are listed in a provisional category in the appendix Paranoid Personality Disorder - pervasive and suspicious distrust of others, leading to numerous interpersonal difficul- ties - tend to see themselves as blameless, instead blaming others for their on mistakes and failures, even to the point of ascribing evil motives to others - chronically “on guard” constantly expecting trickery and looking for clues to validate their expectations, while disregarding all evidence to the contrary - they are often preoccupied with doubts about the loyalty of friends and hence are re- luctant to confide in others - commonly bear grudges, refuse to forgive perceived insults and slights and are quick to react with anger - not usually psychotic, most are in clear contact with reality although may experience transient psychotic symptoms during periods of stress - share symptoms with paranoid schizophrenia Causal Factors - little is known about important causal factors - some have argued for partial genetic transmission that may link the disorder to schizophrenia - genetic transmission might occur through the heritability of high level of antagonism (low agreeableness) and neuroticism (anger-hostility are among the primary traits - psychosocial causal factors that are suspected to play a role include parental neglect or abuse and exposure to violent adults Schizoid Personality Disorders - unable to form social relationships and lack interest in doing so - typically do not have good friends, with the possible exception of a close relative - unable to express their feelings and are seen by others as cold and distant - often lack social skills and can be classified as loners or introverts with solitary inter- ests and occupations Tuesday, November 6, 2012 - tend not to take pleasure in many activities, including sexual activity and rarely marry - not very emotionally reactive, rarely experiencing strong positive or negative emotions, but rather show a generally apathetic mood - appear cold and aloof - high levels of introversion (low on warmth, gregariousness, and positive emotions), low on openness to feelings) Causal Factors - early theories considered it to be a likely precursor to the development of schizophre- nia, but this has been challenged - research has failed to establish a link between the 2 disorders or any hereditary basis for schizoid personality disorder - cognitive theories propose that individuals with schizoid personality disorder exhibit cool and aloof behaviour because of maladaptive underlying schemas that lead them to view themselves as self-sufficient loners and view others as intrusive Schizotypal Personality Disorders - excessively introverted and have pervasive social and interpersonal deficits - also have cognitive and perceptual distortions and eccentricities in their communica- tion and behaviour - although contact with reality is usually maintained, highly personalized and supersti- tious thinking is characteristic of people with schizotypal personality and under extreme stress they may experience transient psychotic symptoms - cognitive-perceptual problems include ideas of reference (the belief that conversations or gestures of others have special meaning or personal significance), odd speed, and paranoid beliefs - their oddities in thinking, talking and other behaviours are the most stable characteris- tics of this disorder and are similar to those often seen in schizophrenics - sometimes first diagnosed as exhibiting simple or latent schizophrenia Causal Factors - prevalence is about 3.3% but other estimates are lower - moderately heritable and as genetic and biological association with schizophrenia has been clearly documented - this disorder appears to be part of a spectrum of schizophrenia that often occurs in some of the first-degree of people with schizophrenia Tuesday, November 6, 2012 - teenagers who have schizotypal personality disorder have been shown to be at in- creased risk for developing schizophrenia and schizophrenia-spectrum disorders in adulthood Histrionic Personality Disorder - excessive attention-seeking behaviour and emotionality are key characteristics - tend to feel unappreciated if they are not the centre of attention and their lively, dramat- ic and excessively extroverted styles often ensure that they can charm others into at- tending to them - these qualities do not lead to stable and satisfying relationships because others tire of providing this level of attention - in seeking attention, their appearance and behaviour are often quite theatrical and emotional as well as sexually provocative and seductive - they my attempt to control their partner through seductive behaviour and emotional manipulation but also show a great deal of dependence - usually considered self-centred, vain, excessively concerned about the approval of oth- ers, who see them as overly reactive, shallow and insincere - previous estimates of the prevalence of this disorder in the general population have been in the range of 2-3% - some studies suggest that this disorder occurs more often in women than men but possible reasons have been controversial - one suggests that the number of traits that occur more often in females are involved in the diagnostic criteria, many of the criteria for histrionic personality disorder involve mal- adaptive variants of female-related traits Causal Factors - there is some evidence for a genetic link with antisocial personality disorder, the idea being that there may be some common underlying predisposition that is more likely to be manifested in women as histrionic personality disorder and in men as antisocial per- sonality disorder - histrionic personality disorder may be characterized as involving extreme versions of 2 common normal personality traits, neuroticism and extroversion, 2 traits known to have a partial genetic bias - very high levels of extroversion include high levels of gregariousness, excitement seek- ing, and positive emotions - high levels of neuroticism particularly involve the depression and self-consciousness facets, they are also high to openness to fantasies Tuesday, November 6, 2012 - cognitive theorists emphasize the importance of maladaptive schemas revolving around the need for attention to validate self-worth Narcissistic Personality Disorder - show an exaggerated sense of self-importance, a preoccupation with being admired, and a lack of empathy for the feelings of others - grandiosity is the most important and widely used diagnostic criterion - grandiosity is manifested by a strong tendency to overestimate their abilities and ac- complishments, while underestimating the abilities and accomplishments of others - their sense of entitlement is frequently a source of astonishment to others, although they themselves seem to regard their lavish expectations as merely what they deserve - they behave in stereotypical ways to gain the acclaim and recognition they crave - they often think they can be understood only by other high-status people or should as- sociate only with such people - their sense of entitlement is also associated with an unwillingness to forgive others for perceived slights, and they easily take offence - most researchers believe that people with narcissistic personality disorder have a very fragile and unstable sense of self-esteem underneath all their grandiosity - their great need for admiration may help regulate and protect their fragile self-worth - they are unwilling or unable to take the perspective of others - if they do not receive the validation or assistance they desire, they are inclined to be hypercritical and retaliatory - characterized by low-agreeableness/high antagonism (low modesty, arrogance, grandiosity, and superiority), low altruism, and tough mindedness (lack of empathy) - show high levels of fantasy proneness (openness to experience) and high levels of anger-hostility and self-consciousness - histrionic seeks attention, narcissistic seeks admiration - narcissistic personality disorder may be more frequently observed in men - it is relatively rare and is estimated to occur in about 1% of the population Causal Factors - children go through a phase of primitive grandiosity during which they think that all events and needs revolve around them, for normal development beyond this phase to occur, parents must do some mirroring of the child’s grandiosity - this helps children develop normal levels of self-confidence and a sense of self-worth to sustain them later in life, when the realities of life expose them to blows to their grandiosity Tuesday, November 6, 2012 - narcissistic personality disorder is likely to develop if parents are neglectful, devaluing, or unempathetic to the child, this individual will be perpetually searching for affirmation of an idealized and grandiose sense of self - another stance is that the disorder comes from unrealistic parental overvaluation, it is proposed that “these parents pamper and indulge their youngsters in ways that teach them that their every wish is a command, that they can receive without giving in return and that they deserve prominence without even minimal effort” Antisocial Personality Disorder (ASPD) - continually violate and show disregard for the rights of others through deceitful, ag- gressive, or antisocial behaviour, typically without remorse or loyalty to anyone - tend to be impulsive, irritable, and aggressive and show a pattern of generally irre- sponsible behaviour - this pattern of behaviour must have been occurring since the age of 15, and before the age of 15, the person much have had symptoms of conduct disorder, a similar disorder occurring in children and young adolescents who show persistent patterns of aggression toward people or animals, destruction of property, deceitfulness or theft Borderline Personality Disorder (BPD) - show a pattern of behaviour characterized by impulsivity and instability in interpersonal relationships, self-image and moods - the term borderline personality has a long and rather confusing history - originally it was most often used to refer to a condition that was thought to occupy the “border” between neurotic and psychotic disorders - later borderline became identified with schizotypal personality disorder which is biolog- ically related to schizophrenia - the current diagnosis of BPD is no longer considered to be biologically related to schizophrenia - people with BPD have a highly unstable self-image or sense of self, as well as highly unstable interpersonal relationships - they commonly have a history of intense but stormy relationships, typically involving over idealizations of friends or lovers that alter end in bitter disillusionment and disap- pointment - may make desperate efforts to avoid real or imagined abandonment, perhaps because their fears of abandonment are so intense - their mood or affect is highly unstable and characterized by drastic mood shifts Tuesday, November 6, 2012 - symptoms of affective instability and intense anger are the 2 most stable features - extreme affective instability combined with their high levels of impulsivity often lead to erratic self-destructive behaviours such as gambling sprees or reckless driving - suicide attempts, often flagrantly manipulative but not always - self-mutilation is another feature, in some cases it is associated with relief from anxiety or dysphoria - 70-80% of women with BPD also have analgesia - 75% of people with BPD have cognitive symptoms that include relatively short or tran- sient episodes in which they appear to be out of contact with reality and experience delusions or other psychotic-like symptoms such as hallucinations, paranoid ideas or se- vere dissociative symptoms - only 1-2% of the population may qualify for BPD but they represent about 10% of pa- tients in outpatient and 20% of patients in inpatient clinical settings - 75% of individuals receiving this diagnosis are women Comorbidity with other Axis I and Axis II Disorders - this disorder produces significant impairment in social, academic and occupational functioning - commonly co-occurs with a variety of Axis I disorders, ranging from mood to anxiety, especially panic disorder and PTSD to substance use and eating disorders - in the past, many clinical researchers hypothesized that BPD had a special relation- ship with mood disorders, because about 50% of those with BPD also qualified for a mood disorder diagnosis at some point - other Axis II disorders (dependent, avoidant and OCD) are actually more commonly associated with depression than borderline personality disorder - there is a substantial co-occurrence of BPD with other personality disorders-especially histrionic, dependent, antisocial and schizotypal - the prototypic borderline’s exploitive use of others is usually an angry and impulsive re- sponse to disappointment, whereas the antisocial’s is a guiltless and calculated effort for personal gain - sexuality may play a more central role in the relationships of histrionics Causal Factors - research suggests that genetic factors play a significant role in the development - heritability may be partly a function of the fact that personality traits of impulsivity and affective instability are partially heritable - recent research suggests that the serotonin-transporter gene and the monoamine ox- ides gene may play a role Tuesday, November 6, 2012 - people with BPD appear to be characterized by lowered functioning of serotinin, which is involved in inhibiting behavioural responses (impulsivity) - patients may also show disturbances in the regulation of noradrenergic neurotransmit- ters that are similar to those seen in chronic stress conditions such as PTSD - their hyperresponsive noradrenergic system may be related to their hypersensitivity to environmental changes - much theoretical and research attention has also been directed to the role of psy- chosocial causal factors, unfortunately most is retrospective - many studies have found that people with this disorder usually report a large number of negative, even traumatic events in childhood - many studies suggests BPD is associated with early childhood trauma, but such stud- ies have many shortcomings and cannot tell us that the trauma plays a causal role - first, they rely on retrospective self-reports of individuals who are known for their exag- gerated and distorted views of other people - second, childhood abuse is certainly not a specific risk factor because it is also report- ed at relatively high rates with other personality disorders - third, childhood abuse nearly always occurs in families with various other pathological dynamics which may be more important - Joel Paris offered an interesting multidimensional theory of BPD, he proposes that people who have high levels of 2 normal personality traits (impulsivity and affective in- stability) may have a diathesis to develop BPD, but only in the presence of certain psy- chological risk factors, such as trauma, loss, and parental failure - children who are impulsive and unstable tend to be difficult or troublesome children and therefore may be at increased risk for being rejected and/or abused - BPD may be more prevalent because of the weakening of the family structure Avoidant Personality Disorder - show extreme social inhibition and introversion, leading to lifelong patterns of limited social relationships and reluctance to enter social interactions - because of their hypersensitivity to and their fear of criticism and rebuff, they do not seek out other people, yet they desire affection and are often lonely and bored - do not enjoy their aloneness, their ability to relate comfortably to other people causes acute anxiety and is accompanied by low self-esteem and excessive self-conscious- ness, which is often associated with depression - feeling inept and socially inadequate are the 2 most prevalent and stable features Tuesday, November 6, 2012 - show more generalized timidity and avoidance of many novel situations and emotions and show deficits in their ability to experience pleasure as well - the avoidant personality desires interpersonal contact but avoids it for fear o
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