B32 - Chapter 13.doc

Chapter 13: Personality Disorders • Personality disorder (PDs): a heterogeneous group of disorders that are coded on axis II of the DSM. They are regarded as long-standing, pervasive and inflexible patterns of behaviour and inner experience that deviate from the expectation of a person’s culture and that impair social and occupational functioning (some but not all cause emotional distress) • An actual personality disorder is defined by extremes of several traits and by the inflexible way these traits are expressed • They are often rigid in their behaviour and cannot change it in response to changes in the situation they experience • Individuals would not be diagnosed as having personality disorders unless the patterns of behaviour were long-standing, pervasive and dysfunctional • Often co-morbid with axis I disorders Classifying Personality Disorders: Clusters, Categories and Problems • The reliability of personality disorder diagnoses have improved because of 2 developments o The publication of specific diagnostic criteria o The development of structured interviews specially designed for assessing personality disorders • Test-rests reliability is also an important factor for evaluation • It is often difficult to diagnose a single, specific personality disorder because many disordered people exhibit a wide range of traits that make several diagnoses applicable • Personality disorders can be construed as the extremes of characteristics we all possess • (Livesley, Schoroeder, Jackson and Jang) personality disorder is a failure or inability to come up with adaptive solutions to life tasks... o To form stable, integrated and coherent representation of self and others o To develop the capacity for intimacy and positive affiliations with other people o To function adaptively in society by engaging in prosocial and cooperative behaviours Assessing Personality disorders • Many disorders are ego-syntonic, that is the person with a personality disorder is unaware that a problem exists and may not experience significant distress • The disorders may need to be diagnosed via clinical interview led by trained professionals • Although clinical interviews are preferable, researchers often rely on self- report measures when assessing personality disorder symptoms C h a p t e r 1 3 : P e r s o n a l i t y D i s oPage 11r s • MMPI-2 has been created to assess the symptoms of specific personality disorders – the PSY-5 consists of dimensions of assessing negative emotionality/neuroticism, lack of positive emotionality, aggressiveness, lack of constraint, and pychoticism • The most widely used measure of personality disorder symptoms is the Millon Clinical Multiaxial Inventory which is now in its third edition o It’s a 175 true false inventory that was revised for DSM-IV o Provides subscale measures of 11 clinical personality scales and 3 severe personality pathology scales o Also provides symptom ratings for clinical syndromes located on Axis I of the DSM-IV o Includes a validity index and 3 response style indices that correct for such tendencies as denial and random responding o It’s only moderately effective in terms of its ability to detect faking • Issues of self report measures of personality disorders o Empirical tests comparing the various self-report measures show that they differ in their content and are not equivalent o Cut-off points used to determine the presence of personality disorder often overestimate the number of people who meet diagnostic criteria for particular disorders • The goal is to obtain accurate diagnoses; MCMI-III is best used in conjunction with a clinical interview such as the Personality disorder Examination Personality Disorder Clusters • When a categorical approach is used the DSM-IV-TR criteria are involved, personality disorders are grouped into 3 clusters o Individual in cluster A (paranoid, schizoid, and schizotpyal) seem odd or eccentric (they reflect oddness and avoidness of social contact) o Those in cluster B (antisocial, borderline, histrionic and narcissistic) seem dramatic, emotional, or erratic (extrapunitive and hostile) o Those in cluster C (avoidant, dependent, and obsessive compulsive) appear fearful • Patients with both borderline & schizotypal personality disorders would probably have been diagnosed as schizophrenic using DSM II criteria Odd/Eccentric Cluster • 3  paranoid, schizoid, and schizotypal PDs • Symptoms are similar to those of schizophrenia (especially its prodromal and residual phase) Paranoid Personality Disorder • They are suspicious of others C h a p t e r 1 3 : P e r s o n a l i t y D i s oPage 11r s • They expect to be mistreated or exploited by others and thus are secretive and always on the lookout for possible signs of trickery and abuse • They are reluctant to confide in others and tend to blame them even when they themselves are at fault • They can be extreme jealous and unjustifiably question the fidelity of a spouse or lover • Preoccupied with unjustified doubts about the trustworthiness or loyalty of others • Difference from schizophrenia: hallucinations are not present, there is less impairment in social/occupational functioning • Difference from delusional disorder: full-blown delusions are not present • More frequent in men • Co-occurs with schiotypal, borderline and avoidant personality disorders Schizoid Personality Disorder • Do not appear to desire or enjoy social relationships, usually have no close friends • Appear dull, bland and aloof and have no warm, tender feelings for others • Rarely report strong emotions, have no interest in sex and experience few pleasurable activities • Loners with solitary interests • Prevalence is <1% (slightly less common in women) • Co-occurs with schizotypal, avoidant and paranoid personality disorder • Symptoms are similar to prodromal and residual phase of schizophrenia Schizotypal Personality Disorder • Grew out of the adopted children of schizophrenic parents • Usually have the interpersonal difficulties of schizoid personality and excessive social anxiety that does not diminish as they get to know others • More eccentric symptoms, like hose that defined prodromal and residual phase of schizophrenia • May have odd beliefs or magical thinking (that they are telepathic) • Have recurrent illusions (spirits etc) • May use words in a unusual and unclear fashion and may talk to themselves • Ideas of reference: the belief that events have a particular and unusual meaning for the person • Suspiciousness and paranoid ideation • Affect appears to be constricted and flat • Prevalence 3% & slightly more frequent in men • Co-occurs with other personality disorders o 33% also have borderline personality disorder o 59% have avoidant personality disorder o 59% for paranoid personality disorder o 44% for schizoid personality disorder Etiology of the Odd/Eccentric Cluster C h a p t e r 1 3 : P e r s o n a l i t y D i s o Page 11 s • These disorders are genetically linked to schizophrenia • Family studies provide some evidence that these are clustered to schizophrenia • Schizotypal personality disorder people have deficits in cognitive and neuropsychological functioning (similar to schizophrenia) • Schizoptypal people have enlarged ventricles and less temporal-lobe grey matter Dramatic/Erratic Cluster • They have a wide variety of symptoms  inflated self-esteem  exaggerated emotional display & antisocial behaviour Borderline Personality Disorder • Impulsivity and instability in relationships, mood and self image • Emotions are erratic and can shift abruptly, from passionate idealizations to contemptuous anger • They are argumentive, irritable, sarcastic, quick to take offence and very hard to live with • Unpredictable/impulsive behaviour  gambling, spending, indiscriminate sexual activity and eating sprees (potentially self damaging) • They have not developed a clear and coherent sense of self and remain uncertain about their values, loyalties and career choices • Cannot bear to be alone, have fears of abandonment, and demand attention • May have feelings of depression and emptiness and often attempt suicide and self mutilating behaviour • Most who kill themselves are females • Originally borderline personality was meant for a personality between neurosis and schizophrenia • Begins early adulthood • Prevalence 1-2% & more common in women • Co-occur with Axis 1 mood disorders, substance abuse, PTSD, eating disorders and odd/eccentric cluster Etiology of Borderline Personality Disorder • Object-relations theory o Concerned with the way children incorporate (or introject) the values and images of important people, such as their parents  they manner which children identify with people whom they have strong emotional attachments o They hypothesize that people react to their world through the perspectives of people from their past, primarily their parents (this sometimes conflict with their own wishes) o These patients are in touch with reality but frequently engage in a defence mechanism called splitting (dichotomizing objects into all good or all bad and failing to integrate positive and negative C h a p t e r 1 3 : P e r s o n a l i t y D i s oPage 11r s aspects of another person or the self into a whole)  they see the world in black and white terms o This defence protects the patients weak ego from intolerable anxiety o They’ve been found to have low level of care from mothers, childhood sexual and physical abuse and separation from parents • Biological Factors o BPD runs in the family and they are high in neuroticism (heritable trait) o Poor functioning of the frontal lobes (impulsive behaviour) o Low glucose metabolism in the frontal lobes o Low levels of neurotransmitter serotonin levels (increase anger) • Linehan’s Diathesis-Stress Theory o Develops when people with biological diathesis (possibly genetic) for having difficulty controlling their emotions are raised in a family environment that is invalidating (emotional dysregulation) o This can interact with experiences that invalidate the developing child, leading to this disorder o An invalidating environment – person wants and feelings are discounted and disrespected, and efforts to communicate one’s feelings are disregarded or even punished o Dysrefuation and invalidation interact with each other in a dynamic fashion Histrionic Personality Disorder • Formerly called hysterical personality • People who are overly dramatic and attention seeking • Often use features of their physical appearance (unusual clothes, makeup or hair color) • They display emotional extravagantly but thought to be emotionally shallow) • Self-centered and overly concerned with their attractiveness and uncomfortable when they’re not the center of attention • Can be inappropriately sexually provocative and seductive and easily influenced by others • Speech is often impressionistic and lacking in detail • Prevalence 2-3% and more common in women (higher among separated and divorced people and associated with depression and poor physical health) Etiology of Histrionic Personality Disorder • Little research • Psychoanalytic theory predominates – proposes that emotionality and seductiveness were encouraged by parental seductiveness especially father to daughter C h a p t e r 1 3 : P e r s o n a l i t y D i s oPage 11r s • They are thought to be raised in which parents talk about sex as something dirty but behaved as though it was exciting and desirable • Their exaggerated display of emotion are seen as symptoms of such underlying conflicts and their need to be the center of attention is seen as a defence mechanisms, a way to protect themselves from their true feeling of low self-esteem Narcissistic Personality Disorder • Have grandiose view of their own uniqueness and abilities • They are preoccupied with fantasies of great success • They require constant attention and excessive admiration and believe that only high-status people can understand them • Lack of empathy, feelings of envy, arrogance and their tendency to take advantage of others • Relationships are problematic because they expect others to do special but not to reciprocate back • Prevalence is <1% and co-occurs with BDP Etiology of Narcissistic Personality Disorder • On the surface the person has a remarkable sense of self-importance, complete self-absorption and fantasies of limitless success, but it theorized that these characteristics mask a very fragile self-esteem • Very sensitive to criticism and deeply fearful of failure • They actually think very little of themselves • (Kohut) the self emerges early in life as bipolar structure with an immature grandiosity at one pole and a dependent overidealiatin of other people at the other. A failure to develop healthy self-esteem occurs when parents don’t’ respond with approval to their children’s display of competency (not valued). When parents respond with empathy and warmth the child develops self-esteem but if they only attend to their own needs this personality may develop Antisocial Personality Disorder and Psychopathy • Antisocial personality disorder and Psychopathy are often interchangeably used Characteristics of Antisocial Personality Disorder • 2 major components o Conduct disorder is present before 15 (running away from home,