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PSY240H1 (234)
Lecture 9


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Martha Mc Kay

Lecture 9 Personality Disorders Personality: All the ways we have of acting, thinking, believing, and feeling that make each of us unique. Personality Trait: A complex pattern of behaviour, thought, and feeling that is stable across time and across many situations. Personality Disorder: Long-standing patterns of maladaptive behaviours, thoughts, and feelings. -Enduring pattern of behaviour that is pervasive and inflexible, as well as, stable and of long duration -Causes clinically significant distress or impairment in functioning -Manifests in at least 2 of the following: cognition, affectivity, interpersonal functioning or impulse control -Must show symptoms since adolescence or early adulthood -people with personality disorders also experience acute disorders such as major depression, substance abuse Problems with diagnosis 1)DSM-IV-TR describes these disorders as if they represent something that’s not normal, yet a lot of them are just extreme versions of normal personalities 2)There is a lot overlap between the various diagnostic criteria for various personality disorders 3)Some of the info used for diagnosis is hard for the clinician to obtain (ex. info about how a clinician treats other people) 4)Conceptualized as stable characteristic, but studies have shown that characteristics vary over time -these problems also make it difficult to do research on personality disorders Biases in construction & application -Differences in frequencies with which men and women and individuals of minority groups are diagnosed with different personality disorders – does this reflect bias and an application of negative stereotypes? -Lack of recognition that the expressions of symptoms of a disorder may vary between women and men. -Lack of recognition that the expressions of symptoms of a disorder may vary between groups. 1. Cluster A: ODD-ECCENTRIC DISORDERS Relation to Schizophrenia: Paranoid personalitySchizoid Personality Schizotypal personality Paranoid Personality Disorder Diagnostic A. Evidence of pervasive distrust or suspiciousness of others present Criteria in at least 4 of the following ways: 1) Pervasive suspiciousness of being deceived, harmed, or exploited 2) Unjustified doubts about loyalty or trustworthiness of friends or associates 3) Reluctance to confide in others because of doubts of loyalty or trustworthiness 4) Hidden demeaning or threatening meanings read into benign remarks or events 5) Bears grudges; does not forgive insults, injuries, or slights 6) Angry reactions to perceived attacks on his or her character or reputation 7) Recurrent suspicions regarding fidelity of spouse or sexual partner B. Does not occur exclusively during course of Schizophrenia, Mood Disorder with Psychotic Features, or other psychotic disorder Symptoms -Believe people are chronically trying to deceive or exploit them -Hypervigilant for confirming evidence of suspicions -Misinterpret or Overinterpret situations in line with their suspicions e.g. wife’s cheerfulness = she’s having an affair -Resistant to rationale arguments against their suspicions -Withdrawal from others in order to protect themselves Prevalence Prevalence estimates are between .5 -5% Males > Females Acute psychological problems: major depression, anxiety, substance use Evidence from Family Hx studies – more common in families with a hx of schizophrenia Cognitive theories: underlying belief other people are malevolent and deceptive coupled with lack of self-confidence in ability to defend oneself against others Treatment -Seek treatment when in crisis, e.g., depressed, not for paranoia -Therapist gains trust through highly professional manner rather than warm personal relationship that may be misinterpreted -Must not directly confront paranoid thinking -Focus on increasing sense of self-efficacy- make them think that they can defend themselves if they have to Schizoid Personality Disorder Diagnostic A.Evidence of pervasive pattern of detachment from social Criteria relationships and a restricted range of expression of emotions in interpersonal settings shown in at least 4 of the following ways: 1)Neither desires nor enjoys close relationships 2)Almost always chooses solitary activities 3)Has little if any interest in sexual experiences with another person 4)Takes pleasure in few if any activities 5)Lacks close friends or confidants 6)Appears indifferent to the praise or criticism of others 7)Shows emotional coldness, detachment, or flat affect B. Does not occur exclusively during course of Schizophrenia, Mood Disorder with Psychotic Features, or other psychotic disorders, or a Pervasive Developmental Disorder Symptoms -Lack desire to form interpersonal relationships; emotionally cold -Described as aloof, reclusive, detached, humorless -View interpersonal relationships as unrewarding, messy, intrusive Prevalence -Rare - .4-1.7% -Males > Females, 3:1 -Function well in occupations that do not require interpersonal interactions -Twin studies suggest some heritability of personality features such as low sociability and low warmth -Insecure attachment patterns linked to disorder Treatment -Treatment focus on increasing social skills, contacts, awareness of feelings -Group therapy can help model, and practice social skills Schizotypal Personality Disorder Diagnostic A. A pervasive pattern of social and interpersonal deficits marked by Criteria acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and behavioral eccentricities as indicated by at least 5 of the following: 1)Ideas of reference 2)Odd beliefs or magical thinking 3)Unusual perceptual experiences 4)Odd thinking and speech 5) Suspiciousness or paranoid ideation 6) Inappropriate or constricted affect 7) Behaviour or appearance that is odd, eccentric, or peculiar 8) Lack of close friends or confidants 9) Excessive social anxiety that does not diminish with familiarity B. Does not occur exclusively during course of Schizophrenia, Mood Disorder with Psychotic Features, or other psychotic disorders, or a Pervasive Developmental Disorder Symptoms -Restricted range of emotions, tend to be socially isolated, uncomfortable in interpersonal interactions -Oddities in cognitions: paranoia, ideas of reference, odd beliefs/magical thinking, illusions -Tangential, vague, over-elaborate speech -May have inappropriate or no emotional response -Show deficits in working memory, learning similar to those with schizophrenia Prevalence -Prevalence rates .6 – 5% -Males > Females, 2:1 -Family history, adoption and twin studies support genetic link -More common in 1 degree relatives of people with schizophrenia -Difficulties sustaining attention -Dysregulation in dopamine – high levels in certain areas of brain, similar to schizophrenia Treatment -Antipsychotics -Antidepressants -Psychological therapies -Important to establish good relationship -Increase social contacts, learn socially appropriate behaviours -Group therapy can help increase social skills -Cognitive therapy focuses on objective evidence in the environment to disregard bizarre thoughts 2. Cluster B: Dramatic-Erratic Personality Disorder Antisocial Personality Disorder Diagnostic A. Pervasive pattern of disregard for and violation of the rights of Criteria others occurring since age 15, as indicated by at least 3 of the following: 1)Failure to conform to social norms and repeated lawbreaking 2)Deceitfulness 3)Impulsivity or failure to plan ahead- ex. quitting a job for no reason with no future jobs planned 4)Irritability and aggressiveness 5)Reckless disregard for the safety of self or others 6)Consistent irresponsibility 7)Lack of remorse B. The individual is at least 18 years of age C. There is evidence of Conduct Disorder with onset before age 15. Symptoms -ASPD is characterized by 1) impairment in the ability to form positive relationships and 2) the tendency to engage in behaviours violating basic norms and values. -Show little or no remorse for actions. -Poor impulse control; little tolerance for frustration; easily bored; risk takers with little concern for danger Prevalence -Comprise 50-80 % of jailed men.– criminal history has a lot to do with SPD -Although there is overlap, a diagnosis of ASPD is not the same as a diagnosis of psychopathy (i.e., of being a psychopath). Although psychopathy is a meaningful construct for many psychologists, it is not even a DSM diagnostic category. -Comprise 15-25% of incarcerated groups; only 20% of those with ASPD will meet criteria for psychopathy -Genetic predisposition- 50% concordance rate for monozygotic twins -Testosterone -Low levels of serotonin may underlie problems with impulse control -Attention-deficit/hyperactivity- some adults diagnosed with APD have lifelong problems with attention and hyperactivity -Often show problems with executive functions and deficits in verbal skills -Experience chronic low levels of arousability (link to sensation seeking) -Social cognitive factors- variables such as low intelligence, harsh or abusive parenting, and poor coping with school-based challenges add to risk of eventual ASPD diagnosis Treatment -Prognosis poor in part because person does not see the need for treatment -Treatment often focused on coping mechanisms for anger and on means to get control over impulsive behaviours -Lithium and atypical antipsychotics have been used for controlling impulsive-aggressive behaviours; ongoing trials with SSRIs -Psychopathy not in DSM-IV-TR and has distinct features -Robert Hare of UBC – prominent researcher -PCL-Revised (psychopathy check list) -Measures: Superficial charm Grandiose sense of self-worth Boredom, need for stimulation Pathological lying Manipulative Cold and callous – gain pleasure from humiliating others Cruel and malicious Borderline Personality Disorder Diagnostic A pervasive pattern of instability in interpersonal relationships, self- Criteria image, and affects, and marked impulsivity as indicated by at least 5 of the following: 1)Frantic efforts to avoid real or imagined abandonment 2)A pattern of unstable and intense interpersonal relationships 3)Identity disturbance characterized by a persistently unstable self- image or sense of self 4)Impulsivity in at least two potentially self-damaging areas (e.g. spending, sex, substance abuse, reckless driving) 5)Recurrent suicidal behaviour, gestures, or self-mutilating behaviour 6) Affective instability due to a marked reactivity of mood 7) Chronic feelings of emptiness 8) Inappropriate, intense anger 9) Transient, stress-related paranoid ideation or severe dissociative symptoms Symptoms -Instability in mood, self-concept and interpersonal relationships (rapidly switch from idolizing to despising others) -Impulsive, self-damaging behaviours (often in the form of self- mutilation and suicidal behaviours). - Prone to dissociative states Prevalence -Prevalence – 1-2% -Female > Male -Mixed evidence about genetic links -Possible links to low levels of serotonin, decreased metabolism in prefrontal cortex, and greater activation in the amygdala -Psychodynamic theories: poor early relationships with caregivers and splitting -Uncaring, controlling parenting -A history of childhood physical or sexual abuse has been reported by many Treatment -Anti-anxiety medications and antidepressants to treat symptoms -Psychodynamic- clarify feelings, address splitting, deal with transference-related problems -Schema Therapy- an integrative cognitive-behavioural approach -Dialectical behaviour therapy- another integrative approach blending cognitive-behavioural, interpersonal, and psychodynamic strategies. Histrionic Personality Disorder Diagnostic A pervasive pattern of excessive emotionality and attention seeking, Criteria as indicated by at least 5 of the following: 1)Discomfort in situations in which s/he is not the centre of attention 2)Inappropriate sexually seductive or provocative behaviour 3)Displays rapidly shifting and shallow expression of emotions 4)Consistently uses physical appearance to draw attention to self 5)Has an excessively impressionistic style of speech 6)Shows self-dramatization and exaggerated expressions of emotion 7)Is overly suggestible 8)Considers relationships to be more intimate than they actually are Symptoms -Rapidly shifting moods -Intense, unstable relationships -Wants to be centre of attention Highly dramatic Overtly seductive Emphasizing positive qualities of their physical appearance -Seen as shallow, self-centred, and demanding Prevalence -Prevalence 1.3-2.2% -More women diagnosed than men -Likely separated or divorced -Little known about causes and effective treatments -Psychodynamic – focus on uncovering repressed emotions; expressing emotions in more appropriate ways -Cognitive – focus on identifying assumptions that they can’t function on their own; formulate goals that do not rely on the approval of others Treatment Narcissistic Personality Disorder Diagnostic A pervasive pattern of grandiosity (in fantasy and behaviour), need Criteria for admiration, and lack of empathy, as indicated by at least 5 of the following: 1)Grandiose sense of self-importance 2)Preoccupation with fantasies of unlimited success, power, brilliance, beauty 3)Belief that s/he is “special” and unique 4)Excessive need for admiration 5)Sense of entitlement 6)Tendency to be interpersonally exploitative 7)Lacks empathy 8)Shows arrogant, haughty behaviours or attitudes Symptoms -Similar to histrionic – shallow emotional expression, dramatic, grandiose -Distinct – rely on self-evaluations, dependency on others is weak and dangerous -Overreact to criticism – very angry, ashamed -Interpersonally – demanding; ignore wants/needs of others; exploit to gain power -Can be extremely successful, but when gross overestimations of abilities are made, they can make poor choices and experience many failures Prevalence -Prevalence: <1% -Some genetic evidence -Freud – phase all children pass through before transferring love of themselves to significant others úBecome fixated at this stage if caregivers are untrustworthy or who instill grandiose sense of self -Cognitive – assumptions about self-worth unrealistic resulting from overindulgence and overevaluation in childhood úor believe they are unique and exceptional in reaction to being singled out or as a defense against rejection -Treatment – rarely sought out – focuses on developing more sensitivity towards others, more realistic expectat
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