Chapter 13 - Personality Disorders.doc

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Konstantine Zakzanis

Chapter 13 – Personality Disorders personality disorders – a heterogeneous group of disorders, listed separately on Axis II, regarded as long-lasting, inflexible, and maladaptive personality traits that impair social and occupational functioning - personality disorders are a heterogeneous group of disorders that are coded on Axis II of the DSM; they’re regarded as long-lasting, pervasive, and inflexible patterns of behavior and inner experience that deviate from the expectations of a person’s culture and that impair social and occupational functioning - some, but not all PDs, can cause emotional distress - an actual PD is defined by the extremes of several traits and by the inflexible way these traits are expressed - people with PDs are often rigid in their behavior and cannot change it in response to changes in the situations they experience Classifying Personality Disorders: Clusters, Categories, and Problems - as with other diagnoses, the publication of DSM-III began a trend toward improve reliability - beginning with DSM-III, PDs were also placed on a separate axis, Axis II, to ensure that diagnosticians would pay attention to their possible presence - the reliability of PD diagnoses has improved because of 2 developments: (1) the publication of specific diagnostic criteria (2) the development of structured interviews specially designed for assessing PDs - data now indicate that good reliability can be achieved, even across cultures - by using structured interviews, reliable diagnoses of PDs can be achieved - because PDs are presumed to be more stable over time than some episodic Axis I disorders, (eg: depression), test-retest reliability – a comparison of whether patients receive the same diagnosis when they’re assessed twice with some time interval separating the 2 assessments – is also an important factor in their evaluation - anti-social PD has a high test-retest reliability, indicating that it is a stable diagnosis; a patient given the diagnosis is very likely to receive the same diagnosis when evaluated later - the figures for schizotypal and dependent PDs are very low, indicating that the symptoms of people with these latter 2 diagnoses aren’t stable over time - researchers assessed the stability of PDs in patients with mood disorders and found that the 10-year stability of categorical diagnoses was “relatively poor” - stability coefficients were greater when a dimensional view of PDs was used and shorter time intervals were employed - consistent with the greater stability of anti-social disorders, Cluster B disorders had the greatest stability over time - twas confirmed that there is an overall age-related decline over time in personality dysfunction as people get older - twas concluded that the stability of personality dysfunction varies according to subtle but important differences in the nature of symptoms - acute symptoms are especially likely to decrease over time (eg: self-harming) while symptoms reflecting negative affect are quite stable and these chronic symptoms are likely a reflection of character and personality structure and organization - a major problem with PDs is that it is often difficult to diagnose a single, specific PD because many disordered people exhibit a wide range of traits that make several diagnoses applicable - although some decrease in comorbidity occurred with the publication of DSM-IV, the data still suggest that the categorical diagnostic system of DSM-IV-TR may not be ideal for classifying PDs - the personality traits that constitute the data for classification form a continuum; most of the relevant characteristics are present in varying degrees in most people - tests of a categorical vs. a dimensional approach provide strong support for the dimensional approach - overall, a dimensional approach seems to apply to most other personality characteristics - the PDs can be construed as the extremes of characteristics we all possess - current diagnostic systems are still based on the categorical approach - researchers regard PD as a failure or inability to come up with adaptive solutions to life tasks - they identified 3 types of life tasks and proposed that failure with any one task is enough to warrant a PD diagnosis - the 3 tasks are: 1. to form stable, integrated, and coherent representations of self and others 2. to develop the capacity for intimacy and positive affiliations with other people 3. to function adaptively in society by engaging in prosocial and co-operative behaviors - once one of these conditions exists, disorder is evident and the focus can shift to dimensional ratings Assessing Personality Disorders - a significant challenge is that many disorders are egosyntonic; the person with a PD is unaware that a problem exists and may not be experiencing significant personal distress - the assessment and diagnosis of PDs are enhanced when the significant others in an individual’s life become informants - also, because of the lack of awareness in many cases, disorders may need to be diagnosed via clinical interviews led by trained personnel - another significant challenge is that a substantial proportion of patients are deemed to have a PD not otherwise specified (PDNOS) and these patients don’t fit into existing PD diagnostic categories - twas concluded that PDNOS is the 3 most prevalent type of PD diagnosed via structured interviews, with the prevalence of this PDNOS ranging from 8-13% in clinical samples - although clinical interviews are preferable when seeking to make a diagnosis, researchers often rely on the use of self-report measures when assessing PD symptoms; MMPI-2 can be used to do this - researchers described a set of MMPI-2 scales that they developed to assess 5 dimensional personality constructs to reflect psychopathology; this framework, known as the PSY-5 consists of dimensions assessing negative emotionality/neuroticism, lack of positive emotionality, aggressiveness, lack of constraint, and psychoticism - the PSY-5 seem particularly relevant to certain forms of personality dysfunction - thrdmost widely used measure of PD symptoms is the Milon Clinical Multiaxial Inventory, which is now in its 3 edition - the MCMI-III is a 175 item true-false inventory and the MCMI-III provides subscale measures of 11 clinical personality scales and 3 severe personality pathology scales (schizotypal, borderline, and paranoid) - the MCMI-III also provides symptoms ratings for clinical syndromes located on Axis I of the DSM-IV - it also includes a validity index and 3 response-style indices (known as modifying indices) that correct for such tendencies as denial and random responding - 2 key issues involving self-report measures of PD need to be considered; 1. empirical tests comparing the various self-report measures show that they differ in their content and are not equivalent 2. a general concern involving self-report measures, including PD measures, is that the cut-off points used to determine the presence of a PD often overestimate the number of people who meet diagnostic criteria for particular disorders - ideally if the goal is to obtain accurate diagnoses, a measure such as the MCMI-III is best used in conjunction with a clinical interview such as the Personality Disorder Examination; this extensive structured interview provides dimensional and categorical assessments Personality Disorder Clusters - when a categorical approach is used and DSM-IV-TR criteria are involved, PDs are grouped into 3 clusters; 1. cluster A – (paranoid, schizoid, and schizotypal) seem odd or eccentric; these disorders reflect oddness and avoidance of social contact 2. cluster B – (antisocial, borderline, histrionic, and narcissistic) seem dramatic, emotional, or erratic; behaviors are extrapunitive and hostile 3. cluster C – (avoidant, dependent, and obsessive compulsive) appear fearful Odd/Eccentric Cluster - this cluster comprises 3 diagnoses: paranoid, schizoid, and schizotypal PDs Paranoid Personality Disorder paranoid personality disorder – a disorder in which a person expects to be mistreated by others, becomes suspicious, secretive, jealous, and argumentative; he/she will not accept blame and appears cold and unemotional - one with PPD is suspicious of others; they’re always on the lookout for possible signs of trickery and abuse; such individuals are reluctant to confide in others and tend to blame them even when they themselves are at fault; they can be extremely jealous and may unjustifiably question the fidelity of a spouse or lover - patients with PPD are preoccupied with unjustified doubts about the trustworthiness or loyalty of others - they may read hidden negative of threatening messages into events (eg: the individual may believe that a neighbor’s dog deliberately barks in the early morning to disturb him/her) - with this diagnosis symptoms such as hallucinations aren’t present, and there is less impairment in social and occupational functioning; also, full-blown delusions are not present - PPD occurs most frequently in men and co-occurs most frequently with schizotypal, borderline, and avoidant personality disorders - prevalence = 1% Schizoid Personality Disorder schizoid personality disorder – a disorder in which the person is emotionally aloof, indifferent to the praise, criticism, and feelings of others, and usually a loner with few, if any, close friends and with solitary interests - patients with this don’t appear to desire or enjoy social relationships and usually have no close friends; they appear dull, bland, and aloof and have no warm, tender feelings for others; they rarely report strong emotions, have no interest in sex, and experience few pleasurable activities - this disorder is slightly less common among women than men; prevalence = 1% - comorbidity is highest for schizotypal, avoidant, and paranoid personality disorders Schizotypal Personality Disorder schizotypal personality disorder – a disorder in which a person is eccentric, has oddities of thought and perception (magical thinking, illusions, depersonalization, derealization), speaks digressively and with over-elaborations, and is usually socially isolated; under stress he/she may appear psychotic - people with this disorder may have odd beliefs or magical thinking (eg: superstitiousness, beliefs that they’re psychic and telepathic) and recurrent illusions - in their speech, they may use words in an unusual and unclear fashion; eg: “I’m not a very talkable person” - their behavior and appearance may also be eccentric; they may talk to themselves - also common are ideas of reference (the belief that events have a particular and unusual meaning for the person), suspiciousness, and paranoid ideation - this disorder is slightly more frequent among men than women; prevalence = 3% - a significant problem in the diagnosis of schizotypal PD is its comorbidity wit other PDs Etiology of the Odd/Eccentric Cluster - the search for causes has been guided by the idea that these disorders are genetically linked to schizophrenia - family studies provide at least some evidence that PDs of the odd/eccentric cluster are related to schizophrenia - patients with schizotypal personality disorder have deficits in cognitive and neuropsychological functioning that are similar to those seen in schizophrenia; also in keeping with schizophrenia research, patients with schizotypal personality disorder have enlarged ventricles and less temporal-lobe grey mater Dramatic/Erratic Cluster - the diagnoses in the dramatic/erratic cluster – borderline, histrionic, narcissistic, and anti-social personality disorders – include patients with a wide variety of symptoms, ranging from variable behavior to inflated self-esteem, exaggerated emotional displays, and anti-social behavior Borderline Personality Disorder borderline personality disorder – a disorder in which people are impulsive and unpredictable, with an uncertain self-image, intense and unstable social relationships, and extreme mood swings - the core features of this disorder are impulsivity and instability in relationships, mood, and self-image - emotions are erratic and can shift abruptly, particularly from passionate idealization to contemptuous anger; patients with BPD are argumentative, irritable, sarcastic, quick to take offence, and very hard to live with - these people haven’t developed a clear and coherent sense of self and remain uncertain about their values, loyalties, and career choices; they can’t bear to be alone, have fears of abandonment, and demand attention - subject to chronic feelings of depression and emptiness, they often attempt suicide and engage in self- mutilating behavior, such as slicing into their legs with a razor blade; 1/10 BPD commit suicide - most BPD patients who kill themselves are female rather than male and most suicides occur after multiple attempts rather than on the 1 attempt - BPD typically begins in early adulthood, has a prevalence of 1-2%, and is more common in women than in men - borderline patients are likely to have an Axis I mood disorder and their parents are more likely than average to have mood disorders and other forms of psychopathology - comorbidity is found with substance abuse, PTSD, eating disorders, and PDs from the odd/eccentric cluster Canadian Perspective 13.1 – Borderline Personality and Spouse Abuse - Don Dutton’s analysis of etiological factors has focused on 3 central characteristics of the abusive personality: borderline personality characteristics, anger, and the chronic experience of traumatic symptoms - Dutton suggests that the BPD characteristics of abusive men are responsible for many of the interpersonal problems in abusive relationships -in summary, Dutton’s work shows that men who characteristically engage in abuse are not simply responding to situational factors; instead, they have a personality style with many borderline features Etiology of Borderline Personality Disorder Object-Relations Theory - object-relations theory is concerned with the way children incorporate (or introject) the values and images of important people, such as their parents; in other words, the focus is on the manner in which children identify with people to whom they have strong emotional attachments - these introjected people (object representations) become part of the person’s ego, but they can come into conflict with the wishes, goals, and ideals, of the developing adult - object-relations theorists hypothesize that people react to their world through the perspective of people from their past, primarily their parents or primary caregivers; sometimes these perspectives conflict with the persons own wishes - Kernbeg proposed that adverse childhood experiences – for example, having parents who provide love and attention inconsistently, perhaps praising achievements but being unable to offer emotional support and warmth – cause children to develop insecure egos - BPD patients are in touch with reality but frequently engage in a defense mechanism called splitting – dichotomizing objects into all good or all bad and failing to integrate positive and negative aspects of another person or the self into a whole - this tendency causes extreme difficulty in regulating emotions because the borderline patient sees the world, including himself/herself, in black-white terms Biological Factors - BPD runs in families, suggesting that it has a genetic component - BPD are also high in neuroticism, a heritable trait - some data suggest poor functioning of the frontal lobes, which may play a role in impulsive behavior - BPD patients perform poorly on neurological tests or frontal-lobe functioning and show low glucose metabolism in the frontal lobes - consistent with the idea that low levels of the neurotransmitter serotonin are associated with impulsivity when borderline patients were administered a drug to increase serotonin levels, their level of anger decreased Linehan’s Diathesis-Stress Theory - Linehan proposes that BPD develops when people with a biological diathesis (possibly genetic) for having difficulty controlling their emotions are raised in a family environment that’s invading - a diathesis for what Linehan calls emotional dysregulation can interact with experiences that invalidate the developing child, leading to the development of borderline personality - child abuse (sexual and non-sexual) are extreme forms of invalidation - the 2 main hypothesized factors – dysregulation and invalidation – interact with each other in a dynamic fashion; for example, the emotionally dysregulated child makes enormous demands on his/her family; the exasperated parents ignore or even punish the child’s outbursts; this response can lead to the child suppressing emotions, only to have them build up to an explosion, which then gets parental attention - abuse is more frequent among people with BPD than among people diagnosed with most other disorders Histrionic Personality Disorder The Semisuicidal Sophomore histrionic personality disorder – a disorder in which the person is overly dramatic and given to emotional excess, impatient with minor annoyances, immature, dependent on others, and often sexual seductive without taking responsibility for flirtations; formerly called “hysterical personality” - histrionic personality is applied to people who are overly dramatic and attention-seeking; they often use features of their physical appearance, such as unusual clothes, makeup, or hair color, to draw attention to themselves - these individuals, although displaying emotion extravagantly, are thought to be emotionally shallow; they’re self-centered, overly concerned with their attractiveness, and uncomfortable when not the center of attention - their speech is often impressionistic and lacking in detail; for example, they may state a strong opinion yet be unable to give any supporting information - more common among women than among men; prevalence = 2% - the prevalence is higher among separated and divorced people, and it is associated with high rates of depression and poor physical health; comorbidity with BPD is high Etiology of Histrionic Personality Disorder - psychoanalytic theory predominates and proposes that emotionality and seductiveness were encouraged by parental seductiveness, especially father to daughter - patients with HPD are thought to have been raised in a family environment in which parents talked about sex as something dirty but behaved as thought it was exciting and desirable - the exaggerated displays of emotion on the part of histrionic persons are seen as symptoms of such underlying conflicts, and their need to be the center of attention is seen as a defense mechanism, a way to protect themselves from their true feelings of low self esteem Narcissistic Personality Disorder The Long-Suffering Einstein narcissistic personality disorder – a disorder in which people are extremely selfish and self-centered; have a grandiose view of their uniqueness, achievements, and talents; and have an insatiable craving for admiration and approval from others; they’re exploitve to achieve their own goals and expect much more from others than they themselves are willing to give - people with a NPD have a grandiose view of their own uniqueness and abilities; they’re preoccupied with fantasies of great success; they require almost constant attention and excessive admiration and believe that only high-status people can understand them - their interpersonal relationships are disturbed by their lack of empathy, feelings of envy, arrogance, and their tendency to take advantage of others - prevalence = less than 1%%; it most often co-occurs with BPD - narcissistic personality disorder draws its name from Narcissus of Greek mythology; he fell in love with his own reflection, was consumed by his own desire, and was then transformed into a flower Etiology of Narcissistic Personality Disorder - on the surface, the person with NPD has a remarkable sense of self-importance, complete self- absorption, and fantasies of limitless success, but it is theorized that these characteristics mask a very fragile self-esteem - constantly seeking attention and adulation, narcissistic personalities are very sensitive to criticism and deeply fearful of failure - their relationships are few and shallow; people with NPD become angry with others and reject them when they fall short of their unrealistic expectations; their inner lives are impoverished because, despite their self-aggrandizement, they actually think very little of themselves - Kohut suggests that when parents respond to a child with respect, warmth, and empathy, the child is endowed with healthy self-esteem; but when parents further their own needs rather than directly approve of their children, the result may be a narcissistic personality; children neglected in this way don’t develop an internalized health self-esteem and have trouble accepting their own shortcomings; they develop into narcissistic personalities, striving to bolster their sense of self through unending quests for love and approval from others Anti-Social Personality Disorder - in current usage, the terms “anti-social personality disorder” and “psychopathy” (sometimes referred to as “sociopathy”) are often used interchangeably, although there are important differences between the 2 Characteristics of Anti-Social Personality Disorder anti-social personality disorder – a disorder in which a person, also called a psychopath of a sociopath, is superficially charming and a habitual liar, has no regard for others, shows no remorse after hurting others, has no shame for behaving in an outrageously objectionable manner, is unable to form relationships and take responsibility, and does not learn from punishment - the DSM-IV-TR co
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