Chapter 13

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Konstantine Zakzanis

PSYB32: Abnormal Psychology Meera Mehta Summer 2012 Chapter 13: Personality Disorders - Personality disorders—(PDs) a heterogeneous group of disorders that are coded on Axis II of the DSM o Regarded as long-standing, pervasive and inflexible patterns of behaviour and inner experience that deviate from the expectations of a person’s culture and that impair social and occupational functioning o Some, but not all, can cause emotional distress o PD is defined by the extremes of several traits and by the inflexible way these traits are expressed o People with PDs are often rigid in their behaviour and cannot change it in response to changes in the situations they experience - The personality each of us develops over the years reflects a persistent means of dealing with life’s challenges, a certain style of relating to other people Classifying Personality Disorders; Clusters, Categories and Problems - The reliability of personality disorder diagnoses has improved because of two developments 1) The publication of specific diagnostic criteria 2) The development of structured interviews specially designed for assessing personality disorder - Interviews with people who know the patient well are sometimes part of the diagnostic workup and improve the accuracy of diagnosis - PDs are presumed to be more stable over time than some episodic Axis I disorders o Test-retest reliability, a comparison of whether patients receive the same diagnosis when they are assessed twice with some time interval separating the two assessments, is also an important factor in this evaluation  Anti-social personality disorder has a high test-retest reliability, indicating that it is a stable diagnosis  Schizotypal and dependent personality disorders are very low, indicating that the symptoms of people with such diagnoses are not stable over time - Durbin and Klein 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 personality disorder was used and short time intervals were employed - There is an overall age-related decline over time in personality dysfunction as people get older - The stability of personality dysfunction varies according to subtle but important difference in the nature of symptoms o Acute symptoms are especially likely to decrease over time while symptoms reflecting negative affect are quite stable and these chronic symptoms are likely a reflection of character and personality structure and organization - 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 o 55% of patients with borderline PD also met the diagnostic criteria for schizotypal PD o 47% , the criteria for anti-social PD o 57%, the criteria for histrionic PD - Data still suggest that the categorical diagnostic system of DSM-IV-TR is not ideal for classifying personality disorders - 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. dimensional approach provide strong support for the dimensional approach - Canadian researchers have provided some evidence to suggest that the psychopathy underscoring anti-social personality may represent a discrete category; however, another recent analysis has concluded that psychopathy should be considered dimensional - Overall, a dimensional approach seems to apply to most other personality characteristics - John Livesley from UBC shows that when people with a PD take a general personality inventory, what is revealed is a personality with a structure that is similar to that of normal people but is simply most extreme - Lakehead University has shown that dimensional differences exist when characterizing normal vs. abnormal personality o personality disorders reflect extreme and rigid response tendencies that differ in degree, not in kind, from the response of people without disorders o personality disorders can be construed as the extremes of characteristics we all possess - Livesly, Schroeder, Jackson and Jang regard personality disorder as a failure of inability to come up with adaptive solutions to life tasks - Livesley identified three types of life tasks and proposed that failure with any one task is enough to warrant a PD diagnosis - These three tasks include 1) To form stable, integrated and coherent representations of self and others 1 | P a g e PSYB32: Abnormal Psychology Meera Mehta Summer 2012 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 behaviours - Once one of these tasks fails, disorder is evident and the focus can shift to dimensional ratings Assessing Personality Disorders - Many disorders are egosyntonic: the person with a PD is typically unaware that a problem exists and many not be experiencing significant personal distress, meaning they lack insight into their own personality - The assessment and diagnosis of PDs are enhanced when the significant others in an individual’s life become informants - Due to a lack of personal awareness in many cases, disorders may need to be diagnosed via clinical interviews led by trained personnel - A substantial proportion of patients are deemed to have personality disorder not otherwise specified (PDNOS) and these patients do not fit into existing personality disorder diagnostic categories - Verheul and Widiger concluded that PDNOS is the third-most prevalent type of personality disorder diagnosed via structured interviews, with the prevalence of this PDNOS ranging from 8 to 13% in clinical samples - Tyrer et al. reviewed these and other problems and concluded that “the assessment of personality disorder is currently inaccurate, largely unreliable, frequently wrong, and in need of improvement” - Clinical interviews are preferable when seeking to make a diagnosis, but researchers often rely on the use of self-report measure when assessing PD symptoms - Harkness, McNulty, and Ben-Porath described a set of personality constructs to reflect psychopathology o This framework, known as the PSY-5, consists of dimensions assessing negative emotionality/neuroticism, lack of positive emotionality, aggressiveness, lack of constraint and psychoticism o PSY-5 dimensions are promising because they seem particularly relevant to certain forms of personality dysfunction  Trull et al. noted that the PSY-5 constraint scale should be robustly associated with anti-social PD symptoms given that the constraint scale has items that assess lying, stealing, and getting into legal trouble  Michael Bagby showed that both the PSY-5 and the NEO-PI(R) were strong, significant unique predictors of the symptoms of 10 PDs  The PSY-5 was comparatively better at predicting paranois, schizotypal, narcissistic, and anti-social PD symptom counts - The most widely used measure of PD symptoms is the Millon Clinical Mutiaxial Inventory, now in its third edition (MCMI-III) - It provides subscale measures of 11 clinical personality scales o Schizoid, avoidant, depressive, compulsive, passive-aggressive, self-defeating and three severe personality pathology scales (schizotypal, borderline, and paranoid) - The MCMI-III also provides symptom ratings for clinical syndromes located on Axis 1 of DSM-IV, such as somatoform disorder and post-traumatic stress disorder - The MCMI-III includes a validity index and three response-style indices that correct for such tendencies as denial and random responding o The inclusion of these scales reflects Millon’s recognition of the need to assess response biases and other self- report tendencies that can undermine the data obtained via self-report scales o The updated 2009 version of the MCMI-III has new norms and additional scoring o It now incudes “therapy-guiding facet scales”, known as the Grossman Facet Scales o These facet scales were added to facilitate Millon and Grossman’s new treatment approach called personalized therapy - Personalized Therapy— therapy is tailored to each person’s unique personality and associated needs and personality style - Two key issues involving self-report measures of PD need to be considered 1) The various self-report measure differ in their content and are not equivalent o University of Alberta examined the prevalence of PD in university students by administering three self-report PD scales, including the MCMI-II, the MMPI PD scale, and the Coolidge Axis Two Inventory (CATI) o For men, narcissistic PD was the most prevalent disorder according to the MCMI-II and CATI results, but the MMPI measure indicated that paranoid PD was the most prevalent o For women, the most prevalent disorder according to MCMI-II results was avoidant PD, but it was narcissistic PD according to CATI responses and paranoid PD according to MMPI responses 2) A general concern involving self-report measures, including PD measures, is that the cut-off points used to determine the presence of a personality disorder often overestimate the number of people who meet diagnostic criteria for particular disorders 2 | P a g e PSYB32: Abnormal Psychology Meera Mehta Summer 2012 o Sinha and Watson found that 26.28% of women surveyed had an avoidant PD o A common pattern in comparative research is that only a proportion of those who appear to have a diagnosable disorder on the basis of the self-report measure actually are diagnosed following more detailed examination using clinical criteria o Blanco et al. compared the results of a US national epidemiological study for college students versus same-aged young adults not attending university o Found that 17.68% of students met criteria for PD in their lifetime versus 21.55% of non-college-attending peers o About 1 in 5 people met criteria for one or more PDs o About 1 in 5 people met criteria for an alcohol use disorder - Personality disorder diagnoses were determined by Blanco et al. based on the results of a structured clinical interview Personality Disorder Clusters - PDs are grouped into three clusters 1) Cluster A o Individuals in cluster A (paranoid, schizoid, and schizotypal) seem odd or eccentric o These disorders reflect oddness and avoidance of social contact 2) Cluster B o Individuals in cluster B (borderline, histrionic, narcissistic, and anti-social) seem dramatic, emotional, or erratic o Behaviours are extrapunitive and hostile 3) Cluster C o Individuals in cluster C (avoidant, dependent, and obsessive-compulsive) appear fearful - Recent evidence suggests that perhaps a fourth cluster, cluster D, should be considered as well - Cluster D would involve splitting the obsessive-compulsive features into a separate category reflecting the themes of obsession and inhibition - People with borderline and schizotypal PDs would probably have been diagnosed as schizophrenic using DSM-II criteria - The initial draft of DSM-5, in recognition to the overlap among disorder categories and the difficulties distinguishing between certain disorders, has proposed going to a reduced framework based on only five categories 1) Antisocial/psychopathic 2) Avoidant 3) Borderline 4) Obsessive-compulsive 5) Schizotypal Odd/Eccentric Cluster - Comprises of three diagnoses: paranoid, schizoid and schizotypal PDs - The symptoms of these disorders bear some similarity to the symptoms of schizophrenia, especially to the less severe symptoms of its prodromal and residual phases PARANOID PERSONALITY DISORDER - Paranoid Personality Disorder— a disorder in which a person expects to be mistreated by others, becomes suspicious, secretive, jealous and argumentative. (S)he will not accept blame and appears cold and unemotional o Reluctant to confide in others and tend to blame them even when they themselves are at fault o They can be extremely jealous and may question the fidelity of a spouse of lover o Preoccupied with unjustified doubts about the trustworthiness or loyalty of others  They may read hidden negative or threatening messages into events o Diagnosis is different from schizophrenia, paranoid-type, because symptoms such as hallucinations are not present and there is less impairment in social and occupational functioning o Differs from delusional disorder because full-blown delusions are not present o Occurs most frequently in men and co-occurs most frequently with schizotypal, borderline, and avoidant PDs o One of the more commonly diagnoses PDs in community samples and PPD is best represented as a continuous dimension rather than a discrete category 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 o Appear dull, bland and have no warm, tender feelings for others o Prevalence is less than 1% and is slightly less common in women than among men o Comorbidity is highest in schizotypal, avoidant and paranoid PDs, most likely because of the similar diagnostic criteria in the four categories 3 | P a g e PSYB32: Abnormal Psychology Meera Mehta Summer 2012 o The diagnostic criteria for schizoid PD are also similar to some of the symptoms of the prodromal and residual phases of schizophrenia 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 overelaborations, and is usually socially isolated o Under stress, (s)he may appear psychotic o Grew out of Danish studies of the adopted children of schizophrenic parents o Diagnosed criteria for schizotypal PD were devised by Spitzer, Endicott, and Gibbon o Usually have the interpersonal difficulties of the schizoid personality and excessive social anxiety that does not diminish as they get to know others o Several additional, more eccentric symptoms, identical to those that define the prodromal and residual phases of schizophrenia, occur in schizotypal PD o Cognitive limitations and restrictions found in schizophrenia are also evident in schizotypal PD o Have odd beliefs or magical thinking and recurrent illusions o In their speech, they may use words in an unusual and unclear fashion o Their behaviour and appearance may also be eccentric; they may talk to themselves o Common are ideas of reference, suspiciousness, and paranoid ideation o Widiger et al. found that paranoid ideation, ideas of reference and illusions were the symptoms most relevant for making a diagnosis o Prevalence of this disorder is about 3% and is slightly more common among men than women - Significant problem in the diagnosis of schizotypal PD is its comorbidity with other PDs o Morey found that 33% of people diagnosed with schizotypal PD also met the diagnostic criteria for borderline PD, while 59% also met the criteria for avoidant PD and paranoid PD o The comorbidity between Axis I and II disorders is higher for schizotypal PD than for any other PD, and the degree of comorbidity with borderline PD and narcissistic PD continues to be very high ETIOLOGY OF THE ODD/ECCENTRIC CLUSTER - Search for causes has been guided by the idea that these disorders are genetically linked to schizophrenia, perhaps as less severe variants of this Axis I disorder 1) Family studies of paranoid PD for the most part find higher than average rates in the relatives of people with schizophrenia or delusional disorder 2) Family studies have shown that the relatives of people with schizophrenia are at increased risk for this disorder o Squires-Wheeler found increased rates in the first-degree relatives of people with depression, suggesting that schizotypal PD is related to disorders other than schizophrenia - Genetic factors play some role in etiology, but a recent study of twins in Norway found that the heritabilities of PDs were modest and ranged from 20 to 41% o The lowest heritability estimate was found for schizotypal PD and the largest heritability estimate was found for anti-social PD o Found no evidence that there were unique genetic factors distinguishing cluster A, B, and C disorders - PDs of the odd/eccentric cluster are related to schizophrenia - People with schizotypal PD have deficits in cognitive and neuropsychological functioning that are similar to those seen in schizophrenia - People with schizotypal PD have deficits in cognitive and neuropsychological functioning that are similar to those seen in schizophrenia - Schizotypal PD is associated with enlarged ventricles and less temporal-lobe grey matter - Berenbaum et al. showed that schizotypal PD was linked with a history of post-traumatic stress disorder and childhood maltreatment even after controlling for the links that these factors also had with anti-social and borderline personality disorder symptoms Dramatic/Erratic Cluster - Diagnoses in the dramatic/erratic cluster- borderline, histrionic, narcissistic, and anti-social personality disorders- include clients with a wide variety of symptoms, ranging from variable behaviour to inflated self-esteem, exaggerated emotional displays and anti-social behaviour 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 4 | P a g e PSYB32: Abnormal Psychology Meera Mehta Summer 2012 o Core features of this disorder are impulsivity and instability in relationships, mood, and self-image o Attitudes and feelings toward other people may vary considerably and inexplicably over short periods of times o Emotions are erratic and can shift abruptly, particularly from passionate idealization to contemptuous anger o Argumentative, irritable, sarcastic, quick to take offence and very hard to live with o Unpredictable and impulsive behaviour of people with BDP may include gambling, spending, indiscriminate sexual activity and eating sprees  Impulsivity is not exclusive to BDP  Montreal researches have argued that impulsivity is one trait that underscores all four disorders in the dramatic and erratic clusters o Individuals with BDP have not developed a clear and coherent sense of self and remain uncertain about their values, loyalties and career choices o Cannot bear to be alone, have fears of abandonment, and demand attention o Subject to chronic feelings of depression and emptiness, they often attempt suicide and engage in self-mutilating behaviour o Research in Canada indicates that 1 in 10 people with BDP commit suicide o According to Joel Paris, in contrast to typical patterns, most BDP sufferers who kill themselves are females rather than male and most suicides occur after multiple attempts rather than on the first attempt o Follow-up data suggest that those who die by suicide are higher in impulsivity and violent-aggressive features linked with cluster B disorders o Originally, the term implied that the person was on the borderline between neurosis and schizophrenia  The current conceptualization comes from two main sources  Gunderson, Kolb and Austin proposed a set of specific diagnostic criteria similar to those that ultimately appeared in DSM-III  Study of the relatives of those people with schizophrenia done by Spitzer et al. - BDP typically begins in early adulthood, has a prevalence of 1 to 2% and is more common in women than in men - BDP sufferers are most likely to have an Axis I mood disorder and their parents are more likely to average to have mood disorders and other forms of psychopathology - Comorbidity is found with substance abuse, post-traumatic stress disorder, eating disorders and personality disorders from the off/eccentric cluster - Paris reviewed recent evidence and concluded that most clients with BDP recover over time o The results of a 27-year investigation conducted in Montreal found that gradual improvement over time occurred for most clients, such that only 7.8% met criteria for BDP 27 years later o The mortality rate of the sample as a whole was substantially elevated, relative to Canadian norms, as many BDP patients had premature deaths o The McLean study of Adult Development by Zanarini et. al Is a longitudinal study that also indicates a more positive long-term prognosis, with remission rates of BDP (74%) much higher than believed possible o Psychosocial functioning of BDP patients is still poor and improves only slightly over time o Borderline features are combined with anti-social tendencies in some individuals Etiology of Borderline Personality Disorder - Paris has observed that treatment is challenging and usually not based on theory because the etiology of BPD is still largely unknown Borderline Personality and Spouse Abuse - The presence of a personality dominated by borderline characteristics is an important aspect of Dutton’s theory of batterers - His analysis of etiological factors has focused on three central characteristics of the abusive personality; borderline personality characteristics, anger, and the chronic experience of traumatic symptoms - Dutton suggests that batterers are characterized by an anxious and angry attachment style instead of the secure attachment style that is linked with interpersonal and personal adjustment - BDP characteristics of abusive men are responsible for many of the interpersonal problems in abusive relationships - Several studies attest to the link between spouse abuse and borderline personality characteristics, but recent longitudinal research suggests that PD is general plays a role o A 20-year study found that cluster A and cluster B features in adolescence predicted subsequent partner violence o Cluster A features that were most implicated included fearfulness and suspiciousness, while cluster B features involved were the anti-social tendencies and the dramatic features implicated in BDP o In contrast, the avoidance inherent in cluster C disorders predicted less likelihood of subsequent partner abuse 5 | P a g e PSYB32: Abnormal Psychology Meera Mehta Summer 2012 - BPD characteristics also appear to undermine attempts at treatment - Dutton et. al found that men with certain PDs have higher levels of post-treatment recidivism in terms of subsequent spouse abuse - 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 Object-Relations Theory - Important variant of psychoanalytic theory - Concerned with the way children incorporate or introject the values and images of important people - The focus is on the manner in which children identify with people to whom they have strong emotional attachments - These introjected people become part of the person’s ego, but they can come into conflict with the wishes, goals, and ideals of the developing adult - Theorists hypothesize that people react to their world through the perspectives of people from their past, primarily their parents or other primary caregivers o These perspectives conflict with the person’s own wishes o Two leading object-relations theorists are Otto Kernberg and Heinz Kohut o Kernberg proposed that adverse childhood experiences cause children to develop insecure egos  People with BPD have weak egos and need constant reassuring, but they retain the capacity to test reality  They 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 aspects of another person or the self into a whole  This tendency causes extreme difficulty in regulating emotions because the person with BPD sees the world, including themselves, in black-and-white terms  People with BPD report a low level of care by their mothers  They view their families as emotionally inexpressive, low in cohesion and high in conflict  Links and van Reekum’s study indicates that they also frequently report childhood sexual and physical abuse  Many of those with BPD have experienced separation from parents during childhood Biological Factors - BPD runs in families, suggesting that it has a genetic component - BPD is also linked with neuroticism, a heritable trait - Some data suggest poor functioning of the frontal lobes, which may play a role in impulsive behaviour - BPD clients perform poorly on neurological tests of frontal-lobe functioning and show low glucose metabolism in the frontal lobes - 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 - Marsha Linehan proposes that BPD develops when people with a biological diathesis for having difficulty controlling their emotions are raised in a family environment that is invalidating - A diathesis for what Linehan calls emotional dysregulation can interact with experiences that invalidates that developing child, leading to the development of borderline personality - An invalidating environment is one in which the person’s wants and feelings are discounted and disrespected, and efforts to communicate one’s feelings are disregarded or even punished - An extreme form of invalidation is child abuse, sexual and nonsexual - The two main hypothesized factors- dysregulation and invalidation- interact with each other in a dynamic fashion - A key piece of evidence supporting Linehan’s theory concerns childhood physical and sexual abuse - Abuse is more frequent among people with BPD than among people diagnosed with other disorders - One exception to this general pattern is dissociative identity disorder, which is also linked with very high rates of childhood abuse - Given the high rates of dissociative symptoms in BDP, the two disorders may be related and dissociation in both disorders may reflect the extreme stress of child abuse - Toss et al. found that the link between child abuse and borderline symptoms was mediated by dissociative tendencies - Linehan herself has cautioned, most aspects of her theory of etiology remain to be investigated HISTRIONIC PERSONALITY DISORDER - 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 sexually seductive without taking responsibility for flirtations 6 | P a g e PSYB32: Abnormal Psychology Meera Mehta Summer 2012 o Formerly called hysterical personality o They often use features of their physical appearance, such as unusual clothes, makeup, or hair colour to draw attention to themselves o These individuals, although displaying emotion, are thought to be emotionally shallow o They are self-centred, overly concerned with their attractiveness and uncomfortable when not the centre of attention o They can be inappropriately sexually provocative and seductive and are easily influenced by others o Their speech is often impressionistic and lacking in detail o This diagnosis has a prevalence of 2 to 3% and is more common in women than among men o The prevalence of HPD is higher among separated and divorced people, and it is associated with high rates of depression and poor physical health o Comorbidity with BDP 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 - People with HPD are thought to have been raised in a family environment in which parents talked about sex as something dirty but behaved as though it was exciting and desirable - This upbringing may explain the preoccupation with sex, coupled with a fear of actually behaving sexually - 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 centre of attention is seen as a defence mechanism, a way to protect themselves from their true feelings of low self-esteem NARCISSISTIC PERSONALITY DISORDER - Narcissistic Personality Disorder—a disorder in which people are extremely selfish and self-centred; have a grandiose view of their uniqueness, achievements and talents; and have an insatiable craving for admiration and approval from others o They are exploitative to achieve their own goals and expect much more from others than they themselves are willing to give o They are preoccupied with fantasies of great success o They require almost constant attention and excessive admiration and believe that only high-status people can understand them o Their interpersonal relationships are disturbed by their lack of empathy, feeling of envy, arrogance, and their tendency to take advantage of others o The prevalence of NPD is less than 1% o It most often co-occurs with BPD 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 - Narcissistic personalities are very sensitive to criticism and deeply fearful of failure - Sometimes they seek out others whom they can idealize because they are disappointed in themselves, but others are not allowed to become genuinely close o Their relationships are few and shallow o People with NPD become angry with others and reject them when they fall short of their unrealistic expectations - Their inner lives are impoverished because they actually think very little of themselves - According to Kohut, the self emerges early in life as a bipolar structure with an immature grandiosity at one pole and a dependent overidealization of other people at the other o A failure to develop healthy self-esteem occurs when parents do not respond with approval to their children’s displays of competency o The child is not values for his or her own self-worth but rather as a means to foster the parents’ self-esteem - Kohut suggests that when parents responds to a child with respect, warmth, and empathy, the child is endowed with healthy self-esteem o But when parents further their own needs rather than directly approve of their children, the result may be a narcissistic personality o Children neglected in this way do not develop an internalized, healthy self-esteem and have trouble accepting their own shortcomings o 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 AND PSYCHOPATHY 7 | P a g e PSYB32: Abnormal Psychology Meera Mehta Summer 2012 - The terms “anti-social personality disorder” and psychopathy” are often used interchangeably, although there are important differences between the two o Anti-social behaviour is an important component of both terms Characteristics of Anti-Social Personality Disorder - Anti-social Personality Disorder—a disorder in which a person, also called a psychopath or 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 - ADP involves two major components 1) A conduct disorder is present before the age of 15  Truancy, running away from home, frequent lying, theft, arson, and deliberate destruction of property are major symptoms of conduct disorder  Upwards of 60% of children with conduct disorder later develop APD 2) This pattern of anti-social behaviour continues in adulthood - The DSM diagnosis involves not only certain patters of anti-social behaviour, but patterns that began in childhood - Adults with anti-social PD show irresponsible and anti-social behaviour working only inconsistently, breaking laws, being irritable and physically aggressive, defaulting on debts, and being reckless o They are impulsive and fail to plan ahead, and, although completely aware of lies and misdeeds, may neither show regard for truth nor experience remorse for their misdeeds - It is estimated that about 3% of adult men and 1% of women in the United States have anti-social personalities - A community study conducted in Edmonton found that about 3% of people met DSM criteria for APD - Rates are much higher among younger than among older adults and among people of low socio-economic status - APD is comorbid with a number of other diagnoses, most notably substance abuse - Swanson et. al found that more than 90% of those with APD had at least one other lifetime psychiatric diagnosis - Burt confirmed differences between aggressive and non-aggressive rule-breaking forms of anti-social personality, with environmental factors playing a larger role in the non-aggressive form Characteristics of Psychopathy - On the basis of his clinical experience, Cleckley formulated a set of criteria for recognizing the disorder - Cleckley’s criteria for psychopathy refer less to anti-social behaviour per se than to the psychopathic individual’s thoughts and feelings - One of the key characteristics of psychopathy is poverty of emotions, both positive and negative - Psychopathic people have no sense of shame, and even their seemingly positive feelings for others are merely an act - The psychopath is superficially charming and manipulates others for personal gain - They exploit others even if it involves the use of violence and aggression - Their lack of anxiety may make it impossible for psychopaths to learn from their mistakes, and their lack of positive emotions leads them to behave irresponsibly and often cruelly toward others - Another key point in Cleckley’s description is that the anti-social behaviour of the psychopath is performed impulsively, as much for thrills as for something like financial gain - Most researchers diagnose psychopathy using a checklist developed by Hare Controversies with Diagnoses of APD and Psychopathy - ADP and psychopathy are related, but they are by no means identical o One study found that only about 20% of people with APD scored high on the Hare PCL-R o Harpur and Hare observed that almost all psychopathys are diagnosed with APD but many people diagnosed with APD do not meet the criteria for psychopathy on the PCL-R o Hare et al. criticized the DSM diagnosis of APD because it requires accurate reports of events from many years earlier by people who are habitual liars o 75 to 80% of convicted felons meet the criteria for APD, while only 15 to 20% of convicted felons meet the criteria for psychopathy o Lack of remorse is one of seven criteria for the DSM’s APD diagnosis, and only three of these criteria need to be present to make the diagnosis  A person diagnosed with
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