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Chapter 12- Personality Disorders.docx

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PSYC 3140
Kendra Thomson

Chapter 12 Personality Disorders According to the DSM-IV-TR, personality disorders defined as: ­ “Enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts” and “are inflexible and maladaptive, and cause significant functional impairment or subjective distress” Overview ­ Personality: all the characteristic ways a person behaves and thinks ­ Personality characteristics are “inflexible and maladaptive and cause significant functional impairment or subjective distress” ­ Personality disorders are chronic (originate in childhood, continue throughout adulthood) ­ Because they affect personality, they pervade every aspect of a person’s life (i.e. employment, relationships, even where they live) ­ Having this disorder may distress affected person, however, person may not feel subjective distress; it may be acutely felt by others because of actions of the person with the disorder o Common with antisocial personality disorder (shows blatant disregard for rights of others & shows no remorse) ­ In certain cases, someone other than the person with the personality disorder must decide whether the disorder is causing significant functional impairment, because the affected person often cannot make such a judgment. ­ Many people who have personality disorders in addition to other psychological problems tend to do poorly in treatment ­ Data shows that people who are depressed have a worse outcome in treatment if they also have a personality disorder ­ Most disorders we discuss in this book are on Axis I of the DSM-IV-TR, which includes the standard traditional disorders. o Personality disorders are included on a separate axis, on Axis II, because as a group they are distinct. o Characteristics traits are more ingrained and inflexible with people with personality disorders ­ In the axis system, a patient can receive a diagnosis on only Axis I, only Axis II, or on both axes. ­ A diagnosis on both Axis I and Axis II indicates that a person has both a current disorder (Axis I) and a more chronic problem (e.g., personality disorder) Categorical and Dimensional Models ­ People with personality disorders display problem characteristics over extended periods ­ Their difficulty can be seen as one of degree rather than kind  means that the problems of people with personality disorders may just be extreme versions of the problems many of us experience on a temporary basis, such as being shy or suspicious. ­ The distinction b/w problems of degree and problems of kind is usually described in terms of dimensions instead of categories. ­ The issue that continues to be debated in the field is whether personality disorders are extreme versions of otherwise normal personality variations (dimensions) or ways of relating that are different from psychologically healthy behaviour o (ex: We often label people's size categorically, as tall, average, or short. But height can also be viewed dimensionally, in centimetres or inches) ­ Most people in the field see personality disorders as extremes on one or more personality dimensions (ex you could be a bit shy, or extremely shy) ­ Yet, because we diagnose using DSM (uses categories), it ends up being viewed in categories o Either you have the disorder, or do not. DSM doesn’t rate how, for example, obsessive you are. No in-between is possible when it comes to personality disorders. ­ Advantage of using categorical models is convenience/simplification ­ Problems with categories: o Leads clinicians to view disorders as real “things” ; ex. Realness of an infection or broken arm o Some argue that personality disorders are not things that exist but points at which society decides a particular way of relating to the world has become a problem. o Unresolved issue comes up again: are personality disorders just extreme variant of normal personality or are they distinctly different disorders? ­ Researchers believe that many or all personality disorders represent extremes on one or more personality dimensions. ­ Some have proposed that the DSM-IV-TR personality disorders section be replaced by a dimensional model in which individuals would not only be given categorical diagnoses but also would be rated on a series of personality dimensions ­ Advantages: 1. It would retain more information about each individual 2. It would be more flexible because it would permit both categorical and dimensional differentiations among individuals 3. It would avoid the often arbitrary decisions involved in assigning a person to a diagnostic category ­ Five factor model of personality / “Big Five” o People rated on a series of personality dimensions i. Extraversion - Talkative, assertive, and active (Tendency to join in social situations and feel joy and optimism) ii. Agreeableness - Kind, trusting and warm (Extent to which someone shows both compassion and hostility toward others) iii. Conscientiousness - Organized, thorough, and reliable (Degree of organization and commitment to personal goals) iv. Neuroticism – Nervous, moody and temperamental (Proneness to psychological distress and impulsive behaviour) v. Openness to experience – Imaginative, curious and creative (Curiosity, receptivity to new ideas, and emotional expressiveness) ­ On each dimension, people are rated high, low or between ­ Five dimensions are universal ­ Alternative model by Westen and Shedler: o Identifies 12 personality dimensions i.Psychological health - Ability to love others, find meaning in life, and gain personal insights iiPsychopath - Lack of remorse, presence of impulsiveness, and tendency to abuse drugs iiiHostility - Deep-seated ill will iv.Narcissism - Self-importance, grandiose assumptions about oneself, and tendency to treat others as an audience to provide admiration v. Emotional Dysregulation - Intense and uncontrolled emotional reactions vi. Dysphoria - Depression, shame, humiliation, and lack of any pleasurable experiences vii.Schizoid orientation - Constricted emotions, inability to understand abstract concepts such as metaphors, and few or no friends viii.Obsessionality - Absorption in details, stinginess, and fear of dirt and contamination ix. Thought disorder - Such as believing one has magical powers over others or can directly read their minds x. Oedipal conflict - Adult pursuit of romantic partners who are already involved with others, inappropriate seductiveness, and intense sexual jealousy xi. Dissociated consciousness - Fragmenting of thought and perception often related to past sexual abuse xii.Sexual Conflict - Anxieties and fears regarding sexual intimacy Personality Disorder Clusters  DSM-IV-TR divides the personality disorders into three groups i. Cluster A is called the odd or eccentric cluster; it includes paranoid, schizoid, and schizotypal personality disorders. ii. Cluster B is the dramatic/emotional/erratic cluster; it consists of antisocial, borderline, histrionic, and narcissistic personality disorders. all four disorders in this cluster are characterized by elevated impulsivity iii. Cluster C is the anxious or fearful cluster; it includes avoidant, dependent, and obsessive- compulsive personality disorders.  Recent research shows that the proposed three-cluster structure only holds when the personality disorders are assessed by clinicians, and not when they are accessed via patient self-reports DSM-V Changes: ­ No axis || as in DSM-IV (no longer multiaxial) ­ Proposed revisions to personality disorder not accepted in main body of DSM-V but included as a separate chapter ­ Purpose: to remove arbitrary boundaries between personality disorders & other mental disorders ­ Criteria for the 10 disorders remain the same Statistics and Development  Canadian data on prevalence or personality disorders are lacking, except in the case of anti social disorder  American studies indicate that personality disorders are found in: - 0.5 percent to 2.5 percent of the general population (US) - rates are higher in inpatient and outpatient settings  Personality disorders are thought to originate in childhood or adolescence and continue into the adult years if untreated  People with borderline personality disorder are characterized by their volatile and unstable relationships; 10% attempt suicide, 6 % succeed in their attempts; can improve if they survive past their 30s  People with antisocial personality disorder display a characteristic disregard for the rights and feelings of others; some tend to burn out after the age of about 40 and engage in fewer criminal activities. -co-morbidity rates are high Gender Differences  More common in men: - Paranoid personality disorder - Schizoid personality disorder - Schizotypal personality - Antisocial personality disorder - Obsessive-compulsive personality disorder - Narcissistic personality  Females make up 75% of cases: - Borderline personality disorder  Equal Number: - Histrionic personality disorder - Avoidant personality disorder - Dependent personality disorder  psychologists incorrectly diagnosed more women as having histrionic personality disorder compared to men; can be due to bias against women (features of histrionic personality disorder, such as overdramatization, vanity, seductiveness, and overconcern with physical appearance, are characteristic of the Western “stereotypical female”) Cluster A Disorders: Paranoid Personality Disorder Paranoid Personality Disorder: excessively mistrustful and suspicious of others, without any justification. Assume other people are out to harm or trick them, and therefore they tend not to confide in others. Clinical Description ­ defining characteristic of people with paranoid personality disorder is a pervasive unjustified distrust ­ People with paranoid personality disorder are suspicious in situations in which most other people would agree that their suspicions are unfounded. (barking dog or a delayed airline flight as a deliberate attempt to annoy them) ­ very sensitive to criticism and have an excessive need for autonomy ­ Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her ­ Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates ­ Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her ­ Paranoid personality disorder is similar to paranoid type of schizophrenia and delusional disorder, however, there are differences: o The two mentioned disorders involve delusions (persistent beliefs that are out of touch with reality), whereas paranoid personality disorder does not o Another difference between the paranoid type of schizophrenia and paranoid personality disorder is that the former also involves other psychotic symptoms like hallucinations (e.g., hearing voices), whereas paranoid personality disorder does not ­ Causes: ­ Evidence for biological & psychological contributions to paranoid personality disorder is limited & unclear ­ May be more common in individuals who have relatives with schizophrenia ­ Retrospective research (asking people with this disorder to recall events from their childhood) suggests that traumatic childhood experiences may play a role in the development of paranoid personality disorder 9could be bias since their perspective is already off since childhood) ­ Their maladaptive way of viewing the world as a dangerous place may be due to their parents upbringing ­ Cultural factors have also been implicated in paranoid personality disorder. ­ Certain groups of people (prisoners, refugees etc.) are thought to be particularly susceptible because of their unique experiences Treatment ­ people with paranoid personality disorder are unlikely to seek help, and have difficulty developing the trusting relationships necessary for successful therapy ­ When they do seek therapy, the trigger is usually a crisis in their lives or other problems such as anxiety or depression, and not necessarily their personality disorder ­ Therapists often use cognitive therapy to counter the person's mistaken negative assumptions about others ­ However, there are no confirmed demonstrations that any form of treatment can significantly improve the lives of people with paranoid personality disorder. ­ an Australian survey of mental health professionals indicated that only 11 percent of therapists who treat paranoid personality disorder thought these individuals would continue in therapy long enough to be helped Schizoid Personality Disorder Schizoid personality disorder: 1. Pervasive pattern of detachment from social relationships 2. A restricted range of expression of emotions in interpersonal studies - The term schizoid is relatively old, having been used by Bleuler (1924) to describe people who have a tendency to turn inward and away from the outside world & who lacked emotional expressiveness and pursued vague interests. Clinical Description ­ Seem neither to desire nor enjoy closeness with others, including romantic or sexual relationships. ­ seem “aloof,” “cold,” and “indifferent” to other people ­ Do not seem affected by praise or criticism. ­ homelessness appears to be prevalent among people with this personality disorder ­ The social deficiencies of people with schizoid personality disorder are similar to those of people with paranoid personality disorder, although the deficiencies are more extreme. ­ Those with schizoid personality disorder do not have the same thought processes that characterize the other disorders in Cluster A but they do share the social isolation, poor rapport, and constricted affect o people with paranoid and schizotypal personality disorders often have ideas of reference, mistaken beliefs that meaningless events relate just to them. In contrast, those with schizoid personality disorder share the social isolation, poor rapport, and constricted affect (showing neither positive nor negative emotion) seen in people with paranoid personality disorder Causes and Treatments ­ Childhood shyness is reported to contributed to later adult schizoid disorder ­ Abuse and neglect in childhood are also reported among individuals with this disorder ­ Parents of children with autism are more likely to have schizoid personality disorder ­ It may be that dopamine may contribute to the social aloofness of people with schizoid personality disorder. ­ rare for a person with this disorder to request treatment except in response to a crisis such as extreme depression or losing a job ­ people with schizoid personality disorder often receive social skills training; person may even need to be taught the emotions felt by others to learn empathy ­ The therapist takes the part of a friend or significant other in a technique known as role- playing and helps the patient practice establishing and maintaining social relationships o This type of social skills training is helped by identifying a social network—a person or people who will be supportive ­ Treatment prognosis is generally poor & there’s a lack of research showing that treatment is effective Schizotypal Personality Disorder ­ Schizotypal personality disorder: pervasive pattern of interpersonal deficits featuring acute discomfort with, and reduced capacity for, close relationships, as well as by cognitive or perceptual distortions and eccentricities of behaviour. ­ Behaviour & dress is odd and unusual ­ Social isolated/may be highly suspicious of others ­ Magical thinking, ideas of reference, illusions ­ also behave in ways that would seem unusual to many of us, and they tend to be suspicious and to have odd beliefs ­ considered by some to be on the same spectrum with schizophrenia but without some of the symptoms such as hallucinations and delusions ­ may also meet criteria for major depression Clinical Description ­ Have psychotic-like (but not psychotic) symptoms (such as believing everything relates to them personally), social deficits, and sometimes cognitive impairments or paranoia ­ They have ideas of reference, which means they think insignificant events relate directly to them. However, unlike with schizophrenia, they may be able to acknowledge this is unlikely ­ have odd beliefs or engage in “magical thinking,” believing (ex. Thinking they are telepathic) ­ Unusual perceptual experiences, including such illusions as feeling the presence of another person when they are alone o Ex. Those with schizotypal feel as if there is another person in the room, whereas those with schizophrenia report there is someone in the room ­ Children who later develop this disorder tend to be passive and unengaged and are hypersensitive to criticism ­ Different cultural beliefs or practices may lead to a mistaken diagnosis of schizotypal personality disorder. Causes ­ the word schizotype was used to describe people who were predisposed to develop schizophrenia ­ Schizotypal personality disorder is viewed by some to be one phenotype of a schizophrenia genotype ­ Family, twin, and adoption studies, largely conducted in Norway, have shown an increased prevalence of schizotypal personality disorder among relatives of people with schizophrenia o However, these studies also tell us that the environment can strongly influence schizotypal personality disorder. (ex. a woman's exposure to influenza in pregnancy may increase the chance of schizotypal personality disorder in her children) ­ Biological theories of schizotypal personality disorder are receiving empirical support I.cognitive assessment of persons with this disorder point to mild/moderate decrements in their ability to perform on tests involving memory and learning (may be due to damage in left hemisphere) II. Graves suggests that abnormalities in semantic association abilities may contribute to the thinking oddities displayed by schizotypal individuals. III. To schizotypal people, “loose associations” may not be loose after all. a. A thinking style similar to those with schizotypal are those with high levels of magical ideation (MI). Those with high MI consider unrelated words as more closely associated. Treatment ­ Main focus is on developing social skills ­ 30 percent and 50 percent of the people with this disorder who request clinical help also meet the criteria for major depressive disorder. ­ Treatment include some of the medical and psychological treatments for depression ­ Controlled studies to treat those with schizotypal are few, and results are generally poor ­ Some therapists do not to encourage major changes at all; instead, the goal is to help the person accept and adjust to a solitary lifestyle ­ medical treatment has been similar to that for people who have schizophrenia. ­ In one study, haloperidol, often used with schizophrenia, was given to 17 people with schizotypal personality disorder. Though there was mild improvement, some stopped because of the negative effects - Evidence indicates that those with schizotypal may go on to develop schizophrenia Cluster B disorder: Antisocial Personality Disorder ­ Antisocial personality disorder: pervasive pattern of disregard for and violation of the rights of others ­ among the most dramatic of the individuals a clinician will see in a practice and are characterized as having a history of failing to comply with social norms. ­ completely lacks conscience, empathy, guilt/regrets ­ Irresponsible, impulsive, and deceitful ­ study shows that about 3 percent of adults in Edmonton meet criteria for antisocial personality disorder ­ Robert Hare describes them as social predators who charm, manipulate, and ruthlessly plow their way through life, leaving a broad trail of broken hearts, shattered expectations, and empty wallets Clinical Description ­ long histories of violating the rights of others, behavioural problems & conduct disorder ­ aggressive because they take what they want, indifferent to the concerns of other people. ­ often they appear unable to tell the difference between the truth and the lies they make up to further their own goals ­ no remorse or concern ­ Substance abuse is common- occurs in 60% ­ The long-term outcome for people with antisocial personality disorder is usually poor, regardless of gender ­ One study found that antisocial boys were more than twice as likely to die an unnatural death (e.g., accident, suicide, homicide) as their nonantisocial peers ­ Antisocial disorder has had many names over the years - a) Pinel identified what he called manie sans délire (mania without delirium) to describe -people with unusual emotional responses and impulsive rages but no deficits in reasoning ability - b) Other labels have included “moral insanity,” “egopathy,” “sociopathy,” and “psychopathy” - psycopathy: Non-DSM category similar to antisocial personality disorder but with less emphasis on overt behaviour DSM Diagnostic Criteria: A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15, as indicated by three (or more) of the following: 1. Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure 3. Impulsivity or failure to plan ahead 4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults 5. Reckless disregard for safety of self or others 6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations 7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another B. The individual is at least age 18. C. There is evidence of conduct disorder with onset before age 15. - Hare developed a 20 item checklist for psychopathy; high scores indicate psychopathy - Six of the items Hare includes in Revised Psychopathy Checklist (PCL-R) are: I. Glibness/superficial charm II. Grandiose sense of self-worth III. Proneness to boredom/need for stimulation IV. Pathological lying V. Conning/manipulative VI. Lack of remorse ­ The DSM-IV-TR criteria for antisocial personality focus almost entirely on observable behaviours ­ In contrast, the Cleckley/Hare criteria focus primarily on underlying personality traits ­ not everyone who has psychopathy or antisocial personality disorder becomes involved with the legal system; may be due to IQ ­ Study found that that having a higher IQ may help protect some people from developing more serious problems, or may at least prevent them from getting caught. ­ Because of the difficulty in identifying these people, such “successful” or “subclinical” psychopaths (who meet some but not all the criteria for psychopathy) have not been the focus of much research. ­ In an experiment, Widom recruited a sample of subclinical psychopaths through advertisements in underground newspapers that invited many of the major personality characteristics of psychopathy. o Widom found that her sample appeared to possess many of the same characteristics as imprisoned psychopaths; showing that some psychopathic traits avoid repeated contact with the legal system/ may even function well in society o Identifying psychopaths among the criminal population is impt for predicting future criminal behaviour ­ Study by Ogloff found that criminals who scored high on Hare's PCL-R put in less effort and showed fewer improvements in a therapy program than did criminals who were not p
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