Chapter 13 Notes

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14 May 2011

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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
- 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
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- 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
- 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 individuals 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 3rd 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
- the most widely used measure of PD symptoms is the Milon Clinical Multiaxial Inventory, which is now in
its 3rd 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
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- 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
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 neighbors 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
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