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Chapter 13

detailed Chapter 13 notes.docx

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Konstantine Zakzanis

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Chapter 13: Personality Disorders Personality disorders: heterogeneous group of disorders that are coded on Axis II of the DSM  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 some but not all cause emotional distress  symptoms of many personality disorders come close to describing characteristics that we sometimes possess from time to time, but actual personality disorder is defined by extremes of several traits and by inflexible ways these traits are expressed  patterns of behaviour must be long-standing, pervasive and dysfunctional CLASSIFYING PERSONALITY DISORDERS: CLUSTERS, CATEGORIES, AND PROBLEMS - diagnosis of personality disorders has occurred since days of Hippocrates and were listed in early DSMs - in DSM-III, personality disorders were placed on a separate axis and diagnosis was much more reliable - since personality disorders are considered to be more stable over time that episodic axis-I diagnosis, test-retest reliability is important in evaluation -difficult to diagnose a single, specific personality disorder because many people exhibit a wide range of traits that make several diagnoses available  A study found that 55% of patients with borderline personality disorder also met the diagnostic criteria for schizotypal personality disorder, 47% for anti-social personality disorder, and 57% for histrionic personality disorder - Livesley identified 3 types of life tasks and proposed that failure with any one task is enough to warrant a personality disorder diagnosis: To form stable, integrated, and coherent representation of self and others To develop the capacity for intimacy and positive affiliations with other people To function adaptively in society by engaging in prosocial and co-operative behaviours ASSESSING PERSONALITY DISORDERS - Many disorders are egosytonic- person with a personality disorder is typically unaware that a problem exists and may not be experiencing significant personal distress, lack of insight of own personality - another challenge in diagnosis is that a large proportion of patients are deemed to have personality disorder not otherwise specified (PDNOS) - although clinical interviews are preferable for diagnosis, researchers often rely on the use of self-report measures The most widely used measure of personality disorder symptoms is the Millon Clinical Multitaxial Inventory, now in its 3 edition (MCMI-III) provides subscale measure of 11 clinical personality scales (schizoid, avoidant, depressive, dependent, histrionic, narcissistic, anti-social, aggressive, compulsive, passive-aggressive, and self-defeating) and 3 severe personality pathology scales (schizotypal, borderline, and paranoid) - Personalized therapy: therapies need to be modified to recognize each person’s unique needs and personality styles - self report measures often overestimate the number of people who meet diagnostic criteria for particular disorders, plus the content of diff self report measures are different and not equivalent - self report methods should be supplemented with clinical interviews like the personality disorder examination PERSONALITY DISORDER CLUSTERS When a DSM-IV-TR criterion is involved, personality disorders are grouped into 3 clusters: Cluster A  paranoid, schizoid, and schizotypal  seem odd or eccentric  these disorders reflect oddness and avoidance of social contact Cluster B  Borderline, histrionic, narcissistic, and anti-social  Seem dramatic, emotional, or erratic  Behaviours are extrapunitive, and hostile Cluster C  Avoidant, dependent, and obsessive-compulsive  Appear fearful - perhaps a fourth cluster, cluster D, should be considered – involves splitting the obsessive-compulsive features into a separate category reflecting obsession and inhibition ODD/ECCENTRIC CLUSTER Comprises 3 diagnoses and these disorders are similar to schizophrenia: Paranoid personality disorder:  Being suspicious of others  They expect to be mistreated or exploited by others and thus are secretive and always on the lookout for possible signs of trickery and abuse  Unwilling to confide in others & tend to blame others even when they themselves are at fault  Can be extremely jealous and may unjustifiably question the fidelity of a spouse or lover  Preoccupied with unjustified doubts about the trustworthiness or loyalty of others (neighbor’s dog deliberately barks to disturb him/her)  Hallucinations are NOT present  Occurs most frequently in men  Co-occurs most frequently with schizotypal, borderline & avoidant personality disorders Schizoid personality disorder:  they don’t appear to desire or enjoy social relationships & usually have no close friends  they appear dull, bland, and aloof and have no warm, tender feelings for others  rarely report emotions, have no interest in sex & experience few pleasurable activities  indifferent to praise and criticism  loners with solitary interests  prevalence is less than 1%  slightly less common among women than men  comorbidity is highest for schizotypal, avoidant, and paranoid personality disorders Schizotypal Personality disorder:  usually have the interpersonal difficulties of the schizoid personality and excessive social anxiety that doesn’t diminish as they get to know others  cognitive limitations and restrictions found in schizophrenia are also evident  may have odd beliefs or magical thinking (superstitiousness, beliefs that they are clairvoyant and telepathic) and recurrent illusions (may sense the presence or force or a person not actually there)  common are ideas of reference (belief that events have a particular and unusual meaning for the person), suspiciousness, and paranoid ideation  generally have constricted and flat affect  in their speech, they may use words in an unusual and unclear fashion (“I’m not a very talkable person”)  their behaviour and appearance may be eccentric  they may talk to themselves  paranoid ideation, ideas of reference, and illusions were they symptoms most relevant for making a diagnosis  prevalence of this disorder is about 3%  very comorbid with other personality disorders – 33% of people diagnosed with schizotypal personality disorder met the diagnostic criteria for borderline personality disorder, while 59% met criteria for avoidant personality disorder and paranoid personality disorder  slightly more frequent among men than women Etiology of odd/eccentric cluster: - believe that these disorders are genetically linked to schizophrenia  find higher than average rates in relatives of people with schizophrenia or delusional disorder  relatives with schizophrenia are at increased risk for schizotypal personality disorder - The lowest heritability estimate was found for schizotypal personality disorder and the largest heritability estimate was found for anti-social personality disorder - studies found no evidence that there were unique genetic factors distinguishing cluster A, B and C disorders - Schizotypal personality disorder is associated with enlarged ventricles & less temporal-lobe grey matter, similar to schizophrenia - Schizotypal personality disorder was linked with a history of post-traumatic stress disorder and childhood maltreatment DRAMATIC/ERRATIC CLUSTER 1. Borderline personality: impulsivity and instability in relationships, mood, and self-image - attitudes and feelings toward other people may vary considerably and inexplicably over short periods of time emotions are erratic & can shift abruptly, from passionate idealization to contemptuous anger argumentative, irritable, sarcastic, quick to take offence, and very hard to live with behaviour may include gambling, spending, spending, indiscriminate sexual activity, and eating sprees, and is thus potentially self-damaging do not develop a clear and coherent sense of self and thus they remain uncertain about their values, loyalties, and career choices 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 (1 in 10 people with BDP commit suicide) and engage in self-mutilating behaviour (slicing legs with a razor blade) typically begins in early adulthood has a prevalence of 1-2% and is more common in women likely to have an axis I mood disorder and more likely than others to have mood disorder and other forms of psychopathology  comorbidity is found with substance abuse, PTSD, eating disorders, and personality disorders of odd/eccentric cluster most clients with BDP recover over time Etiology of Borderline personality disorder:  may be due to some family issue during childhood which leads them to develop insecure egos runs in family suggest
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