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Chapter 13

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Konstantine Zakzanis

Chapter 13 – Personality Disorders  Personality Disorders : heterogenous group of disorders that are coded on Axis II of the DSM  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  Cannot change in response to changes in the situations being experienced by the individuals  Placed in Axis II (beginning in DSM-III) so that diagnosticians would pay attention to their possible presence  Improvements due to 1) Publication of specific diagnostic criteria; 2) development of structured interviews specially designed for assessing personality disorders  Use of test-retest reliability since personality disorders are presumed to be more stable over time than episodic nature of some Axis I disorders  Overall age related decline in personality dysfunction as people get older  Acute symptoms more likely to decrease over time (Ex: self-harming) while symptoms reflecting negative affect are stable/chronic (reflection of character and personality structure)  Can be regarded as a failure or inability to come up with adaptive solutions to life tasks  Form stable, integrated, and coherent representations of self and others  Develop capacity for intimacy and positive affiliations with other people  Function adaptively in society by engaging in pro-social and co-operative behaviours Assessing Personality Disorders  Egosyntonic → person with personality disorder is typically unaware that a problem exists and may not be experiencing significant personal distress  Lack insight into their own personality  May be diagnosed with Personality disorder not otherwise specified (PDNOS)  Do not fit into existing personality disorder diagnostic categories  3 most prevalent PD diagnosed via structured interviews (8-13% in clinical samples)  Use of self-report measures (Ex: MMPI-2) → PSY-5 assessment -  Negative emotionality/neuroticism  Lack of positive emotionality  Aggressiveness  Lack of constraint  Psychoticism  Millon Clinical Multiaxial Inventory (MCMI-III) th  175 item true-false inventory at 8 grade reading level that provides 11 clinical personality scales  11 clinical personality scales, 3 severe personality pathology scales Chapter 13 – Personality Disorders  Schizoid, avoidant, depressive, dependent, histrionic, narcissistic, anti-social, aggressive/sadistic, compulsive, passive-aggressive, & self-defeating)  Schizotypal, borderline, & paranoid  Includes validity index and 3 response-style indices that correct for tendencies like denial and random responding  Add Grossman Facet Scales to facilitate personalized therapy and characterize person→ modified to recognize each person’s unique needs and personality styles when trying to help them  Problems o Various self-report measures differ in their content and are not equivalent (can lead to differing interrater reliability o Cut-off points used to determine the presence of a personality disorder often overestimate the # of people who meet diagnostic criteria for particular disorders Personality Disorder Clusters 1. Cluster A → Odd or eccentric; reflect oddness and avoidance of social contact  Paranoid, Schizoid, Schizotypal 2. Cluster B → Dramatic, emotional or erratic; extrapunitive and hostile behaviours  Borderline, Histrionic, Narcissistic, Anti-social 3. Cluster C → Fearful  Avoidant, Dependent, Obsessive-compulsive 4. (**Cluster D → involve splitting the obsessive-compulsive features into a separate category reflecting the themes of obsession and inhibition) Odd/Eccentric Cluster  Bare similarity to symptoms of schizophrenia (especially to less severe symptoms of its prodromal/residual phases)  Paranoid Personality Disorder  Suspicious of others  Expect to be mistreated or exploited by others → secretive and always on lookout for possible signs of trickery and abuse  Reluctant to confide in others, blame them even when they themselves are at fault  Extremely jealous (question fidelity of spouse/lovers)  Preoccupied with unjustified doubts about trustworthiness/loyalty of others  Read hidden negative or threatening messages into events  Ex: neighbour’s barking dog is a conspiracy against individual Chapter 13 – Personality Disorders  No presentations of hallucinations, less impairment in social and occupational functioning, no full blown delusions  Most common in men, co-occurs frequently with schizotypal, borderline, and avoidant PDs  Schizoid Personality Disorder  Do not appear to desire or enjoy social relationships and usually have no close friends  Appear dull, bland, aloof and have no warm feelings for others  Rarely report strong emotions, no interest in sex, experience few pleasurable activities  Indifferent to criticism and praise → loners with solitary interests  <1% prevalence, slightly more common in women  High co-morbidity with schizotypal, avoidant, paranoid PDs  Schizotypal Personality Disorder  Have interpersonal difficulties of the schizoid personality and excessive social anxiety that does not diminish as they get to know others  Additional symptoms seen in schizophrenia (during prodromal and residual) occur in schizotypal → cognitive limitations/restrictions  Odd beliefs, magical thinking (Ex: superstitious, beliefs of telepathy and being psychic)  Recurrent illusions (Ex: sense the presence of others when nobody is there)  Talk to themselves  Ideas of reference (belief that events have particular and unusual meaning for person)  Suspiciousness, paranoid ideations  3% diagnosis, tend to be more frequent among men than women  Co-morbidity: 33% also had borderline, 59% had avoidant and paranoid PDs  High co-morbidity with Axis I disorders compared with other PDs  Linked to history of PTSD, childhood maltreatment  Deficits in cognitive and neuropsychological functioning  Enlarged ventricles and less temporal-lobe grey mater  These disorders may be genetically linked to schizophrenia → appear to be less severe variants of Axis I disorder  Lowest heritability estimate → Schizotypal  Highest heritability → Anti-social Dramatic/Erratic Cluster  Variable behaviour, inflated self-esteem, exaggerated emotional displays, anti-social behaviour Chapter 13 – Personality Disorders  Borderline Personality Disorder  Impulsivity and instability in relationships, mood, and self-image  Varying inexplicable feelings toward other people over short periods of time  Erratic emotions and can shift abruptly → passionate idealization to contemptuous anger  Argumentative, irritable, sarcastic, quick to take offence, and very hard to live with  Impulsive behaviour may lead to gambling, spending, indiscriminate sexual activity, eating sprees → self-damaging  Have not developed a clear and coherent sense of self and remain uncertain about their values, loyalties, and career choices  Cannot bear to be alone, have fears of abandonment, and demand attention  Chronic feelings of depression and emptiness → suicidal, self-mutilating  Most who kill themselves are female rather than male and most suicides occur after multiple attempts  Begin in early adulthood, 1-2% prevalence, more common in women than men  Co-morbid with Axis I mood disorder, parents more likely than average to have mood disorders and psychopathology as well  Also with substance abuse, PTSD, eating disorders, personality disorders from odd/eccentric cluster  Most clients recover over time, but have elevated mortality rates Object-Relations Theory for BPD  Concerned with the way children incorporate values and images of important people (parents)  Focus is on the manner in which children identify with people to whom they have strong emotional attachments  These people become part of the person’s ego, but they may come into conflict with the wishes, goals, and ideals of the developing adult  Hypothesizes that people react to their world through the perspectives of people from their past (parents and caregivers)  These perspectives conflict with the person’s own wishes  May be due to adverse childhood experiences  Ex: parents who provide love and attention inconsistently, unable to offer emotional support  Weak egos and need constant reassurance  Still in touch with reality, but need to engage in defence mechanism  Splitting: dichotomizing objects into all good or all bad and failing to integrate positive and negative aspects of another person into a whole  Sees the world in black-and-white terms (including themselves)  View families as emotionally inexpressive, may have been victims of abuse, separation from parents during childhood Chapter 13 – Personality Disorders Biological Factors for BPD  Runs in families  Linked with neuroticism (heritable trait)  Poor functioning of frontal lobes → play role in impulsivity (may be due to low glucose metabolism)  Increase serotonin levels, decreased level of anger Linehan’s Diathesis-Stress Theory of BPD  Proposes BPD develops when people with a biological diathesis for having difficulty controlling their emotions are raised in a family environment that is invalidating  Invalidating environment → person’s wants and feelings are discounted and disrespected  Efforts to communicate feelings are disregarded or punished (extreme case = child abuse)  Emotionally dysregulated child makes enormous demands on family  Parents may ignore/punish outburst → lead to emotional suppression that eventually leads to explosion (gets parental attention)  Causes reinforcement of aversive behaviours  Histrionic Personality Disorder  Applied to those who are overly dramatic and attention-seeking  Often use features of their physical appearance to draw attention to themselves  Emotionally shallow (even though they display emotional extravagance)  Self-centred, overly concerned with attractiveness  Inappropriately sexually provocative and seductive  Easily influenced by others  Impressionistic speech and lacking in detail (Ex: state strong opinion but unable to support it)  2-3% prevalence, more common among women  Higher among separated/divorced people, associated with depression and poor physical health  Emotionality and seductiveness were encouraged by parental seductiveness  Raised in family environment in which parents talked about sex as something dirty but behaved as though it was exciting/desirable  Explain preoccupation with sex, but fear of actually sexual activity  Self-centredness → defence mechanism to protect themselves from true feelings of low self- esteem Chapter 13 – Personality Disorders  Narcissistic Personality Disorder  Grandiose views of their own uniqueness and abilities  Preoccupied with fantasies of great success  Require constant attention and excessive admiration and believe that only high-status people can understand them  Lack of empathy, feelings of envy, arrogance, and their tendency to take advantage of others, feelings of entitlement  <1% prevalence, co-morbid with Borderline Personality Disorder  Sense of self-centredness may be a mask for fragile self-esteem and fearful of failure (psychoanalytic theory)  Shallow relationships → seek out others that they can idealize because they are disappointed in themselves but do not allow them to come genuinely close  Angry with others, reject them when they fall short of unrealistic expectations  Think very little of themselves  Self-psychology  Self emerges as a bipolar structure → immature grandiosity and dependent overidealization of other people on opposite ends  Failure to develop healthy self-esteem occurs when parents do not respond with approval to their children’s displays of competency o Parents foster their own self-esteem over their children’s o Lead to individuals striving to bolster their sense of self through unending quests for love and approval from others  Anti-Social Personality Disorder 1. Conduct disorder → Truancy, running away from home, lying, theft, arson, and deliberate destruction of property (before the age of 15); 60% with this end up with APD 2. Pattern of anti-social behaviour continues to adulthood  Adults → irresponsible and anti-social behaviour by working only inconsistently, breaking laws, being irritable and physically aggressive, defaulting on debts, and being reckless  Impulsive and fail to plan ahead  Completely aware of lies and misdeeds → show no regard for truth/experience remorse  3% (men), 1% (women) prevalence  Rates are higher among younger than among older adults, and low socio-economic st
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