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Personality Disorders.docx

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Konstantine Zakzanis

Chapter 13 – Personality Disorders:  Personality disorders – heterogeneous disorder set on Axis II of DSM o 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 Classifying Personality Disorders: Clusters, Categories and Problems:  Before diagnosis was very unreliable  DSM 3: placed personality disorders on separate axis 2  Improved because of 2 developments: publication of specific diagnosis criteria, development of structured interviews designed for assessing personality disorders  Inter-rater reliability  PD more stable over time than Axis 1 disorders  Same diagnosis twice in two assessments necessary for PD  Anti-social personality has a stable diagnosis  Schizotypal and dependent personality disorders unstable  Cluster B disorders most stability overtime  Overall age-related decline over time in personality dysfunction as people age  Acute symptoms likely to decrease overtime  Difficult to diagnose a single, specific personality disorder because people show a wide range of traits  Categorical diagnostic of DSM 4 not ideal  Strong support for the dimensional approach  Livesley: 3 types of life tasks (failure of one = diagnosis) o To from stable, integrated and coherent representations of self and others o To develop the capacity for intimacy and positive affiliations with other people o To function adaptively in society by engaging in prosocial and cooperative behaviors  DSM 5: “adaptive failure” – impaired self-identity and adaptive failure in establishing interpersonal relationships  DSM 5: changes reflect dimensional approach Assessing Personality Disorders:  Many disorders are egosyntonic – the person with a personality disorder is typically unaware that a problem exists and may not be experiencing distress – they lack insight into their own personality  PDNOS – personality disorder not otherwise specified – don’t fit into diagnostic categories  Verheul and Widiger: PDNOS 3 most prevalent type of personality disorder  Clinical measures preferred for diagnosis  Many use self-report measures  MMPI-2 – personality inventory used for assessment  PSY-5: 5 dimensional personality constructs to reflect psychopathology, dimensions assessing negative emotionality/neuroticism, lack of positive emotionality, aggressiveness, lack of constraint and psychotism  PSY-5 and NEOPIR 0 strong, significant predictors of symptoms of 10 personality disorders  PSY-5 better at predicting: paranoid, schizotypal, narcissistic and anti-social PD  Most widely used measure othPD symptoms = Million Clinical Multiaxial Inventory 3 – 175 item true-false inventory at an 8 grade reading level o Provide subscale measures of 11 clinical personality scales and three severe personality pathology scales o Also provide symptoms for clinical symptoms on Axis 1 (somatoform and PTSD) o Now includes another way of scoring: therapy guiding facet scales known as Grossman Facet Scales  Facet scales for added to facilitate Millon’s and Grossman’s new treatment approach: personalized therapy – treatment needs to be modified to recognize each person’s unique needs  Two issues with self-report measures: not equivalent, cut-off points use to determine disorder Personality Disorder Clusters:  3 clusters in categorical approach: o A: (paranoid, schizoic and schizotypal) seem odd or eccentric, reflect oddness and avoidance of social contact o B: (borderline, histrionic, narcissistic, and anti-social) seem dramatic, emotional or erratic, hostile and extrapunitive behaviour o C: (Avoidant, dependent, obsessive-compulsive) appear fearful  Empirical evidence on validity of clusters is mixed, research suggest cluster D also  Cluster D would split the obsessive compulsive features into a separate category = obsession and inhibition  DSM 5: 5 categories: antisocial/psychopathic, avoidant/borderline, obsessive-compulsive and schizotypal (odd/eccentric) Odd/Eccentric Cluster:  3 diagnoses: paranoid, schizoid and schizotypal PDs Paranoid Personality Disorder:  Suspicious of others, expect to be mistreated by others  Reluctant to confide in others and tend to always blame themselves  Very jealous and always suspect spouse/lover  Preoccupied with trust/loyalty of others  No hallucinations, less impairment in social and occupational functioning that schizophrenia  Full blown delusions also not present  Occurs most frequently in men  Co-occurs with schizotypal, borderline and avoidant personality disorders  One of the more commonly diagnosed personality disorders Schizoid Personality Disorder:  Do not appear to desire or enjoy social relationships, no close friends  Appear dull, bland and have no warm feelings for others  Rarely report strong emotions, no interest in sex  Loners with solitary interests  Prevalence less than 1%  Slightly less common among women  Comorbid: schizotypal, avoidant and paranoid personality disorders Schizotypal Personality Disorder:  Grew out of a Danish study of adopted children of schizophrenic parents  Have interpersonal personality difficulties of schizoid personality and excessive social anxiety that does not diminish as they get to know others  Cognitive limitations  May also have odd beliefs or magical thinking and recurrent illusions  Eccentric behaviour – may talk to themselves  Affect appears to be constricted and flat  Widiger: paranoid ideation, ideas of reference and illusions were the symptoms most relevant for making a diagnosis  Prevalence about 3%  Slightly more frequent among men than women  Comorbidity high between Axis 1 and 2 disorders (more so for this disorder) Etiology of the Odd/Eccentric Cluster:  Genetically linked to schizophrenia  Family studies show an increased risk  Depressed person – family members increased risk for disorders related to schizophrenia  Heritability modest 20-41%  Lowest heritability – schizotypal personality disorder, highest – anti-social PD  Schizotypal – deficits in cognitive and neuropsychological functioning  Schizotypal personality disorder associated with enlarged ventricles and less temporal-lobe gray matter  Berenbaum: schizotypal linked with history of PTSD and childhood maltreatment Dramatic/Erratic Cluster:  Borderline, histrionic, narcissistic, and anti-social PD Borderline Personality Disorder:  Impulsitivity, instability in relationships, mood and self-image  Attitudes and feelings toward other people vary over short periods of time  Emotions are erratic and can shift quickly  Very hard to live with, quick to take offence, irritable  Gambling, spending, indiscriminate sexual activity and eating sprees  Not developed a clear sense of self, remain uncertain about career, values, choices  Cannot bear to be alone, demand attention  Subject to feelings of depression and emptiness, often commit suicide  Self-mutilating behaviour  1 in 10 commit suicide, mostly females that commit after multiple attempts  Features linked with cluster B disorders  Originally thought to be borderline b/w neurosis and schizophrenia  Typically begins in early adulthood  Prevalence 1-2%, more common in women than men  Also likely to have axis 1 mood disorder, parents with disorder of some sort  Comorbid with: substance abuse, PTSD, eating disorder, personality disorder odd/eccentric cluster  Most clients recover over time  Psychosocial functioning quite poor and improves only slightly over time  Overall level of functioning remains quite poor Borderline Personality and Spouse Abuse:  Dutton: 3 central characteristics of abusive personality: borderline personality characteristics, anger and chronic experience of traumatic symptoms  Blame their partners when something goes wrong  Cluster A and B features when young predicted spousal violence  Cluster A most implicated = fearfulness and suspiciousness  Cluster B = anti-social tendencies and dramatic features implicated in BPD  Avoidance inherent in cluster C predicted less abuse  Men undermine attempts of treatment (women also) Etiology of Borderline Personality Disorder:  Etiology is still largely unknown, hard to treat Object-Relations Theory:  Important variant of psychoanalytic theory is concerned with way children incorporate the values and images of important people, such as their parents  Way in which children identify with people they are close with  These people become part of child’s ego but they can come into conflict with developing adult  People react to their world through the perspectives of people from their past  Weak egos and need constant reassurance in BPD o Retain capacity to test reality  In touch with reality but frequently engage in defence mechanism splitting – looking at object/person as all good or all bad (Sees everything in black and white)  Defence protects them from intolerable anxiety  Report a lower level of care by mothers  View families as emotionally inexpressive, high in conflict, low cohesion  Childhood sexual and physical abuse (BPD)  Many are separated from parents in childhood Biological Factors:  Runs in families suggesting a genetic component  Linked with neuroticism, heritable trait  Poor function of frontal lobes may = impulsive behaviour  Low glucose in frontal lobes, poor function  Low levels of serotonin associated with impulsivity  Given drug to increase serotonin and levels of anger decreased Linehan’s Diasthesis-Stress Theory:  BPD occurs when children with predisposition raised in invalidating family environment  Person’s wants and feelings are diswanted and disrespected and efforts to communicate feelings are punished  2 main hypothesized factors for invalidation: o Dysregulation – child makes enormous demands on family o Invalidation  High rates of disassociate symptoms in BPD, disassociate and BPD – might be extreme stress of child abuse  Most of her theory has to be investigated Histrionic Personality Disorder:  Histrionic personality disorder (HPD) – formerly called hysterical personality, people who are overly dramatic and attention-seeking o Use features of clothes to draw attention o Display emotions vividly o Self-centered, overly concerned with attractiveness, uncomfortable when not the centre of attention o Easily influenced by others o Speech often lacks detail o Prevalence 2-3% more common in women o Higher among separated or divorced people, high rates of depression and poor health o Comorbidity with BPD HIGH Etiology of Histrionic Personality Disorder:  Little research on it  Psychoanalytic theory: emotionality and seductiveness were encouraged by parental seductiveness (Father to daughter)  Thought to have been raised in a family environment in which parents talk about sex as something dirty but behaved as though it is exciting  Preoccupation with sex in this disorder and fear  Seen as conflicts of underlying stress, need attention = defence mechanism Narcissistic Personality Disorder:  Grandiose view of their own uniqueness and abilities  Preoccupied with fantasies of success  Require almost constant attention and excessive admiration and believe that only high-status people can understand them  Interpersonal relationships disturbed by their lack of empathy, feelings of envy, arrogance and tendency to take advantage of others  Prevalence less that 1%  Co-occurs with BPD Etiology of Narcissistic Personality Disorder:  Psychoanalytic: very fragile self-esteem o Very sensitive to criticism, fear failure o Others not allowed to become close with them o Relationships are few and shallow o Inner lives are impoverished because they think very little of themselves  Kohut: 2 books The analysis of Self and restoration of self – have established a variant to psychoanalysis = self-psychology o Self-emerges early in life as bipolar structure (grandiosity and overidealization of other people) o Failure to develop healthy self-esteem o Child not valued for his/her self-worth but rather as a means to foster parents self- esteem o When parents respond with warmth, empathy, respect child’s self-esteem rises Ant
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