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Chapter 13

PSYB32- Chapters 13 Notes

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University of Toronto Scarborough
Konstantine Zakzanis

Chapter 13: Personality Disorders • Personality disorder (PDs) are a heterogeneous group of disorders that are coded on Axis II of the DSM. They are 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, can cause emotional distress. Classifying Personality Disorders: Clusters, Categories, and Problems • The reliability of personality disorders diagnoses, then, has improved because of two developments: (1) the publication of specific diagnostic criteria; and (2) the development of structured interviews specially designed for assessing personality disorders. Assessing Personality Disorders • Some key points need to be made about the assessment of personality disorders. A significant challenge is that many disorders are egosyntonic: the person with a personality disorder is typically unaware that a problem exists and may not be experiencing significant personal distress; that is, they lack insight into their own personality. • Another significant challenge is that a substantial proportion of patients are deemed to have a personality disorder not otherwise specified (PDNOS) and these patients do not fit into existing personality disorder diagnostic categories. • This framework, known as the PSY-5, consists of dimensions assessing negative emotionality/neuroticism, lack of positive emotionality, aggressiveness, lack of constraint, and psychoticism. • PSY-5 and the NEO-PI(R) were strong, significant unique predictors of the symptoms of 10-personality disorders. • Perhaps the most widely used measure of personality disorder symptoms is the Millon Clinical Multiaxal Inventory, now in its third edition. The MCMI-III is a 175-item true-false inventory at an eighth grade reading level that was revised to parallel DSM-IV. • The update 2009 version of the MCMI-III has new norms and additional scoring. It now includes “therapy-guiding facet scales” (e.g. interpersonal style, cognitive style) known as the Grossman Facet Scales that further characterize the person who answered the MCMI-III. These facet scales were added to facilitate Milon and Grossman’s (2007) new treatment approach known as personalized therapy. Personality Disorder Clusters • Personality disorders are grouped into three clusters: 1. Individuals in cluster A (paranoid, schizoid, and schizotypal) seem odd or eccentric. These disorders reflect oddness, and avoidance of social contact. 2. Those in cluster B (borderline, histrionic, narcissistic, and anti- social) seem dramatic, emotional, or erratic. Behaviours are extrapunitive and hostile. 3. Those in cluster C (avoidant, dependent, and obsessive- compulsive) appear fearful. Odd/Eccentric Cluster • The odd/ eccentric cluster comprises three diagnoses: paranoid, schizoid, and schizotypal PDs. The symptoms of these disorders bear some similarity to the symptoms of schizophrenia, especially to the less severe symptoms of its prodromal and residual phases. Paranoid Personality Disorder • The individual with paranoid personality disorder (PPD) is suspicious of others. • PPD occurs most frequently in men and co-occurs most frequently with schizotypal, borderline, and avoidant personality disorders. Schizoid Personality Disorder • People with schizoid personality disorder do not appear to desire or enjoy social relationships and usually have no close friends. They appear dull, bland, and aloof and have no warm, tender feelings for others. They rarely report strong emotions, have no interest in sex, and experience few pleasurable activities. • Comorbidity is highest for schizotypal, avoidant, and paranoid personality disorders. Schizotypal Personality Disorder • The concept of the schizotypal personality grew up of Danish studies of the adopted children of schizophrenic parents. Although some of these children developed full-blown schizophrenia as adults, an even larger number developed what seemed to be an attenuated form of schizophrenia. • People with schizotypal personality disorder usually have the interpersonal difficulties of the schizoid personality and excessive social anxiety that does not diminish as they get to know others. • Those with schizotypal personality disorder may also have odd beliefs or magical thinking and recurrent illusions. Etiology of the Odd/Eccentric Cluster • Family studies of paranoid personality disorders for the most part find higher than average rates in the relatives of people with schizophrenia or delusional disorder. • Family studies have shown that the relatives of people with schizophrenia are at increased risk for this disorder. • The lowest heritability estimate was found for schizotypal personality disorder and the largest heritability estimate was found for anti-social personality disorder. Dramatic/Erratic Cluster • The diagnoses in the dramatic/erratic cluster – borderline, histrionic, narcissistic, and anti-social personality disorders – include clients with a wide variety of symptoms, ranging from variable behaviour to inflated self-esteem, exaggerated emotional displays, and anti-social behaviour. Borderline Personality Disorder • The core features of this disorder are impulsivity and instability in relationships, mood, and self-image. • Emotions are erratic and can shift abruptly, particularly from passionate idealization to contemptuous anger. BPD sufferers are argumentative, irritable, sarcastic, quick to take offence, and very hard to live with. • Individuals with BPD have not developed a clear and coherent sense of self and remain uncertain about their values, loyalties, and career choices. They cannot bear to be alone, have fears of abandonment, and demand attention. • BPD typically begins in early adulthood, has a prevalence of 1% to 2% and is more common in women than in men. • Comorbidity is found with substance abuse, posttraumatic stress disorder, eating disorders, and personality disorders from the odd eccentric cluster. Object-Relations Theory • Object-relations theory, an important variant of psychoanalytic theory, is concerned with the way children incorporate (or introject) the values and images of important people, such as their parents. In other words, the focus is on the manner in which children identify with people to whom they have strong emotional attachments. • Splitting: dichotomizing objects into all good or all bad and failing to integrate positive and negative aspects of another person or the self into a whole. This tendency causes extreme difficulty in regulating emotions because the person with BPD sees the world, including himself or herself in black-and-white terms. • The diagnosis of histrionic personality formerly called hysterical personality is applied to people who are overly dramatic and attention-seeking. They often use features of their physical appearance, such as unusual clothes, makeup, or hair colour, to draw attention to themselves. These individuals, although displaying emotion extravagantly, are though to be emotionally shallow. They are self-centred, overly concerned with their attractiveness, and uncomfortable when not the centre of attention. • People with a narcissistic personality disorder (NPD) have a grandiose view of their own uniqueness and abilities. To say that they are self-centred is an understatement. They require almost constant attention and excessive admiration and believe that only high-status people can understand them. • The prevalence of NPD is less than 1%. It most often co-occurs with BPD. Etiology of Narcissistic Personality Disorder • Heinz Kohut established a variant of psychoanalysis known as self-psychology. According to Kohut, the self emerges early in life as bipolar structure with an immature grandiosity at one pole and a dependent overidealization of other people at the other. A failure to develop healthy self-esteem occurs when parents do
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