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Chapter 13

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University of Toronto Scarborough
Konstantine Zakzanis

1 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; theyre regarded as long-lasting, pervasive, and inflexible patterns of behavior and inner experience that deviate from the expectations of a persons 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 expressed - 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 theyre 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 arent 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 2 character and personality structure and organization - 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 diagnosis - 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 prdients dont fit into existing PD diagnostic categories - twas concluded that PDNOS is the 3 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 rd now in its 3 edition - the MCMI-III is a 175 item true-false inventory and the MCMI-III provides subscale measuresof 11 clinical personality scales and 3 severe personality pathology scales (schizotypal, borderline, and 3 paranoid) - 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 clusters; 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 extra-punitive 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; theyre 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 arent 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 - prevalence = 1% 4 schizoid personality disorder a disorder in which the person is emotionally aloof, indifferent to the praise, criticism, and feelings of others, and usually a loner with few, if any, close friends and with solitary interests - patients with this dont 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 - this disorder is slightly less common among women than men; prevalence = 1% - comorbidity is highest for schizotypal, avoidant, and paranoid personality d
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