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Chapter 13


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Konstantine Zakzanis

Chapter 13Personality Disorderspersonality disordersa heterogeneous group of disorders listed separately on Axis II regarded as longlasting inflexible and maladaptive personality traits that impair social and occupational functioningpersonality disorders are a heterogeneous group of disorders that are coded on Axis II of the DSM theyre regarded as longlasting 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 experienceClassifying Personality Disorders Clusters Categories and Problems as with other diagnoses the publication of DSMIII began a trend toward improve reliability beginning with DSMIII 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 culturesby using structured interviews reliable diagnoses of PDs can be achievedbecause PDs are presumed to be more stable over time than some episodic Axis I disorders eg depression testretest reliabilitya comparison of whether patients receive the same diagnosis when theyre assessed twice with some time interval separating the 2 assessmentsis also an important factor in their evaluationantisocial PD has a high testretest 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 10year stability of categorical diagnoses was relatively poorstability coefficients were greater when a dimensional view of PDs was used and shorter time intervalswere employed consistent with the greater stability of antisocial disorders Cluster B disorders had the greatest stability over time it was confirmed that there is an overall agerelated decline over time in personality dysfunction as people get olderit was 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 selfharming while symptoms reflecting negative affect are quite stable and these chronic symptoms are likely a reflection of 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 applicablealthough some decrease in comorbidity occurred with the publication of DSMIV the data still suggest that the categorical diagnostic system of DSMIVTR 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 approachoverall a dimensional approach seems to apply to most other personality characteristicsthe 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 cooperative behaviorsonce 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 patients dont fit into existing PD diagnostic categoriesrd it was concluded that PDNOS is the 3 most prevalent type of PD diagnosed via structured interviews with the prevalence of this PDNOS ranging from 813 in clinical samples although clinical interviews are preferable when seeking to make a diagnosis researchers often rely on the use of selfreport measures when assessing PD symptoms MMPI2 can be used to do this researchers described a set of MMPI2 scales that they developed to assess 5 dimensional personality constructs to reflect psychopathology this framework known as the PSY5 consists of dimensions assessing negative emotionalityneuroticism lack of positive emotionality aggressiveness lack of constraint and psychoticism the PSY5 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 now in rdits 3 editionthe MCMIIII is a 175 item truefalse inventory and the MCMIIII provides subscale measures of 11 clinical personality scales and 3 severe personality pathology scales schizotypal borderline and paranoid the MCMIIII also provides symptoms ratings for clinical syndromes located on Axis I of the DSMIV it also includes a validity index and 3 responsestyle indices known as modifying indices that correct for such tendencies as denial and random responding 2 key issues involving selfreport measures of PD need to be considered1 empirical tests comparing the various selfreport measures show that they differ in their content and are not equivalent2 a general concern involving selfreport measures including PD measures is that the cutoff points used to determine the presence of a PD often overestimate the number of people who
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