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Chapter 13

chapter 13

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Konstantine Zakzanis

1 Chapter 13: Personality disorder Borderline personality disorder: frequent mood swings, periods of depression and extreme irritability Personality disorders (PD) are a heterogeneous group of disorders that are coded on Axis II of DSM; they are regarded as long-standing, pervasive and inflexible patterns of behaviour and inner experience that deviate from the expectations of the persons culture and that impair social and occupational functioning; some but not all can cause emotional distress It is defined by extremes of several traits and by inflexible way these traits are expressed People are often rigid in their behaviour and cannot change it in response to changes in the situation they experience Individuals cannot be diagnosed as having PD unless the patterns of behaviour were long-standing, pervasive and dysfunctional Paranoid PD: you feel you are target of some joke and people are talking about you; it has to occur frequently and intensely and it prevents the development of close personal relationships CLASSIFYING PERSONALITY DISORDERS: CLUSTERS, CATEGORIES AND PROBLEMS Reliability of PD diagnoses has been improved because of two developments (1) publication of specific diagnostic criteria and (2) development of structured interviews specially designed for assessing PDs Inter-rater reliability (the extent to which raters agree); by using structured interviews, reliable diagnoses of PDs can be achieved; interviews with ppl who know the patient well are sometimes part of the diagnostic workup and improve the accuracy of the diagnosis Since PDs are presumed to be more stable over time than some episodic Axis I disorders, test-retest reliability (comparison of whether patients receive the same diagnosis when they are assessed twice with some time interval separating the two assessments) is important factor for evaluations Antisocial personality disorder has a high test-retest reliability, indicating that it is a stable diagnosis; a patient given the diagnosis is likely to receive the same diagnosis when evaluated later Figures for schizopal and dependent PDs are very low, indicating the symptoms of people with these are not stable overtime Test-retest reliability of diagnoses is poor Study of PD diagnoses in opiate dependent patients: they used semi-structured interviews and found that test-retest reliability for any specific PD is poor; the reliability for anti-social PD was higher but this was still much lower than the summary by Zimmerman Stability coefficients were greater when a dimensional view of PD was used and shorter intervals were employed Overall age-related decline over time in personality dysfunction as people get older 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 (self-harming) while symptoms reflecting negative affect are quite stable and these chronic symptoms are likely a reflection of character and personality structure and organization www.notesolution.com 2 Often difficult to diagnose a single, specific PD because many disordered people exhibit a wife range of traits that make several diagnoses applicable 55% of patients with borderline PD also met diagnostic criteria for schizotypal PD, antisocial PD and histrionic PD Categorical diagnostic system of DSM Iv may not be ideal for classifying PDs; personality traits that constitute the data for classification form a continuum; most of the relevant characteristics are present in varying degrees in most people; strong support for dimensional approach because it applies to most personality characteristics People with PD take a general personality inventory, what is revealed is a personality with a structure that is similar to that of normal people but is simply extreme Dimensional differences exist when characterizing normal vs. Abnormal personality; PD reflect extreme and rigid response tendencies that differ in degree, not in kind, from the responses of people without disorders PDs can be construed as the extremes of characteristics we all possess Livesley et. Al. Regard PD as failure or inability to come up with adaptive solutions to life tasks; identified three types of life tasks and proposed that failure with any one task is enough to warrant a PD diagnosis:- (1) to form stable, integrated, coherent representations of self and others (2) to develop the capacity of intimacy and positive affiliations with other people (3) to function adaptively in society by engaging in prosocial and co-operative behaviours o Once one of these conditions exists, disorder is evident and the focus can shift to dimensional ratings ASSESSING PDs Egosyntonic: person with the PD is unaware that the problem exists and may not be experiencing significant personal distress; however people who interact with them may have great deal of discomfort or upset Assessment and diagnosis enhanced when significant other in an individuals life become informants Because of lack of self awareness, disorders may need to be diagnosed via clinical interviews led by trained personnel Substantial proportion of patients are deemed to have PD not otherwise specified (PDNOS) and these do not fit into existing PD diagnostic categories PDNOS is the third most prevalent type of PD diagnosed via structured interviewed, with prevalence ranging from 8-13% in clinical samples Self-report measures used when assessing PD symptoms o MMPI-2 is a personality inventory; scoring schemes have been created to assess the symptoms of specific PDs o PSY-5: set of MMPI-2 scares developed to assess 5 dimensional personality constructs to reflect psychopathologythis framework consists of dimensions assessing negative emotionality/neuroticism, lack of positive emotionality, aggressiveness, lack of constraint and psychoticism; it has been corroborated via confirmatory factor analyses and they are promising because they seem relevant to certain forms of personality dysfunction www.notesolution.com 3 o PSY-5 constraint scale should be associated with anti-social PD symptoms given that the constraint scale has items that assess lying, stealing, getting into legal trouble Millon Clinical Multiaxial Inventory (MCMI-III): 175 term true-false inventory that was revised parallel to DSM 4; it proves subscale measures of 11 clinical personality scales and 3 severe personality pathology scales (shizotypal, borderline and paranoid) o Provides symptoms ratings for clinical syndromes located on Axis I of the DSM 4, such as somatoform disorder and PTSD o It includes validity index and three response-style indices (modifying indicies) that correct for such tendencies as denial and random responding o Millions recognition of the need to assess response biases and other self-report tendencies that can undermine the data obtained via self-report scales o Two issues involving self report measures of PD that 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) cut off points used to determine the presence of PD often overestimate the number of people who meet diagnostic criteria for particular disorders Common pattern in comparative research is that only a proportion of those who appear to have a diagnosable disorder on the basis of self-report measure actually are diagnosed following more detailed examination using clinical criteria If goal is to obtain accurate diagnoses, a measure such as MCMI-III is best used in conjunction with a clinical interview such as personality disorder examinationthis interview provides dimensional and categorical assessments PERSONALITY DISORDER CLUSTERS 1) Individual in Cluster A (paranoid, schizoid, and schizotypal) seem odd or eccentric; oddness and avoidance of social culturesimilar to symptoms of schizophrenia, especially to the less severe symptoms of its prodromal and residual phases 2) Cluster B (anti-social, borderline, histrionic and narcissistic) are dramatic, emotional and erratic; behaviour are extrapunitive and hostile 3) Cluster C (avoidant, dependent and obsessive-compulsive) appear fearful ODD/ECCENTRIC CLUSTER Paranoid Personality Disorder (PPD): suspicious of others; they expect to be mistreated or exploited by others and thus are secretive and always on the lookout for possible signs of trickery and abuse They are reluctant to confide in others and tend to blame them even when they themselves are at fault Can be extremely jealous and may unjustifiably question the fidelity of a spouse or lover They are preoccupied with unjustified doubts about trustworthiness or loyalty of others Read hidden negative or threatening messages into events www.notesolution.com 4 Different from schizophrenia paranoid type because symptoms such as hallucinations are not present and there is less impairment in social and occupational functioning Differs from delusional disorder because full-blown are not present Occur more in men and co occur frequently with schizotypal, borderline and avoidant PDs Prevalence is 1% 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 Rarely report strong emotions, have n
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