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Chapter 12

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University of Toronto St. George

Chapter 12 Defining and diagnosing personality disorders • Personality: all the ways we have of acting, thinking, believing and feeling that make each of us unique • Personality trait: complex pattern of behaviour, thought and feeling that is stable across time and across many situations • Personality disorder: long-standing pattern of maladaptive behaviours, thoughts and feelings; adult must have shown these symptoms since adolescence or early adulthood; controversial because of conceptualization of these disorders and their assessment • Place in DSM: placed on Axis II of the diagnostic system instead of Axis I of the acute disorders; people with personality disorders often experience one of the acute disorders (like major depression or substance abuse); have problems in relationships • Cluster A: characterized by odd or eccentric behaviours and thinking; paranoid PD, schizoid PD and schizotypal PD; features of schizophrenia but no psychosis; behaviours simply odd and inappropriate o Symptoms: inappropriate or flat affect, odd thought and speech patterns and paranoid; maintain grasp on reality • Cluster B: characterized by dramatic, erratic and emotional behaviour and interpersonal relationships; antisocial PD, histrionic PD, borderline PD, narcissistic PD o Symptoms: manipulative, volatile and uncaring in social relationships; prone to impulsive, sometimes violent behaviours that show little regard for their own safety or needs of others; behave in wild/exaggerated ways or even engage in suicidal attempts to try to gain attention • Cluster C: characterized by anxious and fearful emotions and chronic self-doubt; dependent PD, avoidant PD and obsessive-compulsive PD o Symptoms: little self-confident and difficult relationships with others; concerned about being criticized or abandoned by others • Problems with DSM categories: DSM treats these disorders as categories, as if they represent something qualitatively different from a “normal” personality though the disorders represent extreme versions of normal traits; great deal of overlap in diagnostic criteria for PDs; diagnosing a PD requires information that is hard for a clinician to obtain; PDs conceptualized as stable characteristics of an individual though studies indicate that people very in number and severity of symptoms; some (including John Livesley) propose dimensional models of PD • Gender and ethnic biases: some argue that some disorders are extreme versions of negative stereotypes of women’s or men’s personalities; DSM doesn’t recognize that expressions of the symptoms of a disorder may naturally vary between groups; over or under-diagnosis in different genders; need to balance criteria to include equal numbers of symptoms and diagnoses that are pathological variants of masculine and feminine personality traits Odd-eccentric personality disorders • Overview: some consider these to be part of the schizophrenia spectrum; often occur in people who have first degree relatives with schizophrenia; may be precursors or milder versions of schizophrenia; have unusual beliefs or perceptual experiences that fall short of delusions and hallucinations • Paranoid personality disorder: chronic, pervasive and unwarranted mistrust of others that is maladaptive; weak relationship to schizophrenia; deeply believe other people are chronically trying to deceive/exploit them and are preoccupied with concerns about loyalty/trustworthiness of others; hyper-vigilant; overly susceptible to criticism; misinterpret or over-interpret situations in line with their suspicions; can become withdrawn or aggressive and arrogant o Prevalence and prognosis: epidemiological studies suggest that between 0.5 and 5.6% of the population can be diagnosed with PPD; males outnumber females three to one; increased risk for acute psychological problems, including major depression, anxiety disorders, substance abuse and psychotic episodes; unstable interpersonal relationships; poor prognosis with symptoms intensifying under stress o Theories: somewhat more common in families of people with schizophrenia than families of healthy control subjects; no twin/adoption studies have been done; cognitive theorists see it as the result of an underlying belief that other people are malevolent and deceptive, combined with a lack of self-confidence about being able to defend oneself against others, necessitating constant vigilance o Treatment: patients often do not feel a need for treatment of their paranoia and therapists’ attempts may be misinterpreted; therapist must be calm, respectful and straightforward and not attempt to engender a warm personal relationship; rely on indirect of raising questions in patients’ minds; cognitive therapy focuses on increasing sense of self-efficacy for dealing with situations, thus decreasing their fear/hostility towards others • Schizoid personality disorder: chronic lack of interest in and avoidance of interpersonal relationships; lack of emotions or emotional understanding; aloof, reclusive, detached; rare, with about 0.4 to 1.7% of adults manifesting the disorder at sometime in their lives; males outnumber females 3:1 o Theories and treatments: slight unclear relationship to schizophrenia; twins studies suggest that personality traits of low sociability/warmth may be partially inheritable (indirect evidence); insecure attachment patterns and compulsive self-reliance unique to the diagnosis; psychosocial treatments focus on increasing the person’s social skills/contacts and awareness of their own feelings; therapist can model expression of feelings; social skills training through role-plays and homework assignments; group therapies • Schizotypal personality disorder: socially isolated, restricted range of emotions, uncomfortable in interpersonal interactions; children with this are passive, socially unengaged and hypersensitive to criticism; distinguishable by oddities in cognitions; paranoid or suspiciousness, ideas of reference (random events are related to them), odd beliefs/magical thinking and illusions (just short of hallucinations); tangential, vague or over-elaborate speech; inappropriate or no emotional responses; easily distracted; deficits in working memory, learning and recall; strong relationship to schizophrenia (considered a mild version) but people maintain basic contact with reality o Prevalence: lifetime prevalence between 0.5 to 5.2%; twice as diagnosed in males than females; odd/eccentric beliefs can’t be part of cultural beliefs; African-American patients more likely than Caucasians/Hispanics to be diagnosed; could be exposure to conditions that enhance biological vulnerabilities like perinatal brain damage, urban living and low socioeconomic status o Theories: transmitted genetically to some degree; psychotic like traits highly inheritable; people with SPD show problems in the ability to sustain attention on cognitive tasks, deficits in memory, issues with smooth pursuit eye tracking (frontal lobe dysfunction); dysregulation of dopamine (abnormally high levels); similar brain structure abnormalities to schizophrenics; few psychological theories o Treatment: same drugs for schizophrenia; traditional neuroleptics (haloperidol, thiothixene) and atypical antipsychotics (olanzapine) to relieve psychotic-like symptoms; antidepressants also for people in distress; therapists need close relationships with clients; help them increase social contacts and learn socially appropriate behaviours through social skills training (group therapy helpful); crucial component of cognitive therapy is teaching them to look for objective evidence in their environment for their thoughts and to disregard bizarre thoughts Dramatic-erratic personality disorders • Overview: engage in dramatic and impulsive behaviours without regard for their safety or that of others (ex: suicidal behaviours); unstable emotions; lack of concern for others; lots of research for first two disorders but not for others • Antisocial personality disorder: antisocial behaviour earlier called moral insanity (Pritchard), psychopathic (Koch) and psychopath (late nineteenth and early twentieth centuries for maladaptive personalities); key features today are impairment in the ability to form positive relationships and tendency to engage in behaviours that violate social norms/values; deceitful (con or lies to others for profit/pleasure); commit violent criminal offenses; little remorse for actions; poor control of one’s impulses prominent characteristic; low tolerance for frustration; act impetuously; easily bored and restless; 50-80% of men in jail diagnosable • Psychopathy: broad personality traits emphasized over observable behaviours; superficial charm, grandiose sense of self-worth, tendency toward boredom and need for stimulation, pathological lying, ability to be conning and manipulative and a lack of remorse; cold, callous, cruel, malicious; dogmatic in opinions and gain pleasure by competing with/humiliating others; successful psychopaths are better able to maintain an outward appearance of normality (“mask of sanity”); • Prevalence of ASPD: one of the most common PDs; 3.7% of the population meets the criteria; corresponding low levels of education; 80% of sufferers also abuse substances; tendency to engage in antisocial behaviours is one of the most stable personality characteristics in this disorder; most would be diagnosed with conduct disorder in early childhood; for some, antisocial behaviour diminishes with age • Biological theories: substantial support for genetic influence on antisocial behaviours, particularly criminal ones; high levels of testosterone present in utero affect the development of the foetal brain in ways that promote aggressiveness; low levels of serotonin contribute to impulsive and aggressive behaviours; deficits in brain parts involved in executive functions (planning behaviour, sustaining concentration, self-awareness and self-monitoring); low levels of arousability lead to fearlessness in dangerous situations and/or stimulation seeking behaviour (consider reinforcements) • Social cognitive theories: children with antisocial tendencies have parents who are harsh and neglectful and the children interpret interpersonal situations in ways that promote aggression o ADHD: attention deficit hyperactivity disorder; significant problems with inhibiting impulsive behaviours and maintaining attention; children with this develop antisocial behaviour in response to social rejection and punishment • Treatments: patients tend to believe they don’t need treatment and are prone to blaming others for current situations; focus on helping person gain control over anger and impulsive behaviours by recognizing triggers and developing alternative coping strategies; increase empathy; lithium and atypical antipsychotics used to control impulsive/aggressive behaviours; suggestions that SSRIs may also be effective • Borderline personality disorder: out of control emotions that can’t be smoothed, hypersensitivity to abandonment, tendency to cling too tightly to people, history of hurting oneself; instability key feature as mood, self-concept and interpersonal relationships all extremely unstable; often describe a desperate emptiness; proneness to transient dissociative states; manifests differently from one person to another; great deal of overlap between this and other personality disorder; co-diagnosis with an acute disorder; difficulties in meeting social obligations • Prevalence: between 1-2% of the population will develop BPD in their lifetime; more diagnosed in women than in men; high users of outpatient mental-health services; more diagnosed in people of colour and in lower socioeconomic classes • Biological theories: mixed evidence that it is genetically transmitted; children of BPD mothers more likely to have impulse control disorders, etc; greater activation of the amygd
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