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Chapter 7

Chapter 7: Psychophysiological Disorders, Chapter 10: Eating Disorders Ch 12: Personality Disorders CH13: Sexual and Gender Identity Disorders

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Western University
Psychology 2310A/B
Rod Martin

The Personality Disorders 11/12/2012 9:48:00 AM The Concept of a Personality Disorder All people display some consistency in their behaviour and thinking, and this consistency is the basis for describing people as having a particular “personality” There are many adjectives used to describe a person, but all of us sometimes display variations of these features We only describe someone as having a personality characteristic if that feature is typically displayed over time and in various situations Traits: cross-situationally consistent and persistent features  Each person possesses several traits, the combination of which describes their personality Personality disorders: patterns of highly maladaptive personality traits Acc to DSMIV – personality traits are “enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts  Ignores the fact that the behaviour of most of us is also modified by context People with personality disorders have a more rigid and inflexible personality, and it is often displayed independently of context  Behaviour often seems highly inappropriate to most others  May initially display appropriate beh in a given situation but cannot typically sustain it for long periods or when under stress DSMIV – personality traits only constitute a personality disorder when they are inflexible and maladaptive Often show far more restricted range of traits than most people  more likely to be categorized by a single dominant, dysfunctional trait, rather than a variety of traits like most people All Axis I disorders are associated with subjective distress  they are maladaptive and harmful primarily for the person afflicted with the condition Personality disorders include conditions that cause distress primarily for other people Controversial why we diagnose a condition that causes the affected person little distress  The field of abnormal psychology does not wish to cause harm to a person through the stigma of a diagnostic label  Run the risk of circular logic with such labels by implying that they have some explanatory power  Abnormal psychology seeks to classify these conditions in order to aid in the diagnosis, treatment and prediction of behaviour Psychopathy is a good example of a construct that helps to predict behaviour Personality disorders represent a significant health problem for those with the condition  Associated with various forms of personal impairment and extensive treatment use DSM-IV-TR provides 5 criteria in defining personality disorders  Criterion A: the pattern of beh must be manifested in at least two of: cognition, emotions, interpersonal functioning, or impulse control  Criterion B: the enduring pattern of behaviour be rigid and consistent across broad range of personal and social distress  Criterion C: this behaviour should lead to clinically significant distress  Criterion D: stability and long duration of symptoms, with onset in adolescence or earlier  Criterion E: the behaviour cannot be accounted for by another mental disorder DSMIV lists specific personality disorders according to 3 broad clusters: A. odd and eccentric disorders (paranoid, schizoid, schizotypal); B. dramatic, emotional, or erratic disorders (antisocial, borderline, histrionic, narcissistic); C. anxious fearful disorders (avoidant, dependent, and obsessive-compulsive). Also includes Personality Disorder Not Otherwise Specified (see table on page 280) A and C have enough features in common to make a reasonably cohesive group, B is heterogeneous Personality disorders are a somewhat neglected diagnostic category When someone has a personality disorder, it can greatly complicate the treatment of Axis I disorders Personality disorders can easily disrupt the alliance between a therapist and client Sometimes personality disorder can be mistaken for Axis 1 condition  Wrong diagnosis could lead to wrong treatment plan, or mistaken drug prescription Treatment of personality disorders is improving – used to be viewed as difficult with poor prognosis Prevalence rates of personality disorders vary considerably depending on the sample and method of diagnosis  Relative to structured interviews, self-reports will likely yield underestimates of APD because people are reluctant to admit that they engage in antisocial behaviours The issue of multi-method assessment is relevant to broader diagnostic issues as well as to treatment and prediction Patients with personality disorders may not be cognizant of the negative impact they have on those close to them Little research has examined the prevalence of personality disorders among general Canadian population Epidemiological studies have typically measured prevalence of APD  1991 Ontario survey estimated 1 year prevalence of APD in general population was 1.7%  1980s Edmonton study; 1.8% of population had APD in 6-month period before survey, and 3.7% reported personality disorder at some point in their lives Most are untreated or treated in the community rather than hospitals In 1999, highest rates of hospitalization for personality disorders were people between 15 and 44; 78% of people were in this age range, and more women than men  In all age groups, personality disorders were more likely to be a contributing rather than main factor determining length of stay in hospital  P disorders are associated with other conditions i.e. suicidal beh that lead to hospitalization Avg length of stay in hospitals due to p disorders is 9.5 days In study of 102 cases of completed suicide, 52 cases involved personality disorders; half of which were cluster B Studies in Europe show lifetime prevalence lower than US Around 6-9% of entire population will have one or more personality disorders in their lifetime Cluster A most prevalent in men who had never married. Cluster B most prevalent in poorly educated men. Cluster C most common among those who had graduated from high school but never married Risk No gender differences for obsessive-compulsive, schizoid or histrionic personality disorders Other risk factors include being native American or black, being a young adult, having low socio-economic status and being divorced, separated, widowed, or never married  In Crawford study, estimated prevalence of any personality disorder is 15.7%; this study criticized for not being representative of the entire US population In effort to address methodological limitations, Lenzenweger examined responses to questions from International Personality Disorder Examination administered to 5692 participants  Cluster C negatively associated with age and education  APD less prevalent among women  Borderline personality disorder positively associated with unemployment  Gender, race/ethnicity, family income, marital status not significantly related to any measures Prevalence rates generally higher among inpatient psychiatric patients than among outpatients  In psychiatric outpatients, prevalence rates around 5%, but jump to 12-37% for psychiatric outpatients  In prison populations, the rates range from 30-70% Personality factors are distinct from other forms of psychopathology in DSMIVTR and appear on Axis II rather than I where most of the other disorders are clustered Clinical disorders (i.e. axis I) have more pronounced symptomology, leading to greater chance of referral to mental health professional Axis I disorders are more likely to be referred to as “mental illnesses” rather than personality disorders Cluster B patients sought treatment the most (49.1%), then cluster C then A Most respondents sought treatment from general medical providers (19%), or psychiatrists (14), or mental health professionals (17%) Most suffering from Axis I disorders have far more impaired functioning than personality-disordered patients  Impaired life circumstances, but actual abilities appear relatively intact compared to those with Axis I dos Egosyntonic: do not view functioning as problematic (people with personality disorders) Egodystonic: disorders that cause distress and are viewed as problematic by the individual sufferer (axis 1) Intervention for personality disorders must initially address the issue of motivation for treatment and treatment readiness Numerous debates on whether distinction between Axis I and II should even be made in future editions of DSM Diagnostic Issues Personality disorders traditionally have presented more diagnostic problems than most of the Axis 1 disorders because of the lower reliability of their diagnosis, their poorly understood etiology, and weak treatment efficacy Two indices of reliability are important in diagnosis – inter-rater reliability (pretty high) and test-retest reliability (low) Livesley argued that personality disorders are better viewed as constellations of traits, each of which lies along a continuum, rather than a disorders that people have or don’t have  whether diagnosis is even warranted Others have suggested that diagnostic criteria for some P disorders are gender biased, or that their application permits the gender biases of the diagnostician to influence diagnosis Many problems with the notion of personality disorders that haven’t been resolved  problem is not so much whether these syndromes exist, but rather how they can be defined in a way that is unbiased, reliable, and leads to effective treatment or prediction  specifically, gender and cultural biases are big subjects of concern Gender and Cultural Issues  Diagnostician must ensure that client’s functioning doesn’t just reflect normative responding in their culture o Ex. Inner city poor kids may learn self-interested strategies in order to survive. These strategies may appear to reveal psychopathology in eyes of privileged kids, while in reality they're just adaptive  Sex role stereotypes may influence clinician’s determination of presence of personality disorders  Emphasis on aggression in criteria for APD may result in under diagnosing females because of gender difs  Suggested that clinicians typically overdiagnose borderline personality disorder in women  Researches in field of domestic violence seem to be exceptional in recognizing importance of studying borderline personality disorder (BLPD) in males o Led to findings that violent males with BLPD have been found to experience significant attachment problems resulting from childhood abuse and neglect that may have placed them at risk to cause harm to intimate partners when they perceive that they are being abandoned  Histronic personality disorder used to be called “hysterical personality” – hysterical is a descriptor traditionally applied to women, so it was thought that changing the name to reflect the actual behaviour might reduce diagnostic biases  impact doesn’t seem to be substantial; still diagnosed in females more  While specific diagnostic criteria for histrionic personality do were found with equal frequency among men and women, women were more likely to be diagnosed with the disorder  Large numbers of males or females are virtually excluded from a diagnosis category because of their gender o Ex. Psychopathy WAY more diagnosed in male inmates than female because females are viewed as incompatible as being psychopathic  research does not agree with this v  Difficult to determine whether differences in the prevalence of personality disorders across genders and ethnic groups represent biases in diagnosis or reflect true differences o There may be cultural differences in the risk for certain disorders Reliability of Diagnosis  Clinicians often fail to agree on a particular diagnosis for a certain patient  Strategies like structured interviews and expanding breadth of information collected increase reliability  Diagnosis should be much more than a simple compilation of behaviours or symptoms o These procedures take longer and many clinicians may be unwilling or unable to spend the necessary extra time  Some P dos can be diagnosed with a high level of reliability with a rile review followed by 1-2 hour interview o It is likely that most personality disorders can be reliably diagnosed given enough information and effort  Recent studies show that reliability is improving  It is possible that personality disorders may not be as chronic as once believed o <50% of personality disordered patients remained at or above diagnostic criteria for initial diagnosis every month for a follow-up period of two years Comorbidity and Diagnostic Overlap  Comorbidity: used to describe the co-occurrence in the same person of two or more different disorders  Overlap: the similarity of symptoms in two or more different disorders – some of the same criteria apply to different diagnoses  Diagnostic criteria for different disorders should be distinct, but for some personality disorders, the criteria remain vague or require significant inference by the clinician that overlap seems likely  Diagnostic criteria for individual personality disorders related better with one another than with criteria from other personality disorders, leading researchers to conclude that the diagnostic criteria of each of the disorders do show some discriminant validity  Recent revisions of DSM encourage to consider multiple diagnoses to be applied to same person o Specific diagnosis often implies course of treatment and differential prognosis and this is complicated by the use of multiple diagnoses Historical Perspective Historically, greatest attention paid to antisocial personality disorder, or related psychopathy than any other P do Machiavelli advocated for use of unscrupulous, manipulative, amoral and deceptive behaviour in achieving power in politics and society  Machiavellianism; become synonymous with callous, manipulative and deceptive personality characteristics One of the first written descriptions of the condition (antisocial) was by Pinel  Described a psychiatric condition associated primarily with amorality rather than psychosis  Referred to it as manie sane délire, or madness without delirium  Observed in patients profound deficits in emotion but no apparent reasoning/intellectual dysfunction  Such patients were prone to stealing, violence, and lying, but seemed to have no other health issues James Pritchard, British psychiatrist; coined term moral insanity to delineate mental condition characterized by absence of morality rather than “madness” seen in other psychiatric patients  Also observed that there was clear emotional dysfunction but cognitive ability was intact  Discussed how individuals suffering from moral insanity seemed to completely disregard the moral, ethical and cultural norms of society  Thought that the “moral principles of the mind” were “perverted or depraved: Koch objected to the term moral insanity and suggested the term psychopathic inferiority  Thought the condition of psychopathy stemmed from a type of biological abnormality that resulted in personality anomalies such as extreme selfishness Sociologists saw social conditions as the critical factors  Replaced the psychopath with the descriptor sociopath Partridge argued that people with this psychopathic inferiority were exhibiting a “social” disorder and coined the term sociopath reflecting the idea that the condition involved an “anti-society” view of life Current conceptualization of psychopathy is founded large in clinical observations of psychiatrist Hervey Cleckley  The Mask of Sanity - his classic text  Proposed that there are a number of defining characteristics of the disorder, including emotional, interpersonal and behavioural elements  Observed that psychopaths were unresponsive to social control and behaved in a socially inappropriate manner  Described a profound emotional deficit, such that deep emotion and anxiety were missing in the psychopath  Theorized that a lack of emotion was at the core of the disorder, with other symptoms following from this emotional shallowness Etiology th Little consideration was given to potential causes of personality disorders in the 19 century Trend changed with development of psychodynamic school and publication of first etiological theories of psychopathy in 1920s; during and after 40s, many causal theories were published To this day there have been no firm conclusions about the factors that cause personality disorders; just theories Psychodynamic Views  See personality disorder as resulting from disturbances in parent-child relationship particularly in problems related to separation-individuation  Process by which child learns that he/she is an individual separate from the mother and all other people and, as a result, acquires a sense of self as an independent person  Difficulties in this process result in either an inadequate sense of self, or problems dealing with others  Evidence that personality-disordered adults are more likely than others to have had disrupted childhoods or parental rejection  This evidence has also served to other environmental theories of personality disorders, esp attachment Attachment Theory  Dominant thinking on the nature/nurture debate has undergone dramatic shifts over time  Recently, “PD symptom constellations identified in adulthood have their origins in childhood”  Many theorists are again turning to the role of early relationships in contributing to adulthood PD  Attachment theory: children learn how to relate to others, particularly in affectionate ways, by the way in which their parents relate to them  Parent-child bond serves as a template for later relationships; if poor, child will lack confidence later in life  The fact that personality disorders usually become obvious during late adolescence when the demands for social interaction become pre-eminent lends some support to the importance of attachment defecits  Patients with PDs typically described their parents as either uncaring, overprotective or both  Battle’s study: childhood maltreatment high; borderline PD more consistently associated with childhood abuse and neglect than other disorders; high prevalence of negative childhood experiences in those with PD Cognitive-Behavioural Perspectives  Suggest a variety of factors that may contribute to emergence of PDs  Cognitive strategies or schemas are said to develop early in life and in PD individuals these schemas become rigid and inflexible  Young: schemas are broad and pervasively maladaptive themes that people hold about themselves and their relationships with others; since they form early in life, they are comfortable and familiar  Views of new events become distorted to maintain the validity of the schemas  People cope with their schemas in ways that may have been adaptive when they were kids trying to survive in a damaging environment, but they continue coping in the same manner into adulthood  Linehan argued that these people come from families who invalidate the emotional experiences of the child and oversimplify the ease with which life’s problems can be solved o They learn that the way to get attention is through a display of outbursts o Theory has been amplified mainly to borderline patients, but applies to all PDs, especially cluster B  Parents also model inappropriate personal styles themselves; evidence that modeling is powerful influence  Parents may inappropriately reward or punish behaviour; responses are not related to child’s behaviour Biological Factors  Most thoroughly explored with APD  Theorists claim that there is either brain dysfunction or a genetic or hormonal basis for these conditions  Proposed that specific disturbances in NT systems in the brain characterize particular types of PDs  Suggested different bio processes are associated with 4 dimensions (i.e. cognitive-perceptual organization, impulsivity-aggression, affective stability, and anxiety-inhibition) that together determine personality  Disruptions in biological underpinnings of these 4 factors might be expected to produce the unique PDs  Some support for biological factors in PDs o Strongest support comes from research with antisocial personality theories o Recent work also suggests likelihood in other disorders  Hans: both schizophrenia and schizotypal PDs occurred exclusively in children of parents with schizophrenia o Children of parents with schizophrenia also were at risk for avoidant PD but not paranoid PD o Relationships especially strong for males  Strongly suggested familial vulnerability to schizophrenia spectrum disorders observable before adulthood  Raine et al: focused on prefrontal cortex; it was already known that structural prefrontal deficits existed in some patients with schizophrenia. They examined whether such deficits would also be found inpatients with schizophrenia spectrum PDs. Used MRIs  PD group showed reduced prefrontal volume and poorer frontal functioning compared to healthy control individuals and psychiatric controls  Recent fMRI studies on patients with borderline personality disorders have begun to appear o Studies map both structure and functioning of brains of people with BLPD while they engage in emotion-inducing tasks such as recalling emotional events or viewing emotional facial expressions o Studies have implicated dysregulated responding of the prefrontal areas of the brain as well as fronto-limbic dysfunction in the form of over-activation of the amygdala  In twin studies, results suggest that childhood PDs may have substantial genetic component Summary of Etiology  Various theories regarding causes of PDs  Synthesis of these theories makes most sense; clear Correlational evidence of bio, family, learning processes and some limited support for psychodynamic accounts  Cluster A dos  most prominent observations are genetic links with schizophrenia and mood disorders o Impaired eye-tracking as measured by smooth pursuit eye movements investigated as bio bases  Cluster B  etiological factors receiving most support are bio factors and attachment problems  Cluster C  causal factor research has been limited despite prevalence of them  Generally, causes of PDs remain murky; longitudinal approaches are essential to resolve this The Specific Disorders Cluster A: Odd and Eccentric Disorders Paranoid Personality Disorder Pervasive suspiciousness concerning the motives of others and a tendency to interpret what others say and do as personally meaningful in a negative way are primary features of someone with this disorder Consistently misread innocent actions/comments of others as being threatening/critical; expect others to exploit them Tend to by hypervigilant and take extreme precautions against potential threats from others Believe that others intend to hurt them; are reluctant to share anything personal for fear it may be used against them Typically humorless and eccentric; seen by others as hostile, jealous, preoccupied with power and control Problems with relationships; most people can’t tolerate their need to control and particularly their jealous and suspicious nature Experience far more paranoid thoughts, have greater difficulty dealing with ambiguity and are more suspicious, and are more likely to misread social cues as evidence of hostility by others Paranoid personality often occurs in relatives of schizophrenics; genetic link between the two has been proposed  Paranoid personality disorder may be a subtype of schizophrenia; other view is that they are “cousins” Main difference in paranoid personality and paranoid schizophrenia is the severity of the paranoid belief  In schizo – paranoid belief is sufficiently bizarre and ingrained that it is considered “psychotic”, a delusion  In personality – paranoid beliefs are non-bizarre, within the realm of possibility, and pertain to general suspiciousness, even though they are mistaken Overlap between paranoid personality and both avoidant and borderline personality dos Paranoid personality disorder was one of the four most persistent types of personality disorder identified  Very hard to give treatment to someone who doesn’t trust anyone; few seek or accept treatment Schizoid Personality Disorder Seem completely disinterested in having any sort of intimate involvement with others and display little emotional responsiveness Detached and self-absorbed; say that they rarely experience intense emotions and may be puzzled by passions of others Loners who are cold and indifferent towards others; seem not to enjoy relationships at all, and prefer being alone Avoid social activities and do not seek or seem to desire sexual relations Most don’t have the skills for effective social interactions, but most don’t care to acquire such skills Frequency of these disorders from DSMIII to DSMIV increased from 1.4% of patients to 11%  Due to reduction in frequency of the diagnosis of schizotypal disorder with a corresponding increase in this  Makes it hard to compare research on schizoid personality conducted before and after DSMIII Problem with this diagnostic category is that it has been focus of little methodologically sound research  Hard to find research participants in the community  Schizoid PD appeared to be distinct from paranoid PD and schizotypal PD  suggested that the disorder may be more related to asocial disorders (ex Asperger’s) Schizotypal Personality Disorder Major feature is eccentricity of thought and behaviour; extremely superstitious and may believe in magic Ideation and behaviour are peculiar and these features tend to turn people away causing social isolation  in turn, the isolation increases the likelihood that they will have unusual thoughts since they have little opportunity to check the accuracy of their cognitions Thinking is permeated by odd beliefs  believe in magical thinking and paranormal phenomena (i.e. telepathy) Similarities with schizophrenia; difference lies in severity and quality of the symptoms – although their beliefs, perceptual experiences, speech and behaviours are odd and tend to isolate them, they are not usually considered to be so eccentric as to meet criteria for delusional and hallucinatory psychotic experiences Disagreement on this issue Biological factors research found strong similarities between schizotypal PDs and schizophrenia  Many family members of schizophrenics exhibit schizotypal symptoms Diagnostic overlap between this PD and other Cluster A PDs is considerable; the meaningfulness and value of distinctions among Cluster A diagnoses have been criticized Treatment emphasis is on schizophrenic-like features  low doses of antipsychotic drugs relieve cognitive problems and social anxiety, and antidepressants also work  medicine has a positive but modest effect Generally the long-term prognosis is poor Cluster B: Dramatic, Emotional, or Erratic Disorders The 4 Cluster Bs don’t have as much in common with each other Alost no descriptors of Cluster B seem to fit the antisocial patients; maybe they should be in a separate category of PDs Antisocial Personality Disorder and Psychopathy: A Confusion of Diagnoses Not all patients with antisocial personalities commit crimes, although most of them who are so diagnosed by clinicians have a criminal record  May just reflect the fact that it is their criminal behaviour that brings them to attention of psychiatrists  Behavioural features of APD do predispose them to crime; unlawfulness is an example in the DSMIV Description of the Disorder  Referred to as psychopaths, sociopaths, or dissocial personalities – terms used interchangeably  APD and psychopathy are NOT the same disorder however often confused  Psychopathy incorporates richer set of emotional, interpersonal and behavioural features than DSMIV definition of APD which focuses on observable behaviour  Few criteria reflecting emotional and interpersonal processes in the DSM  Some overlap between APD and psychopathy; only small portion of APDs are psychopathic, whereas most individuals who are psychopathic would qualify for APD  asymmetric relationship; related but separate  Central issue to the differentiation is DSMIV criteria sufficiently reflect personality domain of the disorder o Employing essentially behavioural criteria may increase diagnostic reliability but may also yield a group of antisocial people who are markedly variable in personality traits  Most widely accepted measure of psychopathy is the Psychopathy Checklist-Revised (PCL-R) o Advantage: specifies both behaviour and personality as features to be considered, and has highly reliable emotional/affective criteria  Essential feature of APD is pervasive pattern of disregard for and violation of rights of others that begins in childhood or adolescence and carries into adulthood; different from other PDs  Notion of psychopathy as a destructive constellation of personality characteristics was the clinical concept leading to definition of APD  DSMIV criteria for APD are highly reliable indicators of socially deviant lifestyle; not the best criteria for tapping the core features of psychopathy (i.e. shallow affect, lack of empathy) best measured by PCL-R Antisocial Personality Disorder (APD)  DSMIV criteria  7 exemplars reflecting violation of rights of others: nonconformity, callousness, deceitfulness, irresponsibility, impulsivity, aggressiveness, recklessness   Reflecting a polythetic approach (only a subset of symps/behs required for diagnosis)  Prevalence o Lifetime prevalence rates for APD are 3% in males, 1% in females  DSMIV o 0.6% in males and females combined  US National Comorbidity Survey Replication o Discrepancy may reflect variability in sampling methods o Incidence in forensic settings expected to be higher - criminal behaviour is dominant feature of APD o Great Britain estimates prevalence of 25-33% of patients in Special Hospitals; criminals who are presumed to have mental disorders went to these hospitals, whereas other just go to jail  Canadian prison estimate – 40% of offenders have APD o Random sample of 495 male inmates, diagnosed 61.5% as having APD using the interview criteria  Etiology of APD o Essential characteristics: callous disregard for others, impulsivity and poor self-regulation, rule breaking and criminality, exploitation of others o Social and family factors were initial explanations; view that parental behaviours can influence development of antisocial functioning o Led to application of family systems approaches to treatment – empirically determined risk factors are targeted within a family-centred model of service delivery  Further encouraged idea of disruptive families as causal factors o Moffit  minority of youth become involved in rule breaking and delinquent beh at an early age and that it is sustained throughout their lifespan o Also suggests important in familial factors and genetic features as risk factors o Heritability measures of antisocial beh/aggression ranging from 44-72% o Bio factors interact with childhood experiences to produce criminality o Neuropsychological markers that combine with certain enviro circumstances (ex. Abuse, neglect, etc) making child vulnerable to developing antisocial lifestyle and personality o Lykken suggested that these individuals are fearless  fearlessness hypothesis says that APD people have higher threshold for feeling fear than others do; events that make most people anxious (ex fear of being punished) have little or no effect on those with APD o Social learning theorists question validity of fearlessness hypothesis o Schmauk suggested that Lykken used electric shock as punisher, so findings might only be relevant to shocks and other physical punishment o As children, APD people are exposed to severe physical punishment from parents that was frequently not contingent upon behaviour; suggested that these people might have learned to be either indifferent to physical punishment or oppositional to such attempts at controlling them o Oppositional behaviour: tendency to do opposite of what is being asked of you  In this case, opp beh would result in punished beh showing increase rather than the expected decreased o Schmauk tested this by repeating Lykken’s study but using 3 different kinds of punishers: physical (electric shocks), tangible (lose money for errors), social (reprimands by experimenter for errors) o With electric shocks as punishers, got the same findings; same with social punishers  results being that APD people performed worse than counterparts o When APD group lost $$ for pressing wrong lever, they quickly learned to avoid the shocked levers, and did so successfully more than their counterparts under any punishment conditions o Schmauk  people with APD were differentially responsive to different kinds of punishments as a result of early learning experiences, rather than completely fearless or unresponsive to punishment o Newman  psychopaths suffer from generalized info processing deficiency involving automatic directing of attention to stimuli that are peripheral to ongoing directed behaviour  Once engaged in reward-based behaviour, psychopath is less likely to attend to other cues to modulate his/her ongoing response  Antisocial+criminal behavior in APDs involves schema-based deficits which comprise anti- social schemas and cognitive distortions not requiring automatic attentional cueing o Research supports idea that psychopathy and APD are different diagnoses  Course and Prognosis of APD o Avg duration of APD from onset of first symptom to last was 19 years o Remittance over time is described as burnout factor; expectations being that symptoms will disappear by 4 decade of life o Other data refutes idea that people with APD do burnout o When APD and substance abuse are comorbid; post-release performance is poorer than those with only one disorder  Treatment for APD o Reviews of treatment efficacy of APD patients has been pessimistic o Treatment in previous decades didn’t reflect current knowledge of effective treatment programs o Attrition from treatment programs is high; proved to be predictive of subsequent reoffending o In substance abuse treatment, APD people fare more poorly than other patients o 2/3 of psychiatrists think APD can be treatable, although poor response to hospitalization o Prognosis is improved if there is treatable anxiety or depressive feature to their beh or if they can be convinced to form an effective therapeutic alliance o Treatment should be aimed at symptom reduction and behaviour management rather than at cure o Treatment of other resistant clients suggests responsivity factor; treatment must be responsive or matched to a particular person’s needs and interpersonal style o Poor treatment may be caused by intervention of insufficient intensity, viewed by patients as irrelevant, or seen as in voluntary o Overreliance on self-report assessment is problematic in a population for whom honesty is subject o Pharmacotherapy is another strategy  short term use of psychopharmalogical agents is most often used to manage difficult or threatening behaviour; side effects of long term drug use and non- compliance have been noted in forensic patients o While meds can provide help, symptom alleviation is rarely sustained, and patients gain no new skills to improve their ability to deal with future situations  Summary of APD o Alternatives to the diagnostic criteria (i.e. PCL-R and ICD-10) may yield better assessments o Prognosis even after treatment remains relatively poor o Antisocial orientation was major predictor of future non-sexual and sexual violent offences o Must see treatment as a management strategy rather than as a cure Psychopathy  Not yet listed on Axis II of DSMIV  Distinctive subgroup of offenders best described by unique interpersonal and affective disposition  Egocentric, deceptive, callous, manipulative people who lack remorse and emotional depth  Commit a disproportionate amount of antisocial and violent behaviour in society (sexual and nonsexual)  Chronic deceivers; often lie for instrumental reasons such as to escape punishment  “Users” of others in their attempts to obtain money, drugs, sex or power  Many are con artists with long history of fraud and scams; some become cult leaders, corrupt politicians or successful corporate leaders, before their frequent downfall  PCL- R is internationally popular as both a research and clinical tool  As measured by the PCL-R, characterized by 20 criteria scored from 0-2 for a max 40 score o Minimum score of 30 is the cut-off for classifying psychopathy  Despite definitional differentiation between APD and psychopathy, little distinction has been made between them in the legal system  Psychopathy and Aggression o Strong link between psychopathic traits and aggression and violence in psych patients/offenders o Found that psychopaths in jail had done an average of 7 crimes; more than 2x their counterparts; helps predict whether an offender is likely to commit future violent behaviour o Psychopaths 5x more likely than counterparts to engage in violent reoffending within 5 years of release from jail o Not only do psychopaths commit more violence, they commit heinous violence o Psychopaths violent crimes = 45.2% more likely to have motive of material gain than counterparts o Non psychopaths= much more likely to display high levels of emption in offenses than psychopaths o In addition to committing more cold-blooded violence, psychopaths may enjoy inflicting violence  Possible link between psychopathy and sadistic interests, deviant sexual arousal  Prevalence of Psychopathy o 1% of Canadian population (300,000) estimated o Near impossible to determine prevalence  inability to receive honest responses from psychopaths o Jails  15-25% inmates are psychopaths; female samples  9-31%  Etiology of Psychopathy o Not possible to offer definite cause o Biological theorists  psychopaths differ in terms of underlying biological functioning and neurological processing o Insensitive to emotional content of info (esp. language and emotional pictorial info o Implicated brain abnormalities  Ex. Because of apparent dysfunction of amygdala, psychopaths use alternative (mainly cognitive) means of processing emotional material to compensate for absence of appropriate limbic input that usually provides info about affective characteristics of stimuli o Neurotransmitters also implicated  Lower 5-HIAA concentrations (metabolite of serotonin) o Impulsive aggressions of psychopaths may be linked by serotonergic hypofunctioning combined with high dopamine activity o Moderate levels of heritability for subscales measuring affect-related traits o High heritability on measures of fearless dominance and impulsive antisocial behaviour o Unlikely that biology is the whole cause; environmental factors too o Link between early emotional deprivation and psychopathy; abused and neglected - higher risk o Experience more negative upbringing (poor discipline, emotional abuse/neglect) and negative school experience o High psychopathy scores associated with both physical abuse and disrupted living arrangements o Porter2 pathways leading to development of psychopathy  Fundamental psychopathy: disorder is inevitable risk of biological (polygenic) predisposition within the individual that hinders development of affective bonds  Secondary psychopathy: development of disorder is heavily dependent on result of negative environmental experiences during formative years of childhood, such as neglect/abuse  Profound affective deficit may be result of person’s ability to detach self from emotions, as opposed to inability to actually experience emotions as is the case with fundamental psychopathy o Possible that psychopathy may have roots in biological predispositions and or environmental experiences depending on individual  Course and Prognosis of Psychopathy o Typically a lifelong condition o Precursors emerge in childhood as “callous/unemotional” traits o Although existence of psychopathy in adults is generally accepted, diagnosing in kids is controversial o Adolescents with higher level of psychopathic traits are more likely to have earlier onset of conduct problems and present with greater variety and severity of delinquent behaviours; more likely to have symptoms and diagnoses of conduct disorder, narcissistic personality disorder and opp def do; score high on impulsivity and sensation seeking  Treatment of Psychopaths o Key requirement is motivation of client o Effectiveness of treatment has not been encouraging; they resist treatment o Longer involvement in outpatient treatment reduced risk of violence among psychopathic people after being discharged from non-forensic inpatient setting o Programs should focus on changing and managing behaviour rather than changing core personality characteristics of the psychopath o Treatment providers must be especially careful not to be deceived into perceiving progress when they are really observing a performance worthy of an Oscar o Intense supervision in the form of probation/parole often necessary Borderline Personality Disorder One of the most poorly named personality disorders Historically meant to describe someone on the border between psychosis and neurosis Most people with BPD don’t experience psychotic symptoms Fluctuations in mood, unstable sense of own identity, and instability in relationships Unpredictable and impulsive, irritable and argumentative  factors interfere with relationships Unable to tolerate being alone and become desperate about relationships although they usually alternate between idealizing and devaluing their partners May blame relationship problems on others instead of accepting personal responsibility; may attempt to undermine achievements when they have nearly succeeded in reaching goals (ex dropping out right before graduating) A few BPD patients may experience psychotic like symptoms in times of stress; not sufficient for Axis I diagnosis Millon  origins of conceptualization of BPD. Examined 4 influential reports on what was called borderline personality organization, borderline syndrome, borderline states, borderline patients More than half of the different criteria were present in only ¼ articles  Only 1 criteria (patient’s maladaptive and inappropriate behaviour at interview) was in all 4 reports The label borderline had been used to identify 2 different constellations of symptoms: a)instability and vulnerability; b) a set of features that had best been described as borderline schizophrenia The DSMIII characteristic (intolerance of being alone) that most accurately distinguished BPD from schizotypal PD was dropped from diagnostic criteria in DSMIIIR and DSMIVTR BPD has lifetime occurrence in around 2% of population; 3:1 W:M ratio Typically begins in adolescence, shows stability over time; 25% diagnosed in childhood still met criteria in middle age Strong disagreement regarding appropriate diagnostic criteria Linehan’s biosocial theory says that the core feature of the disorder was an emotionally dysregulated system that underlies interpersonal dysregulation (interpersonal problems), self-dysreglation (confusion about self), cognitive dysregulation, and behavioural dysregulation (impulsivity) Reliability has been shown to be superior when dimensional (interviews and scales) ratings are used rather than just categorical diagnoses For distinct groups where BPD is frequently comorbid with other Axis II diagnoses, treatment planning must be carefully Considered Etiology of BPD  Evidence implicates disruptions in family and childhood abuse and neglect as factors in development  Females sexually abused in childhood 5x more likely to be di
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