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Chapter 12

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Wilfrid Laurier University
Kathy Foxall

Chapter 12 The concept of personality disorder  Traits- a combinations of which describes there personality  According to DSM –IV-TR, 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 context.  Ppl with personality disorders, personality are more rigid and inflexible, - their beh seems inappropriate  DSM-IV-TR only asserts a personality disorder only when it is inflexible and maladaptive/  Personality disorders include conditions that may cause distress primarily for other ppl o Eg someone with anti-social personality disorder may see nothing wrong with themselves- or think other ppl have the problem o They might cause lots of problems to other like lie, manipulate, be violent, with having little distress about the lack of interaction with others  If we explain the destructible beh of someone with apd , as resulting of an illness then we are using circular reasoning  There are three large scale perspective longitudinal studies known as children in community study of developmental course of personality disorder. , the collaborative longitudinal personality disorders study and the McLean study of adult development, have been consistent in their conclusions that personality disorder represent a significant health problems for those with the conditions.  Personality disorders is associated with various forms of personal impairment  The DSM –IV-TR provides five formal criteria in defining personality disorders: o Criterion A: states that the pattern of behaviour must be manifesting in at least two of the following areas: cognition, emotion, interpersonal functioning, or impulse control. o Criterion B: requires that the enduring pattern of beh be rigid and consistent across a broad range of personal and social situation o Criterion C: states that this beh should lead to clinical distress o Criterion D: requires stability and long duration of symptoms, with onset in adolescence or earlier o Criterion E: states that beh can’t be accounted for another mental disorder.  DSM-IV-TR lists the specific personality disorders according to three broad clusters: o 1. Odd and eccentric disorder ( paranoid, schizoid, and schizotypal) o 2. Dramatic, emotional and erratic disorder ( antisocial, borderline, narcissistic o 3. Anxious, fearful disorder. ( avoidant, dependent, OCD) See table 12.1  Personality disorders can easily disrupt the alliance between a therapist and client  Sometimes personality disorders can be mistake as Axis 1 ( that are less severe)  A wrong diagnosis can lead to a wrong treatment  Studies examining the prevalence examine rates in community  Little research has examined the prevalence of personality disorders among the general Canadian population.  According to a 80;s Edmonton study, 1.8 % popn had APD in the 2 month period before the survey estimated that the one year prevalence rate of APD in the general popn was 1.7 %  Data have major limitations because most ppl hospitalized with personality disorders are a risk to themselves or to others.  Most are untreated or treated in the community rather than in hospitals.  Among men and women, the highest rates of hospitalization for personality disorders in 1999 were in ppl between 15 and 44 yrs of age.  Personality disorders are associated with other conditions, such as suicidal beh that lead to hospitalization.  The average length of stay in hospitals due to personality disorders was 9.5 days  52% of cases with personality dis were from cluster B type  12.2 show lifelong prevalence date from a community study conducted in the US  6 to 9% of the entire population, including community, hospitalized an outpatient samples, will have one or more personality disorders during their life.  Cluster A was the most prevalent in men how had been married  Cluster B disorders were more prevalent in poorly educated men , and cluster C disorders were most common among those who had graduated from high school but who had never married  Overall the risk of having avoidant, dependent, and paranoid personality disorders was greater for females than males, whereas the risk of having APD was greater for males than females  No gender difference in risk for OCD, schizoid,  Prevalence rates are higher among impatient psychiatric patients than among outpatients.  Eg borderline personality disorder, the most common PD (personality disorder) , was reported 11% for outpatients and 19% for inpatients  For many ppl with personality disorders, their funtioning is egosytonic , that is they do not view it as problematic  In contrast the axis 1 disorders are generally considered egodystonic (they cause distress and are viewed as problematic by the individual sufferer.)  Intervention for individuals with PS, then must initially address the issues of motivation for treatment.  Many insurance companies will not assist clients with the cost of treatment for PD Diagnostic issues  With respect to diagnosis, two indices are reliability are important, o 1. Inter-rater reliability – agreement between two raters o 2. Test retest reliability  There are other challenges to the DSM definition of personality disorder and whether a diagnosis is even warranted.  There are many problems with the notion of personality disorder that have not been resolved, and it is clear that further research is needed before a clear defined set of criteria is developed.  Researchers have identified gender and cultural bias in the diagnostic criteria, as subjects of concern. These biases suggests unsatisfactory reliability Gender and cultural issues  In a culturally diverse area clinicians may misdiagnose if they do not take adequate precautions to determine whether certain attitudes and behaviours are apppropriate¸ For distinct cultures or societal subgroups o Economically disadvantaged children living in inner cities may learn self-interested strategies in order to survive  These strategies may, in the eyes of a more privileged clinician, appear to reveal psychopathology, whereas in reality they are adaptive given the environmental context.  Similar concerts exist for gender biases in the diagnosis of personality disorders.  Sex role stereotypes may influence the clinician`s determination of the presence of personality disorders.  Henry and Cohen have suggested that clinicians typically over diagnose borderline personality disorder in women.  Ford and widiger also examined these issues but looked at gender bias both in the diagnostic criteria and in the diagnosis of histrionic personality disorder. They found that while the specific diagnostic criteria for histrionic personality disorder were found with equal frequency among men and women, women were more likely to be diagnosed with the disorder in another study of historic personality disorder women were more commonly diagnosed  Biases in referrals to psychiatric clinics for ppl with histrionic feats or that the application of the diagnosis among those ware are referred is gender biased  Gender bias can become `systemic ‘meaning that men and women are excluded from a diagnosis category because of their gender. o Eg more male inmates are classified as psychopath , very few women are because it is considered incompatible o But this is not the case psychopathy exists in women too  It is hard to see gender difference in PD  There may be patters, suggesting that there are true cultural differences in the risk of certain disorders. Reliability of diagnosis.  There is a failure in reliability for PD, suggesting that clinicians often fail to agree on a particular diagnosis for a specific patient.  Interviews to measure the exact diagnosis take a really long time. And clinicians may be unwilling to spend that time  Zanarinin a examined both the inter-rater ant test retest reliability of axis I and II using structured DSM based interview o The results indicated at least `fair to good `inter rater reliability for all personality disorders diagnosed by experiment clinicians  A major goal for the above mentioned research was to determine the stability of personality disorder over time. Comorbidity and diagnostic overlap  The two terms overt are synonymous. but t they are not  Comorbidity – used to describe the occurrence in the same person of two or more diff disorders  Overlap- similarity of symptoms of two or more disorders. Historical perspective  Greater attention to that we call APD  In the 19 century, scholars cont. to describe ppl who engaged in antisocial beh in the absence of obvious cognitive or psychiatric dysfunction  Similar to Pinel`s notion. psychiatrist James Pritchard coined the term moral insanity to delineate a mental contdion characterized by an absence of morality rather than madness  The thought the moral principle of the mind were `perverted or depraved `in these men  Sociologist replaced the term psychopath with sociopath.  They said psychopathic inferiority were exhibiting a `social `disorder and coined the term sociopath, reflecting the idea that the condition involved in the anti-society  The current idea of psychopathy is founded largely in the clinically observation of psychiatrist hervet cleckly .  He proposed that there are a number of defining characteristic of the disorder, including emotional, interpersonal and beh elements  He saw that psychopaths were unresponsive to social control and behaved in a socially inappropriate manner Etiology  Aside from the hereditary taint , little consideration are given to the cause of PD in the 19 cent  In the 40;s many theories were published . Psychodynamic views  Psychoanalysts see PD as a result form disturbance in the parent – child relationship , esp. separations.  This process by which the child learns that he or she is an individual separate f ormthe mother and other ppl  Thus difficulties in this process result in adequate sense of self or problems with dealing with others ( avoidant) Attachment theory  Dominate thinking on the nature nurture debate has undergone dramatic shifts over time.  Many theorists are again turning to the role of early relationships in contributing to personality pathology in adulthood o Attachment through –asserts that children learn how to relate to others. Esp. in affectionate ways , by the way in which their parents relate to them  When the attachment bond between parents and the child is positive ( supportive ) then they will develop the skills and confidence necessary to relate effectively to others.  The parent child bond serve as a template for all later relationships  When this bond is poor, the child will lack confidence in relation with others.  This analysis has been applied to various personality disorders and the evidence appears to support the role disrupted attachments in the etiology of these disorders.  Research shows that if parent child attachments are poor,, the child will typically develop adult relationship styles that are ambivalence, fear or avoidance.  Poor attachment leads to poor development of intimacy, such that various maladaptive ways of dealing with interpersonal relationships are likely  Levy has argued that poor attachment bods are an antecedent to violence and antisocial patterns in children  The fact that personality disorders usually become obvious during late adolescence when the demands for social interaction become perminent lends some support to the importance of attachment deficits in the origin of these disorder.  Battle examined the childhood histories of 600 patients diagnosed with personality disorders or major depressive disorder, in a mulit site investigation.  The study confirmed that rates of childhood maltreatment among individuals with personality disorders are generally higher ( 73-82 %)  It is not possible to est. causation using this approach because the findings show that very high prevalence of negative childhood experience with PD Cognitive behavioural perspective  They suggests variety of factors that may contribute to the emergence of PD  Cognitive strategies or schemas are said to d
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