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Chapter 12

PSYC 3230 Chapter 12: Abnormal Psychology: Perspectives, DSM-5 Update Edition

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PSYC 3230
James E Alcock

The Personality Disorders T HE C ONCEPT OF P ERSONALITY D ISORDER  Cross-situationally consistent and persistent features are described as traits. Each person possesses several traits, the combination of which describes personality.  A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.  People with personality disorders show a restricted range of traits and are more likely to be characterized by a single dominant, dysfunctional trait.  The personality disorders include conditions that cause distress primarily for other people.  Personality disorders are associated with various forms of personal impairment and extensive treatment use.  The DSM-5 provides six formal criteria in defining personality disorders: o The pattern of behavior must be manifested in at least two of the following areas: cognition, emotions, interpersonal functioning, or impulse control. o The enduring pattern of behavior must be rigid and consistent across a broad range of personal and social situations. o This behavior should lead to clinically significant distress in social, occupational, or other important areas of functioning. o It requires stability and long duration of symptoms, with onset in adolescence or earlier. o The behavior cannot be accounted for by another mental disorder. o The behavioral patterns are not the result of substance abuse.  DSM-5 lists the specific personality disorders per three broad clusters: o Odd and eccentric disorders (paranoid, schizoid, and schizotypal); o Dramatic, emotional, or erratic disorders (antisocial, borderline, histrionic, and narcissistic); and o Anxious and fearful disorders (avoidant, dependent, and obsessive-compulsive).  In addition to these three clusters, the manual also includes personality change due to another medical condition and other specified personality disorder and unspecified personality disorder.  Depending on the sample and method of diagnosis, prevalence rates vary considerably.  Cluster A disorders are most prevalent in men who had never married. Cluster B disorders are most prevalent in poorly educated men. Cluster C disorders are most common among those who had graduated from high school but who had never married.  In 2001-2001, 14.8 percent of American adults met the diagnostic criteria for at least one DSM- IV-TR personality disorder.  The risk of having avoidant, dependent, and paranoid personality disorders was greater for females than for males, whereas the risk of having APD was greater for males than for females.  39 percent of people with a personality disorder receive treatment for their mental health or substance abuse difficulties.  For many people with personality disorder, their functioning is egosyntonic; that is, they do not view it as problematic. Most other mental disorders are generally considered egodystonic; they cause distress and are viewed as problematic by the individual sufferer. D IAGNOSTIC ISSUES  The personality disorders have lower reliability of their diagnosis, poorly understood etiology and weak treatment efficacy.  Personality disorders might be better viewed as constellations of traits, each of which lie along a continuum, rather than as disorders that people simply have or do not have.  Others suggest that the diagnostic criteria for some personality disorders are gender biased. GENDER AND CULTURAL ISSUES  DSM-5 requires diagnosticians to ensure that the client’s functioning does not simply reflect normative responding in the client’s culture.  Sex role stereotypes may influence the clinician’s determination of the presence of personality disorders. o Borderline personality disorder and histrionic personality disorder has long been diagnosed more commonly in females than in males. RELIABILITY OF DIAGNOSIS  Personality disorders require a very thorough and careful consideration of the potential disorder’s pervasiveness and severity, as well as the client’s personality style and motivation.  Most personality disorders can be reliably diagnosed given enough information and effort.  All personality disorders, except for narcissistic personality disorder and paranoid personality disorder, showed “fair to good” test-retest reliability. As well, there is at least “fair to good” inter-rater reliability for all personality disorders. COMORBIDITY AND DIAGNOSTIC OVERLAP  Comorbidity should be used to describe the co-occurrence in the same person of two or more different disorders.  Overlap refers to the similarity of symptoms in two or more different disorders.  Patients diagnosed as borderline have been found to have schizotypal features, and considerable overlap has been observed between borderline diagnoses and other personality disorders.  Schizotypal personality disorder is associated with bother borderline personality disorder and narcissistic personality disorder.  There is a high level of comorbidity between the construct of histrionic personality disorder and borderline, narcissistic, and dependent personality disorder.  Over half of the individuals diagnosed with personality disorders meet the criteria for at least one mental disorder. H ISTORICAL P ERSPECTIVE  Historically, there has been greater attention to what we now call antisocial personality disorder, or the related condition psychopathy, than to any other personality disorder.  Based on Machiavelli’s writings, the term machiavellianism has become synonymous with callous, manipulative, and deceptive personality characteristics. o In addition to subclinical narcissism and subclinical psychopathy, make up the “Dark Triad.”  Pinel described a condition called manie sans délire, or madness without delirium.  James Pritchard coined the term moral insanity to delineate a mental condition characterized by an absence of morality. o The “moral principles of the mind” were “perverted or depraved” in these men.  Koch gave the opinion that a more appropriate term would be psychopathic inferiority. The condition of psychopathy stemmed from a type of biological abnormality.  In the early part of the twentieth century, sociologists replaced the term psychopath with the descriptor sociopath, reflecting the idea that the condition involved an “anti-society” view of life. E TIOLOGY  During and after the 1940s, many causal theories were published, from learning theorists, psychoanalysts, and psychophysiologists.  To this day there have been no firm conclusions about the factors that cause personality disorders. PSYCHODYNAMIC VIEWS  Psychoanalysts see personality disorder as resulting from disturbances in the parent-child relationship, particularly in problems related to separation-individuation. o Difficulties in this process result in either an inadequate sense of self or problems in dealing with other people.  This evidence has served to bolster other environmental theories of personality disorders. ATTACHMENT THEORY  Attachment theory asserts that children learn how to relate to others, particularly in affectionate ways, by the way in which their parents relate to them. o When the bond is poor, children will lack confidence in relations with others and leads to deficits in developing intimacy. As well, they are an antecedent to violence and antisocial patterns in children.  Evidence appears to support the role of disrupted attachments in the etiology of these disorders.  Rates of childhood maltreatment among individuals with personality disorders are generally high.  Borderline personality disorder was more consistently associated with childhood abuse and neglect than were other disorders. COGNITIVE-BEHAVIORAL PERSPECTIVES  Cognitive strategies or schemas are said to develop early in life, and in personality-disordered individuals these schemas become rigid and inflexible. o People cope with their schemas in ways that may have been adaptive when they were children trying to survive in a damaging environment, but they continue coping in this same manner into adulthood. o These people come from families who consistently 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 their parents’ attention is through a display of major emotional outbursts.  Parents may also model inappropriate personal styles themselves, and there is considerable evidence that modelling is a powerful influence on children’s behavior.  Parents may inappropriately reward or punish behavior and the expression of attitudes. o Parents of children who engage in antisocial behavior have been shown to reward or punish their children non-contingently. BIOLOGICAL FACTORS  Biological theorists have claimed that there is either brain dysfunction or a genetic or hormonal basis for these conditions.  Specific disturbances in neurotransmitter systems in the brain characterize particular types of personality disorders.  Different biological processes are associated with four dimensions (i.e., cognitive-perceptual organization, impulsivity-aggression, affective stability, and anxiety-inhibition) that together determine personality. o Disruptions in the biological underpinnings of these four factors might be expected to produce the unique personality disorders.  Both schizophrenia and schizotypal personality disorder occurred exclusively in children of parents with schizophrenia. o Children of parents with schizophrenia also were at increased risk for avoidant personality disorder but not paranoid personality disorder. o These relationships were particularly strong for males.  There is a familial vulnerability to schizophrenia spectrum disorders that is observable before adulthood.  The personality disorder group showed reduced prefrontal volume and poorer frontal functioning compared to both other groups.  Studies have implicated dysregulated responding of the prefrontal areas of the brain as well as fronto-limbic dysfunction in the form of overactivation of the amygdala in borderline patients.  The median “heritability coefficient” for 12 personality disorder scales was .75.  Childhood personality disorders may have a substantial genetic component. SUMMARY OF ETIOLOGY  There is clear correlational evidence of biological, family, and learning processes, and there is some support for psychodynamic accounts.  With respect to Cluster A disorders, the most prominent observations are genetic links with both schizophrenia and mood disorders.  For Cluster B disorders, the two etiological factors that have received the best support are biological factors and attachment problems.  Investigations of causal factors specifically with Cluster C disorders have been very limited.  In general, causes of the personality disorders remain murky. C LUSTER A: O DD AND E CCENTRIC D ISORDERS PARANOID PERSONALITY DISORDER  Pervasive suspiciousness concerning the motives of other people and a tendency to interpret what others say and do as personally meaningful in a negative way are the primary features of someone with paranoid personality disorder.  Individuals with paranoid personality tend to be hypervigilant, and they take extreme precautions against potential threats from others.  They are typically humorless and eccentric, and are seen by others as hostile, jealous, and preoccupied with power and control.  They have numerous problems in relationships. Frequently, patients become socially isolated, and this seems only to add to their persecutory ideas.  A genetic link with schizophrenia has been proposed. It has even been suggested that paranoid personality disorder may be a subtype or “cousin” of schizophrenia. o The main difference in paranoid personality and paranoid schizophrenia is the severity of the paranoid belief.  In schizophrenia, the paranoid belief is sufficiently bizarre and ingrained that it is considered “psychotic”—a delusion.  In paranoid personality, the individual’s paranoid beliefs are non-bizarre, within the realm of possibility, and pertain to general suspiciousness.  There is significant diagnostic overlap between paranoid personality and both avoidant and borderline personality disorders.  Paranoid personality disorder is one of the most commonly diagnosed personality disorders in community samples.  Only a very small proportion of individuals with this disorder would seek or accept treatment. SCHIZOID PERSONALITY DISORDER  Individuals with this condition seem completely uninterested in having any sort of intimate involvement with others, and they display little in the way of emotional responsiveness.  Individuals with schizoid personality disorder are typically loners who are cold and indifferent toward others. They seem not to enjoy relationships of any type. o Most do not have the skills necessary for effective social interaction.  The impact on diagnostic practices of the changes from DSM-III to DSM-III-R revealed that the frequency of schizoid diagnoses increased significantly.  This diagnostic category has been the focus of little methodologically sound research.  This disorder may be more related to asocial disorders than paranoid personality disorder or schizotypal personality disorder. SCHIZOTYPAL PERSONALITY DISORDER  The major presenting feature of individuals with the schizotypal personality disorder is eccentricity of thought and behavior; many are extremely superstitious.  Schizotypal patients are typically socially isolated.  Their thinking tends to be permeated by odd beliefs. They typically believe in magical thinking and paranormal phenomena and may see such skills in themselves.  This condition has some similarities with schizophrenia. The difference lies in the severity and quality of the symptoms. o They are not usually considered to be so eccentric as to meet the criteria for delusional or hallucinatory psychotic experiences.  Biological research has found strong similarities between patients with schizotypal personality disorder and those with schizophrenia.  Many family members of patients with schizophrenia exhibit schizotypal symptoms.  While the symptoms of SPD remain the same, the severity of the symptoms varies depending on sex and age.  Diagnostic overlap between schizotypal disorder and other Cluster A disorders is considerable.  Low doses of antipsychotic drugs relieve the cognitive problems and social anxiety apparent in these patients, and antidepressant medication has also produced positive effects.  Generally the long-term prognosis for schizotypal patients is poor. C LUSTER B: D RAMATIC , E MOTIONAL , OR E RRATIC D ISORDERS  It’s been suggested that antisocial patients belong to a separate category of personality disorders. 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.  The behavioral features of APD predispose these patients to crime, and unlawfulness is one of the examples that DSM-5 provides of the disregard that those with antisocial personalities display toward others. DESCRIPTION OF THE DISORDER  Individuals thus identified have been referred to as psychopaths, sociopaths, or dissocial personalities, with these terms sometimes being used interchangeably.  APD and psychopathy are not the same disorder. Only a small proportion of individuals who qualify for an APD diagnosis are psychopathic, whereas most individuals who are psychopathic would qualify for an APD diagnosis. o APD and psychopathy have an asymmetric relationship.  The Psychopathy Checklist—Revised specifies both behavior and personality as features to be considered. o Personality and lifestyle instability are necessary and sufficient for a diagnosis. o The PCL-R emotional/affective criteria are highly reliable if the rater has the appropriate training.  The essential feature of APD is a pervasive pattern of disregard for and violation of the rights of others that begins in childhood or early adolescence and continues into adulthood.  The DSM-5 criteria for APD are a highly reliable set of indicators of a socially deviant lifestyle; however, they are not the best criteria for tapping the core features of psychopathy. ANTISOCIAL PERSONALITY DISORDER (APD)  The DSM-5 criteria for the diagnosis of APD include seven exemplars reflecting the violation of the rights of others: nonconformity, callousness, deceitfulness, irresponsibility, impulsivity, aggressiveness, and recklessness.  Reflecting a polythetic approach, three or more of the above symptoms must be met for the diagnosis to be applied. PREVALENCE  The DSM-5 reports lifetime prevalence rates for APD between 0.2 percent and 3.3 percent for both males and females.  In Canadian prisons using DSM-III-R, approximately 40 percent of offenders were diagnosed as having APD. ETIOLOGY OF APD  Social and family factors were initial explanations with the view being that parental behaviors can influence the development of antisocial functioning.  A minority of youth become involved in rule breaking and delinquent behavior at an early age and this is sustained throughout their lifespan in one form or another.  Research also suggests the importance of familial/parental factors and genetic features as risk factors for developing APD.  Heritability estimates for measure of antisocial behavior/aggression ranges from 44 to 72 percent.  There appear to be neuropsychological markers that, in combination with specific environmental circumstances, interact to make children vulnerable to developing an antisocial lifestyle and personality.  The fearlessness hypothesis claims that those with APD have a higher threshold for feeling fear than do other people. There appears to be an attentional mechanism that reduces the fear respond in individuals with APD. o Schmauk suggested that these individuals might have learned to be either indifferent to physical punishment or oppositional to such attempts at controlling them.  Oppositional behavior refers to a tendency to do the opposite of what is being asked of the person.  Psychopaths suffer from a generalized information processing deficiency involving the automatic directing of attention to stimuli that are peripheral to ongoing directed behavior. o Once engaged in reward-based behavior, the psychopath is less likely to attend to other cues to modulate his or her ongoing response. o The antisocial and criminal behavior exhibited by those diagnosed as having APD involves schema-based deficits not requiring automatic attentional cuing. COURSE AND PROGNOSIS OF APD  The average duration of APD, from the onset of the first symptom to the end of the last, was 19 years. The remittance over time of symptoms has been described as the burnout factor.  When APD and substance use are comorbid conditions, the post-release performance is poorer than in those offenders who have only one or the other disorder. TREATMENT FOR APD  Programs delivered in the previ
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