Personality Disorders

1. Personality Disorders EPC 695B

2. All humans have personality traits. These are well-ingrained ways in which individuals experience, interact with, and think about everything that goes on around them.

3. Personality Disorders are collections of traits that have become rigid, and work to individual’s disadvantage, to the point that their personality disorders impair functioning or cause distress.

4. All of the DSM-IV-TR personality disorders are patterns of behavior and thinking that have been present since early adult life and have been recognizable in the client for a long time.

5. Personality disorders are probably dimensional, not categorical This means that their components (the traits) are present in normal people, but are accentuated in those with the disorders in question.

6. Generic Criteria for Personality Disorders (p. 689) A lasting pattern of inner experience and behavior that markedly deviates from norms of the client's culture. • The pattern is manifested in at least two of these areas: a.Cognition (how the client perceives and interprets self, others, and events) b.Affect (appropriateness, intensity, lability, and range of emotions) c.Interpersonal functioning d.Impulse control

7. Generic Criteria for Personality Disorders (con’t.) • This pattern is fixed and affects many personal and social situations. • The pattern causes clinically important distress orimpairs work, social, or personal functioning • This pattern has lasted a long time, with roots in adolescence or young adulthood. • The pattern is not better explained by another mental disorder. • The pattern is not directly caused by a GMC or by the use of substances, including medication.

8. Generic Criteria - Summary These general criteria are extremely important. They identify vital points that are central to the diagnosis of any personality disorder. To summarize, a personality disorder is: • Lifelong, • Affects many areas of the client's life, • Causes problems, and • Is not the product of another illness.

9. Let’s look together at the handout: Morrison’s Quick Guide to the Personality Disorders

10. Diagnosing Personality Disorders See additional handouts: • Diagnosing Personality Disorders • Personality Disorders

11. Assessment of Personality Disorders • To make a specific diagnosis - a semi-structured interview can be used, augmented by a self-report personality inventory. a. Semi-structured interviews guide the therapist through a series of questions that assess all of the potential personality disorders. Example: SCIS-II by Spitzer, Williams & Giffon (Helps to avoid impressions that rely on only one or two symptoms rather than the full criteria set.) b. Millon Clinical Multiaxial Inventory II (MCMI-I) is a self- report measure. Self report inventories tend to indicate more personality disorder pathology than reported by clinical interviews. Thus, the inventories are only suggestiveof possible diagnoses and alternatives.

12. Assessment of Personality Disorders (con’t.) Personality disorders are more vulnerable to error of diagnosis than Axis I disorders. Diagnostic errors occur most often when the therapist fails to adhere to the diagnostic criteria or when the therapist has a gender or cultural bias. For example: The counselor may only see one key symptom and make or rule out a diagnosis without carefully looking for the entire cluster of symptoms required to meet DSM criteria.

13. Assessment of Personality Disorders (con’t.) • For example: A study by Morey and Ochoa (1989) found that, when a client with a borderline personality disorder had a symptom of little sexual interest, the client was not diagnosed correctly because clinicians believe that clients with borderline personality disorder are sexually promiscuous.

14. Assessment of Personality Disorders (con’t.) • A study by Ford and Widiger (1989) also found that failure to adhere to criteria made it more likely that the clinician would be influenced by gender and cultural background of client. • For example, clinicians making diagnoses of histrionic and antisocial personality disorder were affected in their diagnoses by the sex of the client (women seen as histrionic, men as antisocial), but when asked to assess, using given criterion symptoms, they were not biased by client sex.

15. Coding Notes 1. If a client has an Axis I diagnosis, but a personality disorder is the main reason the client has come for evaluation, (Principal Diagnosis) should be attached to the Axis II diagnosis. Axis I312.32 Kleptomania Axis II 301.6 Dependent Personality Disorder (Principal Diagnosis) 2. A frequently used defense mechanism can be indicated on the Axis II line: Axis II 301.0 Paranoid Personality Disorder; frequent use of projection See DSM-IV-TR, p. 811: Defense Mechanism and Coping Styles

16. Coding Notes (con’t.)  3. If your client's personality disorder preceded a psychotic disorder (most often Schizophrenia), the diagnosis might read: Axis I 295.10 Schizophrenia, Disorganized Type, Continuous, With Prominent Negative Symptoms Axis II 301.22 Schizoid Personality Disorder (Premorbid)

17. Please look at handout: Correlation between Axis II Personality Disorders and Axis I Mental Disorders

18. Now look at: Profile of Characteristics of Personality Disordersin your packet

19. 301.0 Paranoid Personality Disorder a. Central characteristic: unjustified distrust and suspicion of others. • Because the client fears exploitation, s/he will not confide in others – even those who have earned his/her trust. c.Client reads unintended meaning into benign comments and actions. d.Client will interpret specious occurrences as the result of deliberate intent and will harbor resentment for a long time, perhaps forever. e. These clients are rigid, often litigious, and have an especially urgent need to be self-sufficient.

20. 301.0 Paranoid Personality Disorder f. To others, these clients appear to be cold, calculating, and guarded people who avoid both blame and intimacy. g. When interviewed, they may appear tense and have trouble relaxing. h. This disorder is especially likely to create occupational difficulties; these clients are so aware of rank and power that they frequently have trouble dealing with superiors and co-workers. i. Although it is far from rare (about 1% of the general population), it rarely comes to clinical attention. Usually diagnosed in men. Its relationship (if any) to the development of Schizophrenia, Paranoid Type, remains unclear.

21. 301.0 Paranoid Personality Disorder Treatment Options • Supportive psychotherapy, • Confronting beliefs about therapist, • Pharmacotherapy, • Behavioral Therapy Countertransference • Anger, • Withholding negative feedback Case: Useful Work (DSM-IV-TR Casebook, p. 211)

22. 301.20 Schizoid Personality Disorder • Indifferent to the society of other people • Lifelong loners, who show a restricted emotional range; they appear unsociable, cold and seclusive • Unusually succeed at solitary jobs others find difficult to tolerate • May daydream excessively, become attached to animals, and often do not marry or even have long-lasting romantic relationships • Do retain contact with reality • Disorder is relatively common, affecting perhaps a few percent of the general population • Men are at greater risk than women.

23. 301.2 Schizoid Personality Disorder Treatment Options • Supportive Therapy • Pharmacotherapy • Cognitive reorientation therapy • Group Therapy Countertransference: As watch film, see what feelings he engenders in you. Film: Jerry - Schizoid Personality Disorder

24. 301.22 Schizotypal Personality Disorder • From early age have lasting interpersonal deficiencies that severely reduce capacity for closeness with others. • Also has distorted or eccentric thinking, perceptions, and behaviors that can make these clients seem odd. • Often feel anxious when with strangers and have almost no close friends. d. May be suspicious and superstitious • Peculiarities of thought include magical thinking and belief in telepathy or other unusual modes of communication. • May talk about sensing a "force" or "presence," or have speech characterized by vagueness, digressions, excessive abstractions, impoverished vocabulary, or unusual use of words.

25. 301.22 Schizotypal Personality Disorder g. May eventually develop Schizophrenia. h. Many are depressed when first come to clinical attention. • Eccentric ideas and style of thinking also place these clients at risk for becoming involved with cults. • Gets along poorly with others and, under stress, may briefly become psychotic. • Many marry and work. • Occurs as often as Schizoid Personality Disorder

26. 301.22 Schizotypal Personality Disorder Overlapping Diagnoses: Axis I: Paranoid Schizophrenia; Mood Disorder; Obsessive-Compulsive Axis II: Borderline; Schizoid Treatment Options • Pharmacological • Supportive Therapy Counter-transference • Underestimating importance of treatment to client. Why would that happen?  Case: Wash Before Wearing (DSM-IV Casebook, p. 289)

27. 301.7 Antisocial Personality Disorder • Chronically disregard and violate rights of other people; these individuals cannot or will not conform to the norms of society. • Some are engaging con-artists; others may be graceless thugs. • Women are often prostitutes. • Seem superficially charming, but are aggressive and irritable. • This personality disorder affects nearly every life area: In addition to substance use, there may be fighting, lying, and criminal behavior of every conceivable sort: theft, violence, confidence schemes, and child and spouse abuse. • Claim to have guilt feelings, but do not appear to feel genuine remorse for this behavior.

28. 301.7 Antisocial Personality Disorder • Claim to have guilt feelings, but do not appear to feel genuine remorse for this behavior. • Manipulative interactions with others make it difficult to decide whether or not complaints are genuine. • About 3% of men, but only 1% of women have this disorder. • Accounts for 3 out of every 4 penitentiary prisoners. • More common among lower class populations and runs in families; probably both genetic and environmental. • Disorder decreases possibly with increasing age. Individual mellows out after 30; however, still are substance users. • Death by suicide or homicide is sometimes their lot. • Can't get this diagnosis if antisocial behavior occurs only in the context of substance abuse. Crucial to learn whether clients have engaged in illicit acts when not using substances. • Only one-half of children with anti-social background eventually develop the full adult syndrome.

29. 301.7 Antisocial Personality Disorder Overlapping Diagnoses Axis I Major Depression; Substance abuse Axis II Borderline; Narcissistic Treatment Options: • Morrison: No known effective treatment • Others have said: • Pharmacotherapy; • Marital/Family; • Behavioral (i.e., token economies, assertiveness training; education); • Cognitive Therapy Countertransference: Watch your feelings when you see the film. • Gullibility • Suspiciousness Film: Antisocial Personality Disorder (Tape 3) George #8

30. 301.83 Borderline Personality Disorder • This concept was devised about the middle of the 20th century. Clients were originally (and sometimes still are) said to be on the borderline between neurosis and psychosis. • The existence of this disorder is disputed by many clinicians. • As the concept has evolved into a personality disorder, it has achieved remarkable popularity, perhaps because so many clients can be shoe-horned into its definition. • About 1-2% of general populations may legitimately qualify for this diagnosis. • These clients have a pattern of instability throughout adult live. • The most over-used diagnosis in the DSM-IV. Many of these clients really have Axis I disorders that are more readily treatable, such as Major Depressive Disorder, Somatization Disorder, and Substance-related Disorders. • Often appear in crisis of mood, behavior, or interpersonal relationships.

31. 301.83 Borderline Personality Disorder • Many feel empty and bored; they attach themselves strongly to others, then become intensely angry or hostile when they believe that they are being ignored or mistreated. • Impulsively try to harm or mutilate selves. • These are cries for help, anger, or attempts to numb selves. • Can have brief psychotic episodes, but resolved so quickly that these are seldom are confused with psychoses like schizophrenia. • With all the mood swings, it is difficult for the client with this diagnosis to achieve fell potential • Truly miserable and about 10% commit suicide. • Antecedents: abandonment; abuse

32. 301.83 Borderline Personality Disorder Overlapping Diagnoses Axis I Major depression; Dysthymic Disorder; Adjustment Disorder Axis II Histrionic; Narcissistic; Schizotypal; Antisocial Treatment Options • Expressive psychodynamic therapy; • Object Relations; • Supportive Psychotherapy; • Brief psychotherapy; • Cognitive-behavior therapy  In therapy, it is important to: • Address client’s disappointments, • Confront behavior (“When you sleep with every man you date, I wonder what is happening with you.”) • Understand that behavior is often a result of loneliness and abandonment issues in childhood • Know that you will be overvalued and undervalued, as well as loved and hated. • Countertransference Feelings: Guilt, Rage, Wanting to rescue and reject client Case: “Empty Shell,” p. 237

33. 301.50 Histrionic Personality Disorder • Have long-standing excessive emotionality and attention- seeking that seeps into all areas of lives. • Satisfy need to be on center stage in two main ways: (a) their interests and topics of conversation focus on their own desires and activities; and (b) their behavior, including speech, continually calls attention to themselves. • Over-concerned with physical attractiveness. • Express themselves so extravagantly that it seems like a parody of normal emotionality. • May be promiscuous or have a normal sex life, others may have difficulty with frigidity or impotence. • Moods seem shallow. • Low tolerance for frustration may spawn temper tantrums.

34. 301.50 Histrionic Personality Disorder • Quick to form new friendships, also quick to become demanding. • Have trouble with tasks that require logical thinking such as doing mental arithmetic. • May succeed in jobs that set premium on creativity and imagination. • This disorder is not well studied, but if quite common. • May run in families. • Classical client is female, but disorder can occur in men.

35. 301.50 Histrionic Personality Disorder Overlapping Diagnoses Axis I: Mood Disorders; Somatization Disorder Axis II: Borderline; Narcissistic Treatment Options • Pharmacological; • Behavioral; • Psychodynamic; • Supportive; • Group; Countertransference Seductive Indifference Case: My Fan Club (DSM-IV-TR Casebook, p. 84). Case encompasses both Histrionic and Narcissistic Personality Disorders.

36. 301.81 Narcissistic Personality Disorder • Lifelong pattern of grandiosity (in behavior and in fantasy), thirst for admiration, and lack of empathy. • Permeates most aspect of lives. • Client feels s/he is unusually special. • Commonly exaggerate accomplishments to make self seem bigger than life. (These traits are true only of adults. Children and teenagers are naturally self-centered; this doesn't imply ultimate personality disorder) e. Despite grandiosity, have fragile self-esteem and often feel unworthy.

37. 301.81 Narcissistic Personality Disorder • Sensitive about own feelings, but have little apparent understanding of the feelings and needs of others and may feign empathy. • Because they tend to be concerned with grooming and value youthful looks, they may become increasingly depressed as they age. • Disorder was very poorly studied. Now studied more; people not come for therapy • Most clients are men. • There is no information about family history, environmental antecedents, or other background material. Perhaps mirroring was imperfect. Not seen as person - who child really is. False Self.

38. 301.81 Narcissistic Personality Disorder Overlapping Diagnoses Axis I Major depression; Adjustment disorder with depressed mood Treatment Options Psychodynamic Object Relations Brief Supportive Therapy Client-centered Behavioral Cognitive Paradoxical In therapy, it is important to: • Use metaphors; e.g., cold • Interpret behavior (“When you act so coldly with your wife after she doesn’t understand you, I think that has roots in your childhood when your mother was so distant when you didn’t please her.”) • Use visualization; e.g., crevice Countertransference: Please the client, Anger, Retaliation

39. 301.82 Avoidant Personality Disorder • Feels inadequate and is socially inhibited and overly sensitive to criticism. • Present throughout adult life; however, avoidant traits are common in children and do not necessarily imply eventual personality disorder. c. Self-effacing and eager to please others. • Can lead to social isolation, as he/she may misinterpret innocent comments as critical. • Hangs back in social situations.

40. 301.82 Avoidant Personality Disorder • Tends to have few close friends. • Comfortable with routine. • Sparse research. Uncommon and almost no information about sex distribution and family pattern. i. This disorder may be associated with a disfiguring illness or condition. • Not often seen clinically, for client tends to come for evaluation only when another illness supervenes.

41. 301.82 Avoidant Personality Disorder Overlapping Diagnoses Axis I: Anxiety disorder; Dysthymia; Major depression; Adjustment Disorder with Depressed Mood. Axis II: Dependent; Passive-aggressive Treatment Options • Behavioral (systematic desensitization; assertiveness training) • Cognitive • Paradoxical (Prescribing avoidant behaviors; prescribing rejections) • Psychodynamic • Importance of therapeutic relationship Countertransference Case: • Pushing the client • Over-protectiveness Case: The Jerk (DSM-IV-TR Case Book. p. 124)

42. 301.6 Dependent Personality Disorder • Feels the need to be taken care of. • Desperately fears separation • Client’s behavior can become so submissive and clinging that it may result in others' taking advantage or rejecting the client • Feels helpless and uncomfortable when client is alone. • Needs much reassurance, so has trouble making decisions. • May tolerate considerable abuse (even battering) • DPD may occur commonly, but it has not been well studied. • Afraid of independence, because then others will reject him/her • Found more often among women than men. • Some writers believe that it is difficult to distinguish this diagnosis from Avoidant Personality Disorder.

43. 301.6 Dependent Personality Disorder Overlapping Diagnoses Axis I: Anxiety disorders; Mood disorder Axis II: Histrionic; Narcissistic; Avoidant; Schizotypal Treatment Options • Behavioral (Assertiveness Training; Exposure to anxiety situations) • Cognitive therapy • Family and marital therapy • Group therapy • Psychodynamic therapy Countertransference • Guilt • Over-protectiveness • Rejection Case: Blood is Thicker Than Water (DSM-IV Case book, p. 179)

44. 301.4 Obsessive-Compulsive Personality Disorder a. Perfectionistic and preoccupied with orderliness; needs to exert interpersonal and mental control. b. Many with this personality disorder have no actual obsessions or compulsions at all, though some eventually develop OCD. c. Rigid perfectionism often results in indecisiveness, preoccupation with detail, and insistence that others do things their way. d. Sometimes savers, refusing to throw away even worthless objects they no longer need. e. List makers who allocate their own time poorly, workaholics who must meticulously plan even their own pleasure. f. May resist authority of others, but insist on their own. g. May be perceived as stilted, stiff, or moralistic. h. Condition is fairly common. Diagnosed more often in males than females. i. Probably runs in families

45. 301.4 Obsessive-Compulsive Personality Disorder Overlapping Diagnoses Axis I Mood Disorders; Anxiety Disorders Axis II Avoidant; Dependent Treatment Options • Behavioral (In vivo exposure; compulsive rituals; obsessive ruminations) • Cognitive (thought-stopping; cognitive restructuring) • Paradoxical approaches (to oppositionalism) • Supportive • Psychodynamic (problems collaborating with intellectualizing defenses; resistance; focusing on affect; use of humor). Countertransference • Boredom • Power struggles • Collusion Case: The Workaholic (DSM-IV Case book, p. 147) • Therapist • Compulsivity

46. 301.9 Personality Disorder NOS • Used for clients who have insufficient features for a better-defined personality disorder, but who appears to have long-standing personality traits that have cause difficulties in many life areas. • Can also be used for other personality disorders that have not yet received official DSM sanction. • Many individuals have long-standing personality traits, but these traits cut across several personality disorders and they don’t completely meet the criteria for any one of them. Case: Stubborn Psychiatrist (DSM-IV Case book, p. 166)