Personality Disorders

1. Personality Disorders Chapter 9 November 18, 2005

2. Definition of Personality • “Enduring patterns of perceiving, relating to, and thinking about the environment and oneself, which are exhibited in a wide range of important social and personal contexts”

3. Definition of Personality Disorders • Personality disorders are “enduring patterns of perceiving, relating to, and thinking about the environment and oneself” that “are exhibited in a wide range of important social and personal contexts,” and “are inflexible and maladaptive, and cause either significant functional impairment or subjective distress” (DSM-IV, p. 630)

4. Main Features of PDs • Extreme patterns of thinking, feeling, and behaving that deviate from a person’s culture • Listed on Axis II of the DSM-IV-TR • Begin early in life and remain stable - not contextual or transient • Inflexible and maladaptive • Cause significant functional impairment and subjective distress - ego-syntonic vs. ego-dystonic

5. Problems with the PDs • Low levels of inter-rater reliability • Comorbidity with both Axis I and Axis II • Problems with classification system - Categorical vs. Dimensional System

6. DSM-IV-TR Personality Disorders • Paranoid Personality Disorder • Schizoid Personality Disorder • Schizotypal Personality Disorder • Antisocial Personality Disorder • Borderline Personality Disorder • Histrionic Personality Disorder • Narcissistic Personality Disorder • Avoidant Personality Disorder • Dependent Personality Disorder • Obsessive-Compulsive Personality Disorder

7. Cluster A: Odd or Eccentric • Paranoid PD – is a pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent • Schizoid PD – is a pattern of detachment from social relationships and restricted range of emotional expression • Schizotypal PD – is a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour

8. Paranoid Personality Disorder • suspicious of other’s motives • interprets actions of others as deliberately demeaning/threatening • expectation of being exploited • see hidden messages in benign comments • easily insulted/ bears grudges • appear cold and serious

9. Schizoid Personality Disorder • indifferent to relationships • limited social range (some are hermits) • aloof, detached, called loners • no apparent need of friends, sex • solitary activities • seem to be missing the “human part”

10. Schizotypal Personality Disorder • peculiar patterns of thinking and behaviour • perceptual and cognitive disturbances • magical thinking • not psychotic • perhaps a distant “cousin” of schizophrenia

11. Cluster B: Dramatic, Emotional, or Erratic • Antisocial PD – is a pattern of disregard for, and violation of, the rights of others • Borderline PD – is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity • Histrionic PD – is a pattern of excessive emotionality and attention seeking • Narcissistic PD – is a pattern of grandiosity, need for admiration, and lack of empathy

12. Antisocial Personality Disorder • pattern of irresponsibility, recklessness, impulsivity beginning in childhood or adolescence (e.g., lying, truancy) • adulthood: • criminal behaviour • little adherence to societal norms, • little anxiety • conflicts with others • callous/exploitive

13. Psychopathy • Egocentric, deceitful, shallow, impulsive individuals who use and manipulate others • Callous, lack of empathy • Little remorse • Thrill-seeking • “human predators” (Hare, 1993) • No “conscience”

14. Glib and superficial Egocentric and grandiose Lack of remorse or guilt Lack of empathy Deceitful and manipulative Shallow emotions Impulsive Poor behavior controls Need for excitement Lack of responsibility Early behavior problems Adult antisocial behavior Psychopathy Checklist-Revised (Hare, 1991) – 2 Factors

15. Quote of the day “I’m the most cold-hearted son of a b---- you will ever meet” • Ted Bundy

16. Borderline Personality Disorder • marked instability of mood, relationships, self-image • intense, unstable relationships • uncertainty about sexuality • everything is “good” or “bad” • chronic feeling of “emptiness” • recurrent threats of self-harm/ “slashers”

17. Borderline and comorbidity • High degree of overlap with both Axis I and Axis II disorders • 24%-74% also diagnosed with major depression; 4% to 20% bipolar • 25% of bulimics also diagnosed with BPD • 67% also diagnosed with substance use disorder

18. Histrionic Personality Disorder • excessive emotional displays/ dramatic behaviour • attention-seeking, victim stance • seek re-assurance, praise • shallow emotions, flamboyant, self-centred • very seductive, “life of the party”

19. Narcissistic Personality Disorder • grandiose, sense of self-importance • lack of empathy • hyper-sensitive to criticism • exaggerate accomplishments/ abilities • special and unique • entitlement • below surface is fragile self-esteem

20. Cluster C: Anxious or Fearful • Avoidant PD – is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation • Dependent PD – is a pattern of submissive and clinging behaviour related to an excessive need to be taken care of • Obsessive-Compulsive PD – is a pattern of preoccupation with orderliness, perfectionism, and control at the expense of flexibility

21. Avoidant Personality Disorder • over-riding sense of social discomfort • easily hurt by criticism • always need emotional support • occasionally try to socialize • so distressing they retreat into loneliness

22. Dependent Personality Disorder • submissive, clingy behaviour • fear of separation • easily hurt by criticism

23. Obsessive-Compulsive Personality Disorder • excessive control and perfectionism • inflexible • preoccupied with trivial details • judgmental/moralistic • workaholic/ignore family members • often humourless

24. Personality Disorder Not Otherwise Specified • Meets general criteria for a PD but no specific criteria for a specific PD. • Exhibit at least 10 symptoms of PDs across all subtypes

25. Comorbidity • Average number of PD diagnoses per patient: - 4.6 (Skodal et al., 1988) - 2.8 (Zanaarini et al., 1987) • 3.75 (Widiger et al., 1986)

26. DSM – Categorical Approach • Based on the medical model • Disorder is present or absent

27. Assumptions of the DSM • Personality pathology is suited to be classified into discrete types or disorders • These disorders group themselves into three clusters • The diagnostic criteria naturally fall into the particular personality disorders to which they have been assigned Empirical Evidence doesn’t support these assumptions!!!

28. David Klonsky – University of Virgina “the DSM practice of putting expert opinions into writing and only then conducting tests of reliability and validity cannot lead to an acceptable classification system. Rather it directs scientists to conduct research on, and practitioners to put their trust in, diagnostic labels that may or may not map onto valid constructs that exist in nature. Instead, researchers must turn to objective, empirical methodologies to discover the dimensions or personality pathology, letting the data fall where they may and letting the data determine how personality disorder is best classified”

29. John Livesley - UBC • Dimensional Assessment of Personality Pathology Basic Questionnaire (DAPP) • 4 Dimensions: Emotional Dysregulation; Dissocail Behaviour; Inhibitedness; Compulsivity

30. “ …the evidence on this point is so unequivocal that the only issue to explain is the field’s reluctance to accept empirical evidence” ~ W. John Livesley, (2000) Journal of Personality Disorders, 14, 2, p. 139-140.

31. The “Big 5” Personality Traits • Openness to experience • Conscientiousness • Extraversion • Agreeableness • Neuroticism  personality disorders represent extreme variations of OCEAN

32. Advantages of Categorical System • Ease in conceptualization and communication • Familiarity • Consistency with clinical decision making

33. Disadvantages of the Categorical Approach • Complex and cumbersome • Arbitrary cut-off points • Loss of important information

34. Advantages of the Dimensional Model • Resolution of a variety of classification dilemmas • Retention of Information • Flexibility

35. Disadvantages of the Dimensional Approach • Lack of clinical utility? • Lack of familiarity? Bottom line: not too many disadvantages and most researchers favor it – likely to be adopted in DSM-V