Personality Disorders

Personality Disorders

Personality Traits • characteristic ways of thinking, feeling, and behaving that are stable across time and across situations • considered to be a disorder when • traits are inflexible and maladaptive • cause significant functional impairment and/or distress

The Question • Are people with personality disorders qualitatively different from people without? OR • Are personality disorders simply extreme versions of otherwise normal personality variations?

The Answer • Personality disorders are probably best thought of as extremes on one or more personality dimensions

DSM-IV-TR • Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision • lists diagnostic criteria for each mental disorder

Prevalence • 0.5 - 2.5% of the general population • 2 - 10% of outpatients • 10 - 30% of inpatients

Course • thought to originate in childhood and continue into adulthood • believed to be relatively stable, difficult to treat

Comorbidity • considerable overlap among categories • about 50% of people diagnosed with one personality disorder also meet criteria for another • questions • do people really tend to have more than one personality disorder? • do rates of comorbidity indicate problems with reliability and validity of diagnostic categories?

Lack of Research • for many personality disorders, there is relatively little empirical research on the causes and treatments

Three Clusters • odd/eccentric • dramatic/erratic • anxious/fearful

Cluster A: Odd or Eccentric • paranoid • schizoid • schizotypal

Paranoid Personality Disorder • pervasive pattern of distrust and suspiciousness of others such that their motives are interpreted as malevolent

DSM-IV-TR: at least 4 sx • suspects others are exploiting, harming, or deceiving him • preoccupied with doubts about loyalty/trustworthiness of friends, associates • reluctant to confide in others (fears info will be used against him)

DSM-IV-TR (continued) • reads hidden threatening meanings into benign events • bears grudges, is unforgiving • perceives attacks on character or reputation and is quick to counterattack • suspicious of fidelity of sexual partner

Causes • Biological • slightly more common among relatives of people with schizophrenia • Psychological • theory: certain basic mistaken assumptions about others • “people are malevolent and deceptive” and “they’ll attack you if they get the chance” • result of upbringing? taught by parents?

Treatment • unlikely to seek professional help; difficulty trusting therapist • difficulty that brings them in is a crisis • cognitive therapy • changing person’s mistaken beliefs about others • no confirmed demonstrations that any form of tx works

Schizoid Personality Disorder • pervasive pattern of detachment from social relationships and restricted range of expression of emotion in interpersonal settings

DSM-IV-TR: at least 4 sx • neither desires nor enjoys close relationships • chooses solitary activities • little, if any, interest in sexual experiences with another person • lacks close friends • appears indifferent to praise/criticism • shows emotional coldness, detachment • takes pleasure in few, if any, activities

Causes and Treatment • causes • no research • preference for social isolation resembles aspects of autism • treatment • don’t usually seek tx (only in response to crisis) • point out value of social relationships • learn empathy • social skills training • many therapists believe therapy doesn’t help this group

Schizotypal Personality Disorder • pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships and cognitive or perceptual distortions and eccentricities of behavior

DSM-IV-TR: at least 5 sx • ideas of reference • odd beliefs or magical thinking • unusual perceptual experiences • odd thinking and speech • suspiciousness/paranoia

DSM-IV-TR (continued) • inappropriate or constricted affect • behavior or appearance that is odd, eccentric, or peculiar • lack of close friends • excessive social anxiety: associated with paranoid fears

Causes and Treatment • Biological • more common among relatives of people with schizophrenia • Treatment • research is limited • tx for comorbid depression • psychological: social skills to help reduce isolation or help person adjust to solitary lifestyle • medical: Haldol. Results in improvement in some sx, but many stop taking due to side effects

Cluster B: Dramatic or Erratic • antisocial • borderline • histrionic • narcissistic

Antisocial Personality Disorder • pervasive pattern of disregard for and violation of the rights of others since age 15

DSM-IV-TR • at least 3 sx • failure to conform to social norms with respect to lawful behavior (repeated arrests) • deceitfulness (repeated lying, use of aliases, conning) • impulsivity, failure to plan ahead • irritability and aggressiveness (repeated fights) • reckless disregard for safety of others • consistent irresponsibility (no steady employment, doesn’t honor financial obligations) • lack of remorse (indifferent to or rationalizes having hurt, mistreated, or stolen from others)

DSM-IV-TR (continued) • must be at least 18 • evidence of conduct disorder prior to age 15 • violation of basic rights of others and major social rules • aggression toward people and/or animals • destruction of property • deceitfulness or theft • serious violation of rules (stays out all night, truant)

Psychopathy • antisocial personality disorder overlaps with personality trait called “psychopathy” • glib or superficial charm • grandiose sense of self-worth • proneness to boredom/need for stimulation • pathological lying • conning/manipulative • lack of remorse • not all psychopaths display aggressiveness that is a DSM-IV-TR criterion for antisocial personality

Causes: Biological • genetics • family, adoption, and twin studies show evidence of a genetic link • examples: • offspring of felons raised by adoptive families show higher rates of arrests and antisocial personality disorder than controls • concordance rates for criminality are 55% for MZ twins and 13% for DZ twins

But what do they inherit? • underarousal hypothesis • psychopaths have abnormally low levels of cortical arousal • engage in antisocial and risk-taking behaviors to increase level of arousal • evidence • longitudinal study found that future criminals had lower skin conductance activity, lower heart rate, and more slow-frequency brain wave activity

fearlessness hypothesis • psychopaths have a higher threshold for experiencing fear than most people • evidence • psychopaths are less likely to develop a classically conditioned fear response

Psychological and Social Influences • oversensitivity to reward • will persist in efforts to achieve goal, even when goal is no longer attainable • inconsistent parental discipline • giving in to problem behavior and poor monitoring • other environmental influences • low SES, stress, and degree of mutual trust and solidarity in neighborhood linked to antisocial behaviors

Treatment • prognosis for adults is poor • best strategy is to intervene with “high risk” children • teach parents to use behavioral management principles to reduce problem behavior and increase prosocial behavior • research suggests such programs reduce antisocial behavior

Borderline Personality Disorder • pervasive pattern of instability of interpersonal relationships, self-image, and affects marked by impulsivity

DSM-IV-TR: at least 5 sx • frantic efforts to avoid real or imagined abandonment • intense and unstable interpersonal relationships • alternate between extremes of idealization and devaluation • unstable self-image or sense of self • impulsivity in at least 2 areas that are potentially self-damaging (sex, money)

DSM-IV-TR (continued) • recurrent suicidal behavior or self-mutilation • emotional instability due to marked reactivity of mood • chronic feelings of emptiness • inappropriate, intense anger • transient, stress-related paranoid thoughts or dissociative sx

Causes • family studies • suggest genetic link • suggest that BPD is linked to mood disorders • early trauma • 91% report h/o childhood sexual or physical abuse • one theory • child who has biological vulnerability to emotional dysregulation and is raised by invalidating family

Treatment • few controlled studies • medical • many respond positively to antidepressants and lithium

Treatment (continued) • psychological • dialectical behavior therapy • help people cope with stressors that trigger suicidal behaviors • teach patients how to identify and regulate their emotions • teach problem solving • re-exposure to prior traumatic events to extinguish fear • trust own responses, rather than depend on others for validation • reduces suicide attempts, dropouts from treatment, and hospitalizations

Histrionic Personality Disorder • pervasive pattern of excessive emotionality and attention seeking

DSM-IV-TR: at least 5 sx • uncomfortable when not the center of attention • inappropriate sexually seductive or provocative behavior • rapidly shifting and shallow expression of emotions • consistently uses physical appearance to draw attention to self

DSM-IV-TR (continued) • speech is excessively impressionistic and lacking in detail • shows self-dramatization, theatricality, and exaggerated expression of emotion • highly suggestible • considers relationships to be more intimate than they actually are

Causes and Treatment • very little research • try to teach more appropriate ways of expressing their needs and getting their needs met • point out costs associated with manipulative style

Narcissistic Personality Disorder • pervasive pattern of grandiosity, need for admiration, and lack of empathy

DSM-IV-TR: at least 5 sx • grandiose sense of self-importance • example: exaggerates achievements and talents • preoccupied with fantasies of unlimited success, power, beauty, etc. • believes he/she is special and unique • can only be understood by or associate with other special high status people • requests excessive admiration • sense of entitlement • unreasonable expectations for favorable treatment

DSM-IV-TR (continued) • interpersonally exploitative • lacks empathy • often envious of others, or believes others are envious of him/her • arrogant, haughty behaviors or attitudes

Causes • little research • one theory: • grandiosity is a defense against very fragile self-esteem • develops because parents do not respond with approval to child’s displays of competency

Treatment • little research • therapy focuses on grandiosity, sensitivity to evaluation, and lack of empathy

Cluster C: Anxious or Fearful • avoidant • dependent • obsessive-compulsive

Avoidant Personality Disorder • pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation

Personality Disorders