CHAPTER 9 PERSONALITY DISORDERS

1. CHAPTER 9PERSONALITY DISORDERS

2. Aims and Objectives Define personality and personality disorder Describe the main characteristics of the various personality disorders Provide general models for the aetiology and treatment of personality disorders Outline theories and treatment approaches for specific personality disorders Highlight areas of ongoing controversy

3. Personality disorders Definition of personality Consistent pattern of thinking, feeling, and behaving that is pervasive across situations and enduring over time Five Factor model identifies five essential personality traits Neuroticism Extroversion Openness to experience Conscientiousness Agreeableness Core personality traits have a strong genetic basis Personality functioning exists on a continuum Disordered personality arises out of the same range of genetic material and life experiences as normal personality

4. Personality disorders The definition of personality disorder DSM-IV-TR - enduring patterns of perceiving, relating to, and thinking about the environment and oneself exhibited in a wide range of personal and social contexts Millon has identified three core features that differentiate disordered personality from normal-range problematic behaviours Functional inflexibility Self-defeating behaviour patterns Tenuous stability under stress and marked instability in mood, thinking, and behaviour during difficult life events The diagnosis of personality disorder DSM-IV-TR identifies 10 personality disorders classified into 3 clusters Cluster A – odd or eccentric traits (paranoid, schizoid, and schizotypal) Cluster B – dramatic, emotional, erratic traits (antisocial, borderline, histrionic, and narcissictic) Cluster C – anxious and fearful traits (avoidant, dependent, and obsessive-compulsive)

5. Personality disorders Cluster A Personality Disorders Schizotypal personality disorder Pervasive pattern of social and interpersonal deficits marked by discomfort with/reduced capacity for close relationships; as well as by cognitive and perceptual distortions and eccentric behaviours (mannerisms, dress, use of language) Odd beliefs or magical thinking Suspicious/paranoid – lack of close friends Paranoid personality disorder Defining trait is suspiciousness in almost all situations Reluctant to confide in others – fear that any information shared may be used against them Persistently bear grudges; read hidden meanings into benign comments, events Schizoid personality disorder Detached from social relationships; social withdrawal and isolation Unable to experience social warmth or form attachments to others Display constricted affect - appear aloof, cold, distant

6. Personality disorders Cluster B Personality Disorders Narcissistic personality disorder Pervasive pattern of grandiosity, need for admiration, and lack of empathy Grandiose sense of self-importance Preoccupied with fantasies of unlimited success, power, beauty Believe they are special/unique Often envious of others; believes others envious of them Interpersonally exploitative Histrionic personality disorder Self-dramatisation and exaggerated, theatrical emotional displays Rapidly shifting, shallow expression of emotions Inappropriately flirtatious, sexually seductive, provocative

7. Personality disorders Cluster B Personality Disorders Borderline personality disorder Poor self-identity Erratic mood (depression, anger, emptiness) Unstable and intense interpersonal relationships Impulsive and self-destructive behaviour (drug use, promiscuity) Self harm and suicide attempts common Antisocial personality disorder Detached from social relationships; social withdrawal and isolation Unable to experience social warmth or form attachments to others Display constricted affect – appear aloof, cold, distant

8. Personality disorders Cluster C Personality Disorders Dependent personality disorder Excessive need to be taken care, submissive behaviour, and fears of separation Rely on others for decision-making Fear of abandonment Uncomfortable/helpless when alone Difficulty expressing disagreement with others because of fear of loss of approval Avoidant personality disorder Pattern of social inhibition, inadequacy, hypersensitivity to negative evaluation Show restraint in intimate relationships because of fear of shame/ridicule Reluctant to take risks, engage in new activities – may prove embarrassing Obsessive-compulsive personality disorder Pattern of preoccupation with orderliness, perfectionism, control Preoccupied with rules, lists, schedules – to the extent that the major point of the activity is lost Excessively devoted to work/productivity to the exclusion of leisure, friendships Reluctant to delegate

9. Personality disorders Epidemiology of personality disorders In the general population, overall prevalence rates are between 9 and 13% In mental health settings, estimated prevalence of 25-40% Each of the specific personality disorders has a prevalence of around 1-2% (2-4% for obsessive-compulsive personality disorder) Borderline personality disorder is associated with the greatest levels of disability and handicap Obtaining accurate epidemiological data is problematic Reliable assessment requires trained clinicians using semi-structured interviews and require considerable time and financial commitment Nonetheless, presence of a personality disorder may impede the patient’s ability to recover

10. Personality disorders General models of the aetiology and treatment Factor approaches Five Factor Model – neuroticism, extroversion, openness to experience, conscientiousness, and agreeableness Expanded in 18-factor model, 4 higher-order and 14 lower-order factors (Livesley et al., 1998) Development of personality and personality disorder reflects the same genetic influences Beck’s cognitive model Key component is the presence of dysfunctional core beliefs that influence people’s understanding of themselves, others, and the world Schema - core belief that operates in an automatic manner to influence individual’s perception Cognitive-behavioural treatment for personality disorders differs from standard short-term CBT Young’s schema therapy model Early maladaptive schema believed to be a result of a mixture of biological dispositions and repeated interpersonal distress with significant others in childhood Early maladaptive schemas are rigid, resistant to change, associated with high levels of affect, and significantly impair the functioning of the individual Schema therapy - extensive assessment of schemas, educating the patient about his/her schema, and using behavioural, cognitive, and experiential techniques to create more adaptive schemas

11. Personality disorders General models of the aetiology and treatment Linehan’s biosocial model and dialectical behaviour therapy Developed for borderline personality disorder but has also been applied to antisocial behaviours, substance abuse, and eating disorders Disturbances in borderline personality disorder are due to dysfunction in the emotion regulation system Emotion dysregulation is caused by interaction of biologically-based emotional vulnerability and “drastically invalidating environments” Dialectical behaviour therapy - empirically supported treatment based on this model Individual therapy and weekly group-based skills training to addresses dysregulation Ryle’s cognitive analytic therapy Links concepts from cognitive psychology with an object relations approach Reciprocal role procedure refers to complementary patterns the individual enacts and expects in regards to relationships (e.g., abusive parent and abused child) Therapy focuses on working with patient to develop an understanding of dysfunctional reciprocal role procedures

12. Personality disorders The aetiology and treatment of specific personality disorders Aetiology of cluster A Longstanding association between Cluster A personality disorders and schizophrenia Genetically based neurological abnormality, with certain environmental inputs predisposes an individual to developing a personality with odd, eccentric, or psychotic features, and in extreme cases schizophrenia Strongest relationship is between schizophrenia and schizotypal and paranoid personality disorder, weaker relationship with schizoid personality disorder Treatment of cluster A Limited empirical evidence Intimacy and mistrust issues make it difficult to develop a relationship with therapist Cognitive-behavioural treatment may be used to enhance self-awareness, social skills, and quality of life Pharmacotherapy , including low dose antipsychotic medication and SSRIs, may be helpful

13. Personality disorders The aetiology and treatment of specific personality disorders Aetiology of cluster B – antisocial personality disorder Biological factors have demonstrated a genetic vulnerability, which may entail neurotransmitter disturbance Low levels of serotonin associated with impulsivity and aggressive behaviours Low levels of physiological arousal associated with antisocial personality disorder Environmental factors may play a role, e.g., childhood abuse and harsh parenting Treatment of cluster B – antisocial personality disorder No one treatment approach has demonstrated effectiveness Antisocial individuals may try to misuse therapy Pharmacological approaches, such as lithium and antipsychotic medication have been used to manage impulsive and aggressive behaviours Debate about value of SSRI antidepressants

14. Personality disorders The aetiology and treatment of specific personality disorders Aetiology of cluster B – borderline personality disorder Relative importance of genetics remains unclear Genetic vulnerability may include the trait dimension of neuroticism However, neuroticism may underpin most personality disorders, rather than being a specific risk factor Psychosocial factors - childhood trauma is strongly associated with borderline personality symptoms, but also predicts many other Axis I disorders Treatment of cluster B – borderline personality disorder Evidence that schema therapy and dialectical behaviour therapy may be beneficial Dialectical behaviour therapy associated with long-lasting reductions in suicidal behaviours and the need for hospitalisation Some preliminary findings in support of cognitive analytic therapy

15. Personality disorders The aetiology and treatment of specific personality disorders Aetiology of cluster B – histrionic personality disorder Psychoanalytic explanations focus on parent-child interactions, but very litte evidence to support these forumlations Family studies suggest a genetic role Treatment of cluster B – histrionic personality disorder Lack of empirical findings, cognitive therapy may be helpful Aetiology of cluster C – avoidant personality disorder Genetic contribution suggestive but not conclusive Cognitive models relate avoidant tendencies to early rejection experiences Treatment of cluster C – avoidant personality disorder Preliminary evidence suggests cognitive behavioural therapy is effective

16. Personality disorders The aetiology and treatment of specific personality disorders Aetiology of cluster C – dependent personality disorder Genetic contribution suggestive but not conclusive Some evidence of psychosocial contribution, e.g., early physical abuse Treatment of cluster C – dependent personality disorder Individuals may become overly dependent on the therapist Cognitive and behavioural techniques may be helpful Aetiology of cluster C – obsessive-compulsive personality disorder Possible genetic contribution but not unique According to cognitive theory, core beliefs regarding the intolerable nature of perceived faults or flaws Treatment of cluster C – obsessive-compulsive personality disorder Individuals with obsessive-compulsive personality typically seek treatment for comorbid anxiety or depression Some support for the efficacy of cognitive and behavioural interventions

17. Personality disorders Current challenges and controversies Are personality disorders better represented by dimensions or categories? DSM adopts a categorical approach, however, recent findings have suggested dimensional measures of personality traits would lead to a more accurate approach However, little agreement about the number and type of traits Another approach is to integrate the dimensional and categorical approach, patients would receive a categorical disorder, as well as dimensional ratings What is the role of maladaptiveness in defining and diagnosing personality disorders? Not included in the criteria for all the personality disorders Not clearly defined – subjective

18. Personality disorders Current challenges and controversies What is the role of culture in the development of personality disorders? Culture can affect the expression of temperamental factors Different prevalence rates of personality disorders across cultures Possible changes in personality disorders within cultures across time Culture plays a role in whether certain behaviours are identified as aberrant labeling effect

19. Personality disorders Current challenges and controversies Are there real gender differences in the prevalence of certain personality disorders or do such differences represent diagnostic biases? Differences in diagnostic rates for males and females could reflect bias on the part of clinicians Also, the diagnostic criteria themselves could contain gender bias Psychopathy versus antisocial personality disorder – which is the more vaolid diagnosis? Psychopathy is a constellation of traits, including absence of remorse, tendency to manipulate, etc., and may be more accurate Premature to conclude that antisocial personality disorder can identify those with psychopathy

20. Summary The definition of personality The definition of personality disorder The diagnosis of personality disorder The epidemiology of personality disorders General models of the aetiology and treatment of personality disorders Aetiology and treatment of specific personality disorders Current challenges and controversies