1. CHAPTER NINE Personality Disorders

2. Personality Disorders • What are Personality Disorders? • Classification of Personality Disorders Categorical vs. Dimensional models • Features of Axis II Implications for Assessment • Specific Disorders: Cluster A Cluster B Cluster C

3. Personality • Most mental disorders are defined in terms of states: episodes of symptoms • Personality refers to enduring traits that are fairly stable over time or make a person who s/he is

4. What are Personality Disorders? • Enduring patterns of perceiving,relating to & thinking about the environment and oneself • that are inflexible and pervasive • and cause either significantfunctional impairmentorsubjective distress

5. Categorical Classification of PDs (DSM) • Advantages Familiar & convenient  Ease in communication  Consistent with clinical diagnoses

6. Categorical Classification of PDs (DSM) • Disadvantages  low inter-rater reliability  very high comorbidity  high overlap among symptom criteria  not based on a theoretical model  ambiguity occurs regarding the presence vs. absence of a PD  most commonly diagnosed PD is PD-NOS

7. Dimensional Model of Personality Personality Disorder • Looks at a continuum of normal to abnormal personality • all individuals have some degree of these traits, but those with PDs have maladaptive levels • Various dimensional models exist • Five Factor Dimensional Model trait Normal Traits

8. Five-Factor Model • Neuroticism: expression of negative emotions • Extraversion: interest in interacting with other people; positive emotions • Openness: willingness to consider and explore unfamiliar ideas, feelings, and activities • Agreeableness: willingness to cooperate and empathize with others • Conscientiousness: persistence in pursuit of goals; organization; dependability

9. Dimensional Model • Advantages  Theoretical basis  Retention of information • Leads to less stereotyping • Adaptive traits are also highlighted  Flexible  Resolution of a variety of classification dilemmas • Avoids arbitrary assignment decisions • Addresses problems with comorbidity in the Categorical Model • Higher inter-rater reliability

10. Dimensional Model Disadvantages  Less familiar  Lacks clinical application  May be too complex  Disagreement exists about preference of which dimensional model to use

11. Features of Axis II • Different etiology than Axis I • not always true • More stable than Axis I disorders or more resistant to treatment • however, some Axis I disorders are very stable • some PDs are treatable

12. Features of Axis II • Other disorders: ego-dystonic • personal distress, discomfort with one’s symptoms • Personality disorders: ego-syntonic • ideas and impulses do not bother the person

13. Assessment of PDs • The ego-syntonic nature of personality disorders can make them difficult to assess using traditional measures • Others who have regular contact with an individual might be better judges of how that person’s behavior affects those around him/her

14. Culture and Personality • Culture plays a large role in determining what is appropriate or acceptable at a given time and place • Cultures may differ in:  Degree of emotional expression  Individualism vs. collectivism

15. Clusters of Personality Disorders • Cluster A  Paranoid PD  Schizoid PD  Schizotypal PD • Cluster B  Narcissistic PD  Antisocial PD  Histrionic PD  Borderline PD • Cluster C  Avoidant PD  Dependent PD  Obsessive-Compulsive PD

16. Cluster A Personality Disorders Characterized by odd, eccentric, and/or socially isolated behavior  Paranoid PD  Schizoid PD • Schizotypal PD

17. Paranoid Personality Disorder • A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent. • Reluctant to confide in others • Hold grudges • Finds threatening hidden meaning in benign comments • Doubt the loyalty and trustworthiness of others • Requires 4 of the 7 possible criteria.

18. Paranoid Personality Disorder • Prevalence rates: 0.5 to 2.5 % • More common in men • Unlikely to seek treatment • Treatment – • Trusting atmosphere • Cognitive therapy to correct cognitive errors • Most therapists pessimistic

19. Schizoid Personality Disorder • A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings - Doesn’t desire or enjoy close relationships - Prefers solitary activities and takes pleasure in few things - Is indifferent to praise and criticism • Requires 4 of the 7 possible criteria

20. Schizoid Personality Disorder • Prevalence: < 1% • More common in males • Unlikely to seek treatment • Many therapists think schizoid untreatable

21. Schizotypal Personality Disorder • A pervasive pattern of interpersonal and social deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior • Ideas of reference, magical thinking, and bodily illusions • Suspiciousness/paranoid thinking • Inappropriate affect • Lack of close friends/confidants • Social anxiety • Requires 5 of the 9 possible criteria

22. Schizotypal Personality Disorder • Prevalence: 3-5% • More common in males

23. Schizotypal PD and Schizophrenia • Individuals with schizotypal PD: • Sometimes have a history of psychological trauma, especially childhood maltreatment • Are at an increased risk of developing schizophrenia • Are commonly relatives of individuals with schizophrenia • BUT…the vast majority of individuals with Schizotypal PD still do NOT have relatives with schizophrenia Individuals with Schizotypal PD People with Schizophrenia

24. Cluster B Personality Disorders Characterized by overly dramatic, flamboyant, emotional, and/or erratic behavior Narcissistic PD  Antisocial PD  Histrionic PD  Borderline PD

25. Narcissistic Personality Disorder • A pervasive pattern of grandiosity, need for admiration, and lack of empathy • Preoccupied with fantasies • Associates only with high-status others • Has a strong sense of entitlement • Is interpersonally exploitative • Is envious and thinks others are envious of him/her • Requires 5 of the 9 possible criteria

26. Narcissistic Personality Disorder • Prevalence: 1% • Link with poor parenting • Treatment • Little research • Cognitive therapy to improve empathy & coping with criticism • Vulnerable to depressive episodes, may need treatment for depression

27. Histrionic Personality Disorder • A pervasive pattern of excessive emotionality and attention seeking • Inappropriately seductive/provocative • Impressionistic style of speech • Suggestible, easily influenced by others and circumstances • Considers relationships more intimate than they really are • Requires 5 of the 8 possible criteria

28. Histrionic Personality Disorder • Prevalence: 2-3% • More common in females • Link with Antisocial PD? • Treatment • Behavior therapy and focus on interpersonal relations • Generally poor prognosis

29. Borderline Personality Disorder • A pervasive pattern of instability of interpersonal relationships, self- image, and affects, and marked impulsivity • Fears of abandonment • Suicidal gestures or self-mutilation • Chronic feelings of emptiness • Stress-related paranoid ideation or severe dissociative symptoms • Requires 5 of the 9 possible criteria

30. Borderline Personality Disorder • Prevalence: 2% • More common in females • Link to ASPD • Familial association w/ BPD & mood disorders • Poor/abusive parenting • Early trauma • Challenges in treatment

31. Antisocial Personality Disorder • A pervasive pattern of disregard for and violation of the rights of others • Performing acts that are ground for arrest • Deceitfulness • Impulsivity • Consistent irresponsibility • Lack of remorse • Requires: • Age 18 or older • Evidence of Conduct Disorder by age 15

32. Antisocial Personality Disorder • Conduct Disorder  Antisocial  Prison • Often comorbid with substance abuse • Poor prognosis • Prevalence: 3% in males, 1% in females • May “burn out” after age 40

33. Psychopathy • Deceptiveness or duplicity • Absence of empathy, compassion or remorse toward the victims of the psychopath's exploitative self-interest. • Can often be charming and appear socially well-adjusted. • May or may not engage in criminal behavior.

34. Antisocial PD and Psychopathy • Earlier conceptualizations of ASPD had a greater overlap with psychopathy • However, due to DSM-IV’s focus on observable behaviors, ASPD is a distinct concept from psychopathy (there is still some overlap) • Psychopathy is a better predictor of recidivism than ASPD

35. Overlap between ASPD, Psychopathy, & Criminality 20% of people with ASPD are Psychopaths ASPD Psychopaths Criminals 75-85% of criminals have ASPD 15-25% of criminals are Psychopaths

36. Overlap between ASPD, Psychopathy, & Criminality ASPD Psychopaths Criminals

37. Criminal Behavior among Male Adoptees

38. Social Factors & the Etiology of ASPD • Inconsistent discipline (or complete lack of discipline) often seen in the prior family history of ASPD men • Kids with a “difficult temperament” are especially irritating to parents • Parents respond inappropriately by giving up or becoming severe in punishment • Person selects friends who share antisocial interests and problems (‘skinheads’, gangs)

39. Continuity in Life-Course-Persistent ASPD • Person’s options become narrowed; locked into further antisocial behavior • Limited range of behavioral skills (can’t pursue more appropriate responses) • Ensnared by consequences of earlier behaviors • drug addiction • parenthood • school dropout • criminal record

40. Psychological Factors: the Etiology of ASPD • Avoidance learning in the lab • Psychopaths unaffected by anticipation of punishment • Hypothesis 1: they can ignore the effects of punishment (emotional poverty) • Hypothesis 2: they have trouble shifting their attention (impulsivity)

41. Cluster C Personality Disorders Characterized by anxious or avoidant behaviors  Avoidant PD  Dependent PD  Obsessive-Compulsive PD

42. Avoidant Personality Disorder • A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation - Avoids interpersonal job activities - Won’t get involved with others - Is preoccupied with criticism and rejection - Views self as socially inept, personally unappealing, or inferior to others - Won’t try new things in case they are embarrassing • Requires 4 of the 7 possible criteria

43. Avoidant Personality Disorder • Prevalence: < 1% • May have biological predisposition combined with poor learning history of early relationships • Can be considered a severe version of social phobia, general type

44. Dependent Personality Disorder • A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation • Has difficulty making everyday and major decisions • Won’t express disagreement • Fails to initiate projects on own • Feels uncomfortable or helpless when alone • Urgently seeks another relationship when one ends • Requires 5 of the 8 possible criteria

45. Dependent Personality Disorder • Prevalence: 2% (no gender difference) • May be linked to early neglect & disruptions in attachment patterns • Treatment -- little research, must make sure client does not become dependent on therapist!

46. Obsessive-Compulsive PD • A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency • Preoccupied with rules, lists, details • Neglects family/friends because of devotion to work • Is overconscientious about rules, ethics, values • Cannot discard worthless objects • Hoards money in case of disaster • Refuses to delegate tasks to others • Requires 4 of the 8 possible criteria

47. Obsessive-Compulsive PD • Prevalence: 1% • More common in males • Don’t confuse with OCD • Some behaviors look similar but OCD is ego-dystonic, OCPD is ego-syntonic • Treatment addresses • Fears underlying need for order & control • Distraction & relaxation techniques

48. Prevalence & Course: PD Summary • PDs often originate in childhood & become ingrained by adulthood • Overall prevalence rate of 10-14% • Course & prognosis depend on disorder, but prognosis is generally poor

50. Optional Slides