Chapter 12 Personality Disorders

1. Chapter 12Personality Disorders 0

2. Personality Disorders: An Overview 0 • Enduring and pervasive predispositions • Perceiving • Relating • Thinking • Inflexible and maladaptive • Distress • Impairment • Coded on Axis II

3. Personality Disorders 0 • 10 specific personality disorders • Several under review for DSM-V • 3 clusters • High comorbidity with Axis I disorders • Poorer prognosis • Therapist reactions • Countertransference

4. Personality Disorders: An Overview 0 • Categorical vs. Dimensional Views • “Kind” vs. “Degree” • DSM is categorical • Reifies concepts • Less flexible • Loss of individual information • Sometimes arbitrary

5. Personality Disorders: An Overview 0 • Five factor model of personality (“Big Five”) • Openness to experience • Conscientiousness • Extraversion • Agreeableness • Emotional stability

6. DSM Personality Disorder Clusters 0 • Cluster A • Odd or eccentric • Paranoid, schizoid, schizotypal • Cluster B • Dramatic, emotional, erratic • Antisocial, borderline, histrionic, narcissistic • Cluster C • Fearful or anxious • Avoidant, dependent, obsessive-compulsive

7. Personality Disorders: Facts and Statistics 0 • Prevalence = 0.5 - 2.5%, may be closer to 10% • Outpatient = 2 - 10% • Inpatient = 10 – 30% • Origins and Course • Begin in childhood • Chronic course • High comorbidity

8. Personality Disorders: Gender Differences 0 • Differences in diagnostic rates • Borderline (75% female) • Clinician bias • Assessment bias • Measures • Criterion bias • Histrionic = extreme “stereotypical female” • No “macho” disorder

9. Personality Disorders: Gender Differences 0

10. Personality Disorders Under Study 0 • Individual disorders • Sadistic • Self-defeating • Categories of disorders • Depressive • Negativistic • Passive aggressive

11. Cluster A: Paranoid Personality Disorder 0 • Clinical Description • Mistrust and suspicion • Pervasive • Unjustified • Few meaningful relationships • Volatile • Tense • Sensitive to criticism

12. Cluster A: Paranoid Personality Disorder 0 • Causes • Possible relationship to schizophrenia • Possible role of early experience • Trauma • Abuse • Learning • “World is dangerous”

13. Cluster A: Paranoid Personality Disorder 0 • Treatment • Unlikely to seek on own • Crisis • Focus on developing trust • Cognitive therapy • Assumptions • Negative beliefs • No empirically-supported treatments

14. Cluster A: Schizoid Personality Disorder 0 • Clinical Description • Appear to neither enjoy nor desire relationships • Limited range of emotions • Appear cold, detached • Appear unaffected by praise, criticism • Unable or unwilling to express emotion • No thought disorder

15. Cluster A: Schizoid Personality Disorder 0 • Causes • Limited research • Precursor: childhood shyness • Possibly related to: • Abuse/neglect • Autism • Dopamine

16. Cluster A: Schizoid Personality Disorder 0 • Treatment • Unlikely to seek on own • Crisis • Focus on relationships • Social skills therapy • Empathy training • Role playing • Social network building • No empirically-supported treatments

17. Cluster A: Schizotypal Personality Disorder 0 • Clinical Description • Psychotic-like symptoms • Magical thinking • Ideas of reference • Illusions • Odd and/or unusual • Behavior • Appearance • Socially isolated • Highly suspicious

18. Cluster A: Schizotypal Personality Disorder 0 • Causes • Schizophrenia phenotype? • Lack full biological or environmental contributions • Preserved frontal lobes • Cognitive impairments • Left hemisphere? • More generalized?

19. Cluster A: Schizotypal Personality Disorder 0 • Treatment Options • Treatment of comorbid depression • Multidimensional approach • Social skill training • Antipsychotic medications • Community treatment

20. Cluster B: Antisocial Personality Disorder 0 • Clinical Description • Noncompliance with social norms • “Social Predators” • Violate rights of others • Irresponsible • Impulsive • Deceitful • Lack a conscience, empathy, and remorse

21. Cluster B: Antisocial Personality Disorder 0 • Nature of psychopathy • Glibness/superficial charm • Grandiose sense of self-worth • Proneness to boredom/need for stimulation • Pathological lying • Conning/manipulative • Lack of remorse • Overlap with ASPD, criminality • Intelligence

22. Cluster B: Antisocial Personality Disorder 0

23. Cluster B: Antisocial Personality Disorder 0

24. Cluster B: Antisocial Personality Disorder 0 • Developmental considerations • Early histories of behavioral problems • Conduct disorder • Families history of: • Inconsistent parental discipline • Variable support • Criminality • Violence

25. Causes of Antisocial Personality 0 • Gene-environment interaction • Genetic predisposition • Environmental triggers • Arousal hypotheses • Underarousal • Fearlessness

26. Causes of Antisocial Personality 0 • Gray’s model of brain functioning • Behavioral inhibition system (BIS) • Low • Reward system (REW) • High • Fight/flight system (F/F)

27. Causes of Antisocial Personality 0 • Interactive, integrative model • Genetic vulnerability • Neurotransmitters • Environmental factors • Family stress • Reinforcement of antisocial behaviors • Alienation from good role models • Poor occupational/social function

28. Antisocial Personality Disorder 0 • Treatment • Unlikely to seek on own • High recidivism • Incarceration • Early intervention • Parent training • Prevention • Rewards for pro-social behaviors • Skills training • Improve social competence

29. Cluster B: Borderline Personality Disorder 0 • Clinical Description • Patterns of instability • Labile, intense moods • Turbulent relationships • Impulsivity • Fear of abandonment • Very poor self-image • Self-mutilation • Suicidal gestures

30. Cluster B: Borderline Personality Disorder 0 • Comorbid disorders • Depression – 24-74% • Suicide – 6% • Bipolar – 4-20% • Substance abuse – 67% • Eating disorders • 25% of bulimics have BPD

31. Cluster B: Borderline Personality Disorder 0 • Causes • Genetic/biological components • Serotonin • Frontolimbic circuit • Cognitive biases • Early childhood experience • Neglect • Trauma • Abuse

32. Cluster B: Borderline Personality Disorder 0 • Treatment • Highly likely to seek treatment • Antidepressant medications • Dialectical behavior therapy • Reduce “interfering” behaviors • Self-harm • Treatment • Quality of life • Outcomes • Demonstrated efficacy • Cortical activation changes

33. Cluster B: Borderline Personality Disorder 0

34. Cluster B: Histrionic Personality Disorder 0 • Clinical Description • Overly dramatic • Sensational • Sexually provocative • Impulsive • Attention-seeking • Appearance-focused • Impressionistic • Vague, superficial speech • Common diagnosis in females

35. Cluster B: Histrionic Personality Disorder 0 • Causes • Little research • Links with antisocial personality • Sex-typed alternative expression?

36. Cluster B: Histrionic Personality Disorder 0 • Treatment • Problematic interpersonal behaviors • Attention seeking • Long-term consequences of behavior • Little empirical support

37. Cluster B: Narcissistic Personality Disorder 0 • Clinical Description • Exaggerated and unreasonable sense of self-importance • Require attention • Lack sensitivity and compassion • Sensitive to criticism • Envious • Arrogant

38. Cluster B: Narcissistic Personality Disorder 0 • Causes • Deficits in early childhood learning • Altruism • Empathy • Sociological view • Increased individual focus • “Me generation”

39. Cluster B: Narcissistic Personality Disorder 0 • Treatment focuses on: • Grandiosity • Lack of empathy • Hypersensitivity to evaluation • Co-occurring depression • Little empirical support

40. Cluster C: Avoidant Personality Disorder 0 • Clinical Description • Extreme sensitivity to opinions • Avoid most relationships • Interpersonally anxious • Fearful of rejection

41. Cluster C: Avoidant Personality Disorder 0 • Causes • Sub-schizophrenia disorder? • Difficult temperament • Early parental rejection • Interpersonal isolation and conflict

42. Cluster C: Avoidant Personality Disorder 0 • Treatment • Similar to social phobia • Increase social skills • Reduce anxiety • Importance of therapeutic alliance • Moderate empirical support

43. Cluster C: Dependent Personality Disorder 0 • Clinical Description • Rely on others for major and minor decisions • Unreasonable fear of abandonment • Clingy • Submissive • Timid • Passive • Feelings of inadequacy • Sensitivity to criticism • High need for reassurance

44. Cluster C: Dependent Personality Disorder 0 • Causes • Little research • Early experience • Death of a parent • Rejection • Attachment

45. Cluster C: Dependent Personality Disorder 0 • Treatment • Limited empirical support • Caution: dependence on therapist • Gradual increases in: • Independence • Personal responsibility • Confidence

46. Cluster C: Obsessive-Compulsive Personality Disorder 0 • Clinical Description • Fixation on doing things the “right way” • Rigid • Perfectionistic • Orderly • Preoccupation with details • Poor interpersonal relationships • Obsessions and compulsions are rare

47. Cluster C: Obsessive-Compulsive Personality Disorder 0 • Causes • Limited research • Weak genetic contributions • Predisposed to favor structure?

48. Cluster C: Obsessive-Compulsive Personality Disorder 0 • Treatment • Similar to OCD • Address fears related to the need for orderliness • Decrease: • Rumination • Procrastination • Feelings of inadequacy • Limited efficacy data

49. Personality Disorders: Future Directions 0 • Completely rethinking personality disorders • Dimensional models