Personality Disorders

1. Personality Disorders Coded on Axis II Defined as: 1) Long-standing, 2) pervasive, and 3) inflexible patterns of behavior and inner experience that deviate from the expectations of a persons culture and that impair social and occupational functioning. Personality is influenced by bio-psychosocial development

2. Personality Disorder: Clinical Features • DSM-IV’S five criteria • Enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individuals culture • Onset can be traced to adolescent or early adult stages • Inflexible and pervasive pattern across a broad range of personal and social situations. • Must be manifest in at least two of the following: cognitive, affective, interpersonal, and impulse control. • Distress/Impairment in important areas of functioning

3. Personality Disorders (cont) • All are conscious upon entering a crowed room but this does not equate with paranoid levels. • A personality disorder is defined by the extremes of several traits and by the rather inflexible and maladaptive way these traits are expressed. • The personality each of us develops over the years reflects a persistent means of dealing with life’s challenges, a certain style of relating to other people (overly dependent, shy, aggressive, appearance)

4. Clinical Features of Personality Disorders • Difficulties in diagnosing personality disorders • Categories are not as sharply defined • Categories are not mutually exclusive • Characteristics that define them are all dimensional • Reliability has been poor in the past but has improved due to: • Publication of specific diagnostic criteria from DSM-III to current editions • Development of structured interviews

5. Paranoid Borderline Histrionic Narcissistic Antisocial Dependent Obsessive Schizotypal Inter-rater Test-Retest .86 .57 .90 .56 .83 .40 .88 .32 .97 .84 .87 .15 .85 .52 .91 .11 Reliability (Zanarini, 2000)

6. Personality Disorder (Clusters) • Cluster A= individuals are odd or eccentric • (paranoid, schizoid, and schizotypal) • Cluster B= individuals are dramatic, emotional or erratic • (antisocial, borderline, histrionic, & narcissistic) • Cluster C= individuals are anxious or fearful • (avoidant, dependent, obsessive-comp)

7. Cluster A Personality Disorders Odd/Eccentric Cluster

8. Paranoid (five) Pervasive suspiciousness of being harmed, deceived or exploited Unwarranted doubts about loyalty of friends or associates Reluctance to confide in others due to above Hidden meaning read into innocuous actions Grudges for perceive wrongs Angry reactions to perceived attacks on character or reputation

9. Schizoid (four) • Lack of desire or enjoyment of close relationships • Almost exclusive preference for solitude • Little interest in sex with others • Few if any pleasures • Lack of friends • Indifference to praise or criticism • Flat affect, emotional detachment

10. Schizotypal (five) • Ideas of reference • Peculiar beliefs or magical thinking (belief in extrasensory perception) • Unusual perceptions (distorted body belief) • Peculiar patterns of speech • Extreme suspiciousness, paranoia • Inappropriate affect • Odd behavior or appearance • Lack of close friends

11. Etiology of Cluster A • Possible genetic links (eg.. Schizophrenic similarities) • Deficits in neuropsychological functioning • Enlarged ventricles and less temporal lobe gray matter in schizotypal personality

12. Cluster B Personality Disorders Dramatic/Erratic Cluster

13. Histrionic Personality (five) • Strong need to be the center of attention • Inappropriately sexually seductive bx • Rapidly shifting expression of emotions • Use of physical appearance to draw attention to self • Speech excessively impressionistic, passionately held opinions lacking detail • Exaggerated theatrical emotional expression • Overly suggestible • Misreads relationships as being more intimate than they really are

14. Histrionic Personality: Etiology • Little research with • Freudian Explanation • Thought to be raised in families where emotionality and seductiveness were encouraged by parental seductiveness. • Parents talk about sex as something dirty yet behave as though it is exciting and desirable.

15. Narcissistic Personality (five) • Grandiose view of one’s importance, arrogance • Preoccupation with one’s success, brilliance, beauty • Extreme need for admiration • Strong sense of entitlement • Tendency to exploit others • Envy of others

16. Narcissistic: Etiology • Parents do not respond with approval to their children’s displays of competency; the child is not valued for his own self worth but is valued as a means to foster the parents self-esteem (Kohut & Wolf, 1978)

17. Antisocial Personality • Pervasive disregard for the rights of others since the age of 15 and at least three of the following characteristics • Repeated law breaking • Deceitfulness, lying • Impulsivity • Irritableness and aggressiveness • Reckless disregard for other and own safety • Irresponsibility (employment or financial) • Lack of remorse

18. Antisocial Personality:Clinical Picture • Inadequate conscience development • Accept ethical values on at a verbal level. • Irresponsible and impulsive behavior • Take rather than earn. Pleasure seekers. • Rejection of authority • Ability to Impress and Exploit • Charming and likable • Appear sincere when caught

19. Antisocial: Etiology I. • Genetics (modest heritability) • Deficient Behavioral Inhibition System • Inhibits behavioral responses to cues signaling punishment • Overactive Behavioral Activation System • Activates behavior in response to rewards • Emotion Deficits • Inability to profit from experience • Respond less anxiously to fear-eliciting stimuli (thus little deterrent effect)

20. Antisocial: Etiology II. • Role of the family • Parental loss, parental rejection, inconsistent or no discipline • Antisocial father • Impulsivity • Lacking in impulse control due to the above reasons

21. A Developmental Perspective

22. Antisocial Personality vs Psychopathy • Both focus on behavioral and affective dimensions but in psychopathy the focus is on the affective dimension while in antisocial personality disorder the focus is more behavioral • Note that some theorists and argue that there is no difference between the two.

23. Borderline Personality (five) • Frantic efforts to avoid abandonment (real or imagined) • Instability and extreme intensity in interpersonal relations (idealize & revile) • Unstable sense of self • Impulsive bx, including reckless spending and sexual promiscuity • Recurrent suicidal and self-mutilating bx • Extreme emotional lability • Chronic feelings of emptiness

24. Borderline Personality: Etiology • Runs in families (genetic) • High in neuroticism (heritable trait) • Impaired frontal lobe functioning • Object relations theory • Splitting and Trauma • Separation from family in childhood • Low family support and high conflict • Emotional dysregulation (child trait) raised by invalidating parents

25. Treatment of Borderline Personality • Dialectical Behavior Therapy (DBT) Goals • Decrease suicidal behavior • Decrease therapy interrupting behaviors (lying) • Decrease escapist behaviors (substance use) • Increase behavioral skills for emotional regulation, interpersonal relations, and tolerance for distress • Treatment Requires Consistency (emotional etc…) on the Part of the Therapist.

26. Cluster C Personality Disorders Anxious Fearful Cluster

27. Avoidant Personality (four) • Avoidance of interpersonal contacts due to fears of criticism or rejection • Unwillingness to get involved with others unless certain of being liked • Restraint in intimate relationships for fear of being shamed or ridiculed • Preoccupied about being criticized or reject • Feelings of inadequacy or inferiority • Extreme reluctance to try new things for fear of being embarrassed

28. Dependent Personality (five) • Difficulty making decisions without others excessive advice and reassurance • Need for others to take responsibility for most major areas of life • Difficulty disagreeing with others for fear of losing support • Difficulty doing things on own because of lack of confidence

29. Dependent Personality (cont) • Doing unpleasant things as a way of getting others approval • Feelings of helplessness when alone • Urgently seeking a new relationship when one ends • Preoccupation with fears of taking care of oneself

30. Obsessive Compulsive (four) • Preoccupation with rules or details to the extent that the major point of an activity is lost • Extreme perfectionism to the degree that projects are seldom completed • Excessive devotion to work to the exclusion of leisure and friendships • Inflexible about morals • Difficulty discarding worthless items • Reluctance to delegate unless others conform to one’s standards • Miserliness and Rigidity and Stubbornness

31. Cluster C: Etiology • Speculation focuses on parent-child relationships and attachment • Dependent personality= overprotective parenting that prevents feelings of self efficacy • Secure base • Parents model fears which are transmitted to child

32. Therapy for Personality Disorders • Object Relations Treatment • Dialectical Behavioral Therapy (borderline) • Modulate and control their extreme emotionality and behaviors • Tolerate feelings of distress • Trust thoughts and emotions • Cognitive Behavioral Treatment • Psychosocial Treatments are Used in General

33. Treatments and Outcomes (cont) • Treating other cluster A and B disorders besides borderline and antisocial • Not much research indicating any promising treatments. • Treating cluster C disorders • Some indication that medication helps with avoidant personality disorder • Efficacy studies • What does the research show? (see above)