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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.

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Personality Disorders

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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


DSM-IV-TR: at least 4 sx

  • avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection

  • unwilling to get involved with people unless certain of being liked

  • shows restraint in interpersonal relationships because of fears of being shamed or ridiculed


DSM-IV-TR (continued)

  • preoccupied with being criticized or rejected in social situations

  • inhibited in new interpersonal situations

  • views self as socially inept, unappealing, or inferior

  • reluctant to take risks or engage in new activities (due to fears of embarrassment)


Causes

  • one theory

    • person born with difficult temperament or personality characteristics

    • parents reject them or don’t provide enough early, uncritical love

    • rejection results in low self-esteem and social alienation


Treatment

  • controlled studies show evidence for effectiveness of behavioral intervention techniques for anxiety and social skills

    • systematic desensitization

    • behavioral rehearsal


Dependent Personality Disorder

  • pervasive and excessive need to be taken care of that leads to submissive, clinging behavior and fears of separation


DSM-IV-TR: at least 5 sx

  • difficulty making everyday decisions

  • needs others to assume responsibility

  • difficulty expressing disagreement

    • due to fears of loss or support or approval

  • difficulty initiating projects or doing things on his/her own

    • due to lack of self-confidence in own judgment or abilities


DSM-IV-TR (continued)

  • goes to excessive lengths to obtain nurturance and support

    • volunteers to do unpleasant things

  • feels uncomfortable or helpless when alone

    • because of fears of being unable to take care of self

  • urgently seeks another relationship as a source of care/support when one ends

  • preoccupied with fears of being left to take care of him/herself


Causes and Treatment

  • causes

    • one theory is that early death of parent or neglect/rejection by caregiver cause person to grow up fearing abandonment

  • treatment

    • little research


Obsessive-Compulsive Personality Disorder

  • pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency


DSM-IV-TR: at least 4 sx

  • preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost

  • perfectionism that interferes with task completion

  • excessively devoted to work and productivity to the exclusion of leisure activities and friendships

  • overconscientious and inflexible about morality, ethics, or values


  • unable to discard worn-out or worthless objects

    • even when they have no sentimental value

  • reluctant to delegate tasks

    • unless others submit to person’s exact way of doing things

  • has miserly spending attitude

    • money to be hoarded for future catastrophes

  • rigidity and stubbornness


Causes and Treatment

  • causes

    • weak genetic contribution

    • possible parental reinforcement of conformity and neatness

  • treatment

    • little research

    • therapy addresses fears that underlie need for orderliness

    • relaxation techniques


Relationship of Personality Disorders to the Big Five

  • Avoidant

    • low on extraversion

    • high on neuroticism

  • Schizoid

    • low on extraversion

    • high on neuroticism (not at high as avoidant)


  • Borderline

    • high on neuroticism

    • low on agreeableness

  • Paranoid

    • low on agreeableness

  • Antisocial

    • low on agreeableness


  • Histrionic

    • high on extraversion

    • high on neuroticism

  • Dependent

    • high on agreeableness

    • high on neuroticism


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