Personality Disorders

1. Personality Disorders

2. Personality defined Stable, consistent pattern of behavior across situations

3. 1960-70's: Michel vs. Epstein Mischel- situations override concept of personality we cannot measure consistent acting Epstein- consistency in behavior is found looking across time the construct is there, we need to work on measurement

4. Personality in the 1990's: DSM-IV (APA, 1994) Trait- "� enduring pattern of perceiving, relating to, and thinking about the environment and oneself that is exhibited in a wide range of social and personal contexts." Trait approach: dimensional Big 5 (OCEAN)

5. PERSONALITY DISORDERS Stable patterns of behavior that are maladaptive DSM-IV (APA, 1994) "� enduring pattern of inner experience and behavior that deviates markedly from the expectation s of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood is stable over time, and leads to distress or impairment."

6. PD DSM-IV Criteria A. Enduring pattern of inner experience & behavior� 2+ of� 1. Cognition (i.e., perception) 2. Affectivity (i.e., range, intensity, lability, & appropriateness) 3. Interpersonal functioning 4. Impulse control Inflexible and pervasive across situations Clinically sig. distress/impairment D. Stable, long-term, since at least early adulthood E. Not manifestation or consequence of other disorder or substance

7. Classification system of DSM-IV: A. Axis II = PD and MR 1. 3 clusters: a. Cluster A: Odd and Eccentric PD b. Cluster B: Dramatic, Emotional, & Erratic PD c. Cluster C: Anxious and Fearful PD 2. Prevalence: lifetime = 10% - 13% (1 out of every 8-10 people)

8. Cluster A: Odd & Eccentric PD 1. PARANOID PD Distrust, suspicious of others Interpret other's motives as malevolent Other's out to take advantage Doubt loyalties of friends Easily angered by perceived insults Resent others who have more Conceptualize self as faultless Secretive, jealous, rigid, unforgiving, hostile, sarcastic

9. Cluster A: Odd & Eccentric PD 2. SCHIZOID PD (detached) Detachment from social relationships Restricted range of affect Form stable, but not close relationships Work settings- low social interaction Reclusive

10. Cluster A: Odd & Eccentric PD SCHIZOTYPAL PD (social deficit) Intense discomfort in IP relationships Cognitive/perceptual distortions (reality testing intact) Eccentric behavior Loners, anxious, socially isolated

11. Cluster B: Dramatic, Emotional, & Erratic PD 1. ANTISOCIAL PD (vs. Asocial) Disregard/violate rights of others Evidence of CD < 15 years old Deceitfulness Impulsivity- disregard consequences Irritability Aggressiveness Disregard safety Irresponsible Lack remorse Failure to conform to social norms

12. Cluster B: Dramatic, Emotional, & Erratic PD 2. BORDERLINE PD Instable relationships Instable self-image Instable affect Impulsive Fluctuating mood (snap!) Self-destructive acts Fear of abandonment

13. Cluster B: Dramatic, Emotional, & Erratic PD 3. HISTRIONIC PD Excessive emotionality Attention seeking Dramatic Overreactive Impressionable Shallowness

14. Cluster B: Dramatic, Emotional, & Erratic PD 4. NARCISSISTIC PD Grandiosity- sense of superiority Need for admiration- entitlement Lack empathy- self-centered

15. Cluster C: Anxious & Fearful PD 1. AVOIDANT PD Soc. inhibition - avoid IP relationships Feelings of inadequacy Hypersensitivity to negative eval. Excessive worry about embarrassment Fear rejection Extreme social anxiety

16. Cluster C: Anxious & Fearful PD 2. DEPENDENT PD Excessive need to be taken care of Submissive (clingy) Fear separation Reluctant to disagree Rely on others to make decisions

17. Cluster C: Anxious & Fearful PD 3. Obsessive-Compulsive PD Preoccupation with details, rules, lists, organization, and schedules Perfectionistic High need for mental and IP control at the expense of efficiency, flexibility, openness Rigid, stubborn, controlled, controlling Devoted to work to detriment of leisure and friendships

18. Issues in Classification: 1. Interrater Reliability 2. Test - Retest Reliability (temporal) 3. Prototype 4. Dimensional vs. Categorical

19. Problems with categorical diagnosis: 1. Not stable over time 2. Individuals with different characteristics receive same diagnosis 3. Individuals with same characteristics receive different diagnosis 4. No clear boundary with normality 5. Most individuals diagnosed multiple, mixed, or atypical 6. Only fair agreement across methods

20. Etiology Biological Factors (Siever & Davis, 1991) 1. Cognitive/ Perceptual organization Sz spectrum 2. Impulsivity/ Aggression - ASPD and Borderline 3. Affective Instability - Histrionic and Borderline 4. Anxiety/ Inhibition - Avoidant, Dependent, ObComp 

21. Etiology B. Psychosocial Factors 1. Object Relations Theory: Psychodynamic theory examining early parental relationships in development of personality and IP 2. Attachment Theory: Emphasis on quality of relationship between child and primary caregiver

22. Etiology C. Biopsychosocial Model: Biological vulnerabilities and strengths interact with the psychosocial environment to create personality (and characteristic manner of interacting with others)

23. GENETIC MATERIAL Strengths tendency to ponder and plan tendency toward moderate affect perceptually organized moderate arousal Weaknesses tendency to attack tendency to be flat, or dramatic perceptually disorganized low or high arousal

24. PSYCHOSOCIAL ENVIRONMENT Chance - war zone, rape, geographically isolated Selected by individual - excitement, security Created by individual - manipulate, non-reactive Others seeking individual- exciting, predictable

25. Pharmacotherapy: Mostly Borderline PD Neuroleptics, antidepressants, lithium, benzodiazepines, and others Appears useful in specific facets only, not in the complex of symptoms

26. Psychodynamic Psychotherapy Mostly Narcissistic and Borderline (Kernberg, 1993) Clear rules and boundaries Active therapist Tolerate patient's deep sadness and hostility Help patient see connections between actions and feelings Discourage self-destructive behavior through confrontation Set limit on patient's dangerous, risk-taking behavior Emphasis on therapeutic alliance, more than on the past Alert to counter - transference

27. Interpersonal Psychotherapy Develop collaborative therapeutic alliance Gain understanding to one's destructive interaction patterns Decide to give up destructive patterns, AND deal with consequential emotions (sadness, fear, etc.) more adaptive IP behavior (e.g., Benjamin's Structural Analysis of Social Behavior, SASB) (e.g., Benjamin's Structural Analysis of Social Behavior, SASB)

28. Cognitive Therapy Assume errors in thought ? problems Work to discover cognitive distortions Replace maladaptive thoughts with more realistic and adaptive thoughts

29. Behavior Therapy e.g. Social Skills Training Graduated exposure techniques match Tx to characteristics (e.g., anxiety, trust, independent action) e.g. Dialectical Behavior Therapy (Linehan, 1993) Group + Individual Therapy Group Therapy- social skills, boundary setting, calmly coping with conflict Individual Therapy- address maladaptive dynamics (e.g., threat of suicide) and emotion modulation