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Personality Disorders: Current Concepts and Controversies 2006 Wolfe-Adler Lecture Sheppard Pratt Health System September 27, 2006 John M. Oldham, M.D. Professor and Chairman Department of Psychiatry and Behavioral Sciences Medical University of South Carolina oldhamj@musc.edu.

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Personality = Temperament + Character


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    1. Personality Disorders: Current Concepts and Controversies2006 Wolfe-Adler LectureSheppard Pratt Health SystemSeptember 27, 2006John M. Oldham, M.D.Professor and ChairmanDepartment of Psychiatry and Behavioral SciencesMedical University of South Carolinaoldhamj@musc.edu

    2. Personality =Temperament + Character

    3. Hippocrates Classification

    4. DIMENSIONAL CATEGORICAL

    5. Examples of Dimensional Systems • Interpersonal Circumplex - Leary, Wiggins, Kiesler • Three factors - Eysenck & Eysenck • Four factors - Livesley et al., Clark et al. • Five factors - Costa & McCrae • Seven factors - Cloninger et al.

    6. Neuroticism Calm – Worrying Even-tempered – Temperamental Self-satisfied – Self-pitying Comfortable – Self-conscious Unemotional – Emotional Hardy – Vulnerable Extroversion Reserved – Affectionate Loner – Joiner Quiet – Talkative Passive – Active Sober – Fun-loving Unfeeling – Passionate Openness to Experience Down-to-earth – Imaginative Uncreative – Creative Conventional – Original Prefer routine – Prefer variety Uncurious – Curious Conservative – Liberal Agreeableness Ruthless – Soft-hearted Suspicious – Trusting Stingy – Generous Antagonistic – Acquiescent Critical – Lenient Irritable – Good-natured Conscientiousness Negligent – Conscientious Lazy – Hardworking Disorganized – Well-organized Late – Punctual Aimless – Ambitious Quitting – Persevering The Five-Factor Model of Personality Adapted from Costa & McCrae 1986

    7. Three Major Brain Systems Influencing Stimulus – Response Characteristics

    8. Cloninger’s Seven-Factor Model • Temperament Domains (Moderately heritable, not greatly influenced by family environment) • Novelty Seeking • Harm Avoidance • Reward Dependence • Persistence 2. Character Domains (Moderately influenced by family environment, only weakly heritable) • Self-transcendence • Cooperativeness • Self-directedness

    9. The DSM Categorical System

    10. DSM-IV Personality Disorders

    11. Connecting Order with Disorder- A Quantitative, Continuum Model

    12. The Personality Style-Personality Disorder Continuum

    13. DSM-IV Definition of Personality Disorder • An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas: • Cognition (i.e., ways of perceiving and interpreting self, other people, and events) • Affectivity (i.e., the range, intensity, ability, appropriateness of emotional response) • Interpersonal functioning • Impulse control

    14. DSM-IV Definition of Personality Disorder B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

    15. DSM-IV Definition of Personality Disorder C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

    16. DSM-IV Definition of Personality Disorder D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood.

    17. DSM-IV Definition of Personality Disorder E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.

    18. DSM-IV Definition of Personality Disorder F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).

    19. Prevalence of PDs in a Community Sample(N=2053)Overall – 13.4%Torgersen, Kringlen, Cramer, 2001

    20. Prevalence of PDs in a Community Sample(N=2053) Personality DisorderPresent Prevalence Paranoid 2.4 Schizoid 1.7 Schizotypal 0.6 Antisocial 0.7 Borderline 0.7 Histrionic 2.0 Narcissistic 0.8 Avoidant 5.0 Dependent 1.5 Obsessive-Compulsive 2.0 Passive-Aggressive 1.7 Self-Defeating 0.8 Torgersen, Kringlen, Cramer; 2001

    21. PD Prevalence Studies Torgersen, 2005

    22. PD Prevalence Studies (n=5081) Torgersen, 2005

    23. AXIS I / AXIS II

    24. Phenomenologically Corresponding Axis I & Axis II Disorders, Potential Biological Indexes, and Characteristic Traits (Core Vulnerabilities), Defenses and Coping Strategies of Dimensions of Personality Disorders * Preliminary data are available in patients with personality disorder (PD)

    25. Schizotypal

    26. Schizotypal PD • Dopamine [+ sx] (Coccaro & Siever, 2005) • Dopamine [- sx] (Siever & Davis, 2004) • Ventricles (Siever, 1991) • Cognitive functioning (Gold & Harvey, 1993) • Working memory (Lees-Roitman et al., 1996) • Verbal memory (Saykin et al., 1991) • Sustained attention (Harvey et al., 1996) • Arousal to stimuli (Siever, 1985)

    27. Spectrum Model

    28. Impulsive/Compulsive Spectrum of Control CompulsiveImpulsive Control  Control Inhibition Disinhibition

    29. Impulsive Disorders Axis II • Borderline Personality Disorder • Antisocial Personality Disorder Axis I • Psychoactive Substance Use Disorder • Bulimia • Paraphilias • Impulsive Control Disorder NEC

    30. ANTISOCIAL

    31. Antisocial Personality Disorder (ASPD)  Prefrontal gray matter volume  Autonomic activity in ASPD May underlie low arousal, poor fear conditioning, lack of conscience, and decision-making deficits in ASPD Raine et al., 2000

    32. Psychopathic Antisocial PD (P-ASPD) • Corpus Callosum in P-ASPD vs Controls:  white matter volume  length  thickness  functional interhemispheric connectivity • May reflect atypical neurodevelopment, e.g., arrested early axonal pruning or ↑ white matter myelination • May help explain affective deficits Raine et al., 2003

    33. Malnutrition and Externalizing Behavior Malnutrition predisposes to neurocognitive deficits, which predispose to persistent externalizing (antisocial and aggressive) behavior throughout childhood and adolescence. Liu et al., 2004

    34. The Gradations of Antisociality • Some antisocial personality traits insufficient to meet DSM criteria; some antisocial traits occurring in another personality disorder • Explosive/Irritable Personality Disorder with some antisocial traits • Malignant Narcissism • Antisocial Personality Disorder, with property crimes only • Sexual Offenses without violence (viz., voyeurism, exhibitionism, frotteurism) • Antisocial Personality Disorder, with violent felonies. (There may be some psychopathic traits, but insufficient to meet Hare’s PCL-R criteria: score >29) • Psychopathy without violence (viz., con-artists, financial scams) • Psychopathy with violent crimes • Psychopathy with sadistic control (viz., unlawful imprisonment of a kidnap victim while awaiting ransom) • Psychopathy with violent sadism and murder, but no prolonged torture • Psychopathy with prolonged torture followed by murder Stone, 2000

    35. Treatability • Presence of • Adequate motivation • Ability to take seriously the nature of one’s antisocial attitudes and behaviors • Absence of • Pathological lying/deceitfulness • Conning/manipulativeness • Lack of remorse or guilt • Callousness/lack of compassion Stone, 2002

    36. Psychopathy • Kraeplin (1915) – Psychopathic personalities • Cleckley (1940) – Psychopath • Hare PCL-R

    37. PCL-R Factor-I Items • Glibness, superficial charm • Grandiose sense of self worth • Pathological lying • Conning/manipulative • Lack of remorse or guilt • Shallow affect • Callous/lack of empathy • Failure to accept responsibility for one’s actions Black, 1999

    38. Example of Offender Recidivism 3 Year Reconviction PCL-R > 30 75% PCL-R 20-29 50% PCL-R 0-19 25% Hemphill et al., 1998

    39. Predictors of ASPD Preschool child’s inability to inhibit socially inappropriate behavior predicts later asocial behavior, and undercontrolled behavior in school-age children is the best predictor of adult antisocial behavior. This association may be the most reliable relation between characteristics in young children and later psychopathology. From Kagan J, Zentner M, Early childhood predictors of adult psychopathology. Harvard Review of Psychiatry, 1996.

    40. Is ASPD Genetic? • Genetic factors do play a significant role in antisocial behavior • Twin studies show genetic factors to be particularly important in AS behavior with early-onset hyperactivity • Genetic factors least influential in adolescent onset delinquency

    41. JIMMY, SIXTH-GENERATION PAIN IN THE ASS

    42. BORDERLINE

    43. Borderline Personality Disorder (DSM-IV) A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. Note: do not include suicidal or self-mutilating behavior covered in Criterion 5. 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self-image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: do not include suicidal or self-mutilating behavior covered in Criterion 5.

    44. Borderline Personality Disorder (DSM-IV) A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts as indicated by five (or more) of the following: 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

    45. Heterogeneity of BPD • DSM-IV - defined BPD is an extremely heterogeneous construct (Est. 256 varieties) • Mix of unstable, stress-induced symptoms and stable personality characteristics (i.e., dimensional traits)

    46. BPD as a Personality Disorder Emerging From the Interaction of Underlying Genetically-Based Traits Impulsive aggression and affective instability = heritable endophenotypes that would contribute significantly to development of BPD Siever et al., 2002

    47. Heritability of BPD • Twin study (Torgersen et al. 2000) • Novelty seeking (Cloninger, 2005) • Impulsivity (New and Siever, 2002)