Personality Disorders

1. Personality Disorders Abnormal Psychology

2. Personality Disorders are: • more subtle and less incapacitating than many Axis I disorders • rigid, inflexible, maladaptive patterns of relating to oneself and one’s environment • most often untreated • egosyntonic (as opposed to egodystonic) • best viewed on a continuum (dimensional)

3. Are PDs really important problems? • disrupt interpersonal relationships • make therapy very difficult when they occur together with Axis I disorders • may represent predispositions toward, or early manifestations of, other Axis I disorders

4. Problems regarding PDs • diagnostic reliability is quite low • tremendous overlap among categories • questions remain about temporal stability • not clear that they are “culturally universal” • little evidence to show that they can be treated successfully

5. PDs are difficult to treat because • person does not recognize that he or she has a problem • interpersonal difficulties interfere with the therapeutic relationship • very little research evidence on treatment efficacy because the PDs overlap so extensively with Axis I disorders

6. General Criteria for PDs (DSM-IV) • an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture • manifested in two or more of the following areas: • 1. cognition • 2. affectivity • 3. interpersonal functioning • 4. impulse control

7. General Criteria for PDs (continued) • enduring pattern is inflexible and pervasive across a range of situations • enduring pattern leads to clinically significant distress or impairment • pattern is stable and of long duration (onset traced at least to adolescence) • pattern is not better explained by another type of mental disorder

8. PD Clusters in DSM-IV • Cluster A: odd, eccentric, socially isolated • Cluster B: flamboyant, overly emotional • Cluster C: anxious or avoidant

9. PDs listed in Cluster A (DSM-IV) • PARANOID: distrust and suspicion of others • SCHIZOID: detachment from social relationships; little expression of emotion • SCHIZOTYPAL: discomfort with close relationships; cognitive and perceptual distortions; eccentricities of behavior

10. PDs listed in Cluster B (DSM-IV) • ANTISOCIAL: disregard for and frequent violation of the rights of others • BORDERLINE: instability of interpersonal relationships, self-image, emotions, and control over impulses

11. PDs listed in Cluster B (DSM-IV) • HISTRIONIC: excessive emotionality and attention-seeking • NARCISSISTIC: grandiosity, need for admiration, lack of empathy

12. PDs listed in Cluster C (DSM-IV) • AVOIDANT: social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation • DEPENDENT: excessive need to be taken care of; submissing, clinging behavior • OBSESSIVE-COMPULSIVE: preoccupation with orderliness and perfectionism

13. Prevalence of “Severe” Personality Disorders

14. Problems with Categorical Approach • tremendous overlap among categories • problems of setting thresholds • need for 10 diagnoses on Axis II creates unnecessary complexity (making decisions on 8 or 9 criteria for each category) • it might be simpler and more accurate descriptively to use a few dimensions

15. Personality Dimensions: The Big Five • neuroticism • extraversion • openness • agreeableness • conscientiousness

16. Personality Dimensions: The Big Five • neuroticism (expression of negative emotions) • extraversion (interest in interacting with other people; positive emotions) • openness (willingness to consider and explore unfamiliar ideas, feelings, and activities

17. Personality Dimensions: The Big Five • agreeableness (willingness to cooperate and empathize with others) • conscientiousness (persistence in pursuit of goals; organization; dependability)

18. Paranoid PD viewed in terms of dimensions • extraversion: low • openness: low • agreeableness: low

19. Histrionic PD viewed in terms of dimensions • neuroticism: high • extraversion: high • agreeableness: low • conscientiousness: low

20. O-C PD viewed in terms of dimensions • neuroticism: high • extraversion: low • openness: low • conscientiousness: high

21. DSM Criteria for Schizotypal PD • a pervasive pattern of social / interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships • cognitive or perceptual distortions and eccentricities of behavior • plus five (or more) of the following:

22. Criteria for Schizotypal PD (5 or more) • ideas of reference • odd beliefs or magical thinking • unusual perceptual experiences • odd thinking and speech • suspiciousness or paranoid ideation • inappropriate or constricted affect • behavior or appearance that is odd or peculiar • lack of close friends or confidants • excessive social anxiety

23. Schizotypal Personality Disorder • closely tied to the concept of schizophrenia • odd or peculiar behaviors frequently seen among the first-degree relatives of schizophrenic patients • overlaps primarily with paranoid, schizoid, and avoidant PDs

24. Etiology and Treatment of Schizotypal PD • mostly focused on genetic factors • treatment usually focused on low doses of antipsychotic medication

25. Kendler’s Roscommon Family Study

26. Borderline Personality Disorder (BPD) • GUNDERSON: identified descriptive features of BPD for DSM-III definition • focused on intense, unstable interpersonal relationships • unstable emotional reactions, including intense anger

27. DSM Criteria for Borderline PD (5 or more) • frantic efforts to avoid abandonment • unstable and intense interpersonal relationships • identity disturbance • impulsivity in areas that are self-damaging • recurrent suicidal behavior or gestures • affective instability / marked reactivity of mood • chronic feelings of emptiness • inappropriate, intense anger • transient, stress-related paranoid ideation

28. Borderline Personality Disorder • AKISKAL: says BPD is a mix of different things, including mild forms of brain dysfunction, conditions that resemble schizophrenia, and sub-clinical mood disorders • when all of that is removed, a “residual” group remains that is difficult to distinguish from many other PDs

29. Etiology of Borderline PD • Akiskal on etiology of his “residual” group • they suffer from the negative consequences of parental loss during childhood • infant monkeys separated from their mothers experience persistent attachment problems and high negative affect • relationships with peers are disrupted

30. Etiology of Borderline PD • research studies frequently point to abuse by parents (borderline adolescents) • but what is the direction of effect ? • note people with other types of mental disorders also report childhood abuse and neglect (e.g., Brown’s work on anxiety disorders)

31. Psychopathy and Antisocial PD • two different traditions for this disorder • both attempting to define same concept • Hervey Cleckley (1941) The Mask of Sanity • described “the psychopath” as being intelligent and superficially charming • but also deceitful, unreliable, and incapable of learning from experience • disregard for the truth; lack of remorse

32. Psychopathy and Antisocial Personality • Lee Robins (1966) Deviant Children Grown Up • described (as adults) people who had been treated many years earlier at a child guidance clinic • conduct disorder among boys predicted antisocial behavior in adults • formed basis for ASP in DSM-III

33. DSM Criteria for Antisocial PD • a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by 3 (or more) of the following:

34. DSM Criteria for Antisocial PD (3 or more) • failure to conform to social norms (re laws) • deceitfulness • impulsiveness • irritability and aggressiveness (e.g., fights) • reckless disregard for safety of self or others • consistent irresponsibility (e.g., failure to work) • lack of remorse • plus evidence of conduct disorder before age 15

35. Shift to DSM-III definition of ASP • improved reliability • questionable validity • more criminals defined as meeting criteria for ASP (50% meet DSM-III, but only 35% meet Cleckley’s definition of psychopathy)

36. Etiology of ASP / Psychopathy • adoption studies point to influence of genetic factors • Cadoret et al. (1995) found an interaction between genetic factors and rearing environment • adverse adoptive home environment increases risk of conduct disorder in offspring of antisocial parents

37. Criminal Behavior among Male Adoptees

38. Social Factors and the Etiology of ASP • inconsistent discipline (or complete lack of discipline) often seen in the prior family history of ASP men (Robins, 1966) • kids with a “difficult temperament” are especially irritating to parents • parents respond inappropriately (giving up, or becoming severe in punishment) • person selects friends who share antisocial interests and problems

39. Continuity in Life-Course-Persistent ASP • person’s options become narrowed; locked into further antisocial behavior • limited range of behavioral skills (can’t pursue more appropriate responses) • ensnared by consequences of earlier behaviors (drug addiction, parenthood, school dropout, criminal record)

40. Psychological Factors: the Etiology of ASP • avoidance learning in the lab (sequences) • psychopaths unaffected by anticipation of punishment • Hypothesis 1: they can ignore the effects of punishment; they are emotionally impoverished • Hypothesis 2: they have trouble shifting their attention; they are impulsive