Chapter 13 Personality disorders

1. Chapter 13Personality disorders Alice Cheng, Ph.D. University of Hartford

2. Personality Disorders • Personality disorders are characterized by • chronic interpersonal difficulties • problems with one’s identity or sense of self

3. Clinical Features of Personality Disorders • The definition of personality disorders in DSM-IV-TR is based on five criteria • Criterion A: The pattern must be manifested in at least two of the following areas: • cognition • affectivity • interpersonal functioning • impulse control

4. Clinical Features of Personality Disorders • The definition of personality disorders in DSM-IV-TR is based on five criteria • Criterion B: The enduring pattern must be inflexible and pervasive across a broad range of personal and social situations

5. Clinical Features of Personality Disorders • The definition of personality disorders in DSM-IV-TR is based on five criteria • Criterion C: This pattern leads to clinically significant distress or impairment of functioning

6. Clinical Features of Personality Disorders • The definition of personality disorders in DSM-IV-TR is based on five criteria • Criterion D: The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early childhood

7. Clinical Features of Personality Disorders • The definition of personality disorders in DSM-IV-TR is based on five criteria • Criterion E: The pattern is not better accounted for as a manifestation or consequence of another mental disorder

8. Difficulties Doing Research on Personality Disorders • Difficulties in diagnosing personality disorders are caused by a number of factors, including • diagnostic criteria are not as sharply defined as for other Axis I categories • diagnostic categories are not mutually exclusive • personality characteristics are dimensional in nature

9. Difficulties Doing Research on Personality Disorders • Difficulties in studying the causes of personality disorders spring from • The fact that such disorders have received consistent attention only since DSM-III was published in 1980 • The fact that these disorders are less amenable to thorough study • The fact that most studies todate are retrospective

10. Personality Disorders The DSM groups personality disorders into three clusters: Cluster A: People who are perceived as odd or eccentric. This cluster includes paranoid, schizoid, and schizotypal personality disorders. Cluster B: People whose behavior is overly dramatic, emotional, or erratic. This grouping consists of antisocial, borderline, histrionic, and narcissistic personality disorders. Cluster C: People who often appear anxious or fearful. This cluster includes avoidant, dependent, and obsessive–compulsive personality disorders.

11. Overview of Personality Disorders

12. Categories of Personality Disorders • Provisional categories include • passive-aggressive • depressive

13. Paranoid Personality Disorder Paranoid personality disorder - A personality disorder characterized by undue suspiciousness of others’ motives, but not to the point of delusion. People who have paranoid personality disorder tend to be overly sensitive to criticism, whether real or imagined. Clinicians need to weigh cultural and sociopolitical factors when arriving at a diagnosis of paranoid personality disorder.

14. Diagnostic Criterion • A) A pervasive distrust and suspicion of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: • suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her • is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates • is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her • reads benign remarks or events as threatening or demeaning. • persistently bears grudges, i.e., is unforgiving of insults, injuries, or slight • sperceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counter attack • has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

15. Schizoid Personality Disorder Schizoid personality disorder - A personality disorder characterized by persistent lack of interest in social relationships, flattened affect, and social withdrawal. Often described as a loner or an eccentric, the person with a schizoid personality lacks interest in social relationships. The person’s emotions usually appear shallow or blunted, but not to the degree found in schizophrenia. http://www.youtube.com/watch?v=niOEoRn3cA0

16. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: • neither desires nor enjoys close relationships, including being part of a family • most always chooses solitary activities • has little, if any, interest in having sexual experiences with another person • takes pleasure in few, if any, activities • lacks close friends or confidants other than first-degree relatives • appears indifferent to the praise or criticism of others • shows emotional coldness, detachment, or flattened affect

17. Schizotypal Personality Disorder Schizotypal personality disorder - A personality disorder characterized by eccentricities of thought and behavior, but without clearly psychotic features. Schizotypal personality disorder may be slightly more common in males than in females and is believed to affect about 3% of the general population. Investigators also find higher rates of the disorder among African Americans than among Caucasians or Hispanic Americans. http://www.youtube.com/watch?v=IJRQGxvTeT8

18. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) • Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, bizarre fantasies or preoccupations) • Unusual perceptual experiences, including bodily illusions • Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped) • Suspiciousness or paranoid ideation Inappropriate or constricted affect • Behavior or appearance that is odd, eccentric, or peculiar • Lack of close friends or confidants other than first-degree relatives • Social anxiety that tends to be associated with paranoid fears rather than negative judgments about self.

19. Antisocial Personality Disorder Antisocial personality disorder - A personality disorder characterized by antisocial and irresponsible behavior and lack of remorse for misdeeds. They are not “antisocial” in the colloquial sense of seeking to avoid people. People with antisocial personalities also tend to be impulsive and fail to live up to their commitments to others.

21. Antisocial Personality Mass murderer Henry Lee Lucas, a drifter and violent career criminal, fits the stereotype of an antisocial personality.

22. Lifetime prevalences of antisocial personality disorder by gender. Antisocial personality disorder is more than five times as common among men than women. However, the disorder has been rising more rapidly among women in recent years.

23. Antisocial Behavior and Criminality We tend to think of antisocial behavior as synonymous with criminal behavior. Although it is the case that antisocial personality disorder is associated with an increased risk of criminality, not all criminals have antisocial personalities nor do all people with antisocial personality disorder become criminals. Many people with antisocial personality disorders are law abiding and successful in their careers, even though they may treat others in a callous and insensitive manner.

24. Antisocial Personality and Psychopathy • Individuals eighteen and over may be diagnosed with antisocial personality disorder if the following criteria are met: • at least three behavioral problems occurring after age 15 • at least three instances of deviant behavior before age 15 • the antisocial behavior is not a symptom of another mental disorder

25. Borderline Personality Disorder • Borderline personality disorder (BPD) - A personality disorder characterized by abrupt shifts in mood, lack of a coherent sense of self, and unpredictable, impulsive behavior. • At the core is a pervasive pattern of instability in relationships, self-image, and mood, along with a lack of control over impulses. • Pathological fear of real or imagined abandonment and rejection. • People with borderline personality disorder tend to be uncertain about their personal identities—their values, goals, careers, and perhaps even their sexual orientations.

26. A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: • Frantic efforts to avoid real or imagined abandonment. • pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. • Identity disturbance: markedly and persistently unstable self-image or sense of self. • Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving) • 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). • Chronic feelings of emptiness • Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). • Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms

27. Cutting. People with borderline personalities may engage in impulsive acts of self-mutilation, such as cutting themselves, perhaps as a means of temporarily blocking or escaping from deep, emotional pain.

28. Borderline Personality Disorder Self-mutilation is sometimes an expression of anger or a means of manipulating others. Such acts may be intended to counteract self-reported feelings of “numbness,” particularly in times of stress. Individuals with BPD often have very troubled relationships with their families and others Splitting - An inability to reconcile the positive and negative aspects of the self and others, resulting in sudden shifts between positive and negative feelings.

29. http://www.youtube.com/watch?v=eOphgCJX1FY

30. Histrionic Personality Disorder Histrionic personality disorder - A personality disorder characterized by excessive need for attention, praise, reassurance, and approval. The term is derived from the Latin histrio, which means “actor.” People with histrionic personality disorder tend to be dramatic and emotional, but their emotions seem shallow, exaggerated, and volatile. The disorder was formerly called hysterical personality.

31. A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: • is uncomfortable in situations in which he or she is not the center of attention • interaction with others is often characterized by inappropriate sexually seductive or provocative behavior • displays rapidly shifting and shallow expression of emotions • consistently uses physical appearance to draw attention to self • has a style of speech that is excessively impressionistic and lacking in detail • shows self-dramatization, theatricality, and exaggerated expression of emotionis suggestible, i.e., easily influenced by others or circumstances • considers relationships to be more intimate than they actually are.

32. Narcissistic Personality Disorder Narcissistic personality disorder - A personality disorder characterized by adoption of an inflated self-image and demands for attention and admiration. They expect others to notice their special qualities, even when their accomplishments are ordinary, and they enjoy basking in the light of adulation. They are self-absorbed and lack empathy for others. http://www.youtube.com/watch?v=f9jRDHGabp8&feature=related

33. A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: • has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements) • is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love • believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions) • requires excessive admirationhas a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations • is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends • Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others • is often envious of others or believes others are envious of him or her • shows arrogant, haughty behaviors or attitudes

34. Narcissistic Personality Disorder Interpersonal relationships are invariably strained by the demands that people with narcissistic personality impose on others and by their lack of empathy with, and concern for, other people. They seek the company of flatterers and, although they are often superficially charming and friendly, their interest in people is one-sided: They seek people who will serve their interests and nourish their sense of self-importance. They have feelings of entitlement that lead them to exploit others.

35. Avoidant Personality Disorder Avoidant personality disorder - A personality disorder characterized by avoidance of social relationships due to fears of rejection. They may have few close relationships outside their immediate families. They also tend to avoid group occupational or recreational activities for fear of rejection.

36. A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: • avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection • is unwilling to get involved with people unless certain of being liked • shows restraint initiating intimate relationships because of the fear of being ashamed, ridiculed, or rejected due to severe low self-worth • is preoccupied with being criticized or rejected in social situations • is inhibited in new interpersonal situations because of feelings of inadequacy • views self as socially inept, personally unappealing, or inferior to others • is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

37. Dependent Personality Disorder Dependent personality disorder - A personality disorder characterized by difficulty making independent decisions and overly dependent behavior. Dependent personality disorder has been linked to other psychological disorders, including major depression, bipolar disorder, and social phobia, and to physical problems, such as hypertension, cancer, and gastrointestinal disorders like ulcers and colitis.

38. Obsessive–Compulsive Personality Disorder Obsessive–compulsive personality disorder - A personality disorder characterized by rigid ways of relating to others,perfectionistic tendencies, lack of spontaneity, and excessive attention to detail. Persons with obsessive–compulsive personality disorder are so preoccupied with the need for perfection that they cannot complete work on time. Their efforts inevitably fall short of their expectations, so they redo their work.

39. pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: • Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost • Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met) • Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity) • Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification) • Is unable to discard worn-out or worthless objects even when they have no sentimental values • reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things • Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes • Shows rigidity and stubbornness

40. Problems with the Classification of Personality Disorders Problems Distinguishing Personality Disorders from Anxiety and Mood Disorders Overlap Among Disorders Difficulty in Distinguishing Between Normal and Abnormal Behavior Confusing Labels with Explanations

41. Sexist Biases The construction of certain personality disorders may have sexist underpinnings. The diagnostic criteria seem to label stereotypical feminine behaviors as pathological with greater frequency than stereotypical masculine behaviors. Take the example of histrionic personality, which seems a caricature of the traditional stereotype of the feminine personality: flighty, emotional, shallow, seductive, attention-seeking.

42. Are there sexist biases in the conception of personality disorders? The concept of the histrionic personality disorder seems to be a caricature of the highly stereotyped feminine personality. Why, then, is there not also something akin to a macho male personality disorder, which caricatures the highly stereotyped masculine personality?

43. Hans Kohut One of the principal shapers of modern psychodynamic concepts is Hans Kohut, whose theory is labeled self psychology because of its emphasis on processes in the development of a cohesive sense of self. Freud believed that the resolution of the Oedipus complex was central to the development of adult personality. Kohut disagreed, arguing that what matters most is how the self develops—whether the person is able to develop self-esteem, values, and a cohesive and realistic sense of self as opposed to an inflated, narcissistic personality

44. Hans Kohut To Kohut, early childhood involves a normal stage of healthy narcissism. Infants feel powerful, as though the world revolves around them. Infants also normally perceive their parents as idealized towers of strength and wish to be one with them and to share their power. Empathic parents reflect their children’s inflated perceptions by making them feel that anything is possible and by nourishing their self-esteem (e.g., telling them how terrific and precious they are).

45. Otto Kernberg Otto Kernberg (1975), a leading psychodynamic theorist, views borderline personality in terms of a failure in early childhood to develop a sense of constancy and unity in one’s image of oneself and others. From this perspective, borderline individuals cannot synthesize contradictory (positive and negative) elements of themselves and others into complete, stable wholes. Rather than viewing important people in their lives as sometimes loving and sometimes rejecting, they shift back and forth between pure idealization and utter hatred.

46. Margaret Mahler Margaret Mahler, another influential modern psychodynamic theorist, explained borderline personality disorder in terms of childhood separation from the mother figure. Mahler and her colleagues believed that during the first year infants develop a symbiotic attachment to their mothers.

47. Learning Perspectives Learning theorists focus on maladaptive behaviors rather than disorders of personality. They are interested in identifying the learning histories and environmental factors that give rise to maladaptive behaviors associated with diagnoses of personality disorders and the reinforcers that maintain them. Learning theorists suggest that childhood experiences shape the pattern of maladaptive habits of relating to others that constitute personality disorders.

48. Family Perspectives Many theorists have argued that disturbances in family relationships underlie the development of personality disorders. Consistent with psychodynamic formulations, researchers find that people with borderline personality disorder (BPD) remember their parents as having been more controlling and less caring than do reference subjects with other psychological disorders. When people with BPD recall their earliest memories, they are more likely than other people to paint significant others as malevolent or evil.

49. Biological Perspectives Much remains to be learned about the biological underpinnings of personality disorders. Most of the attention in the research community has centered on antisocial personality disorder and the personality traits that underlie the disorder, which is the focus of much of our discussion.

50. Genetic Factors We have learned that first-degree biological relatives (parents and siblings) of people with certain personality disorders, especially antisocial, schizotypal, and borderline types, are more likely to be diagnosed with these disorders than are members of the general population. Genetic factors appear to play a role in the development of certain psychopathic personality traits, such as callousness, impulsivity, and irresponsibility. Investigators find that a variant on a particular gene is associated with antisocial behavior in adult men, but only in those who were maltreated in childhood.