PERSONALITY DISORDERS

1. PERSONALITY DISORDERS Personality features versus Disorder Categorical versus Dimensional Approaches Overview of major disorders Issues and concerns Antisocial Personality Disorder Borderline Personality Disorder

2. Definitions • Personality = the enduring patterns of thinking, feeling and reacting that define a person • Personality Disorder = “an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture” APA,2000 • Must fit both the general and the specific criteria for DSM diagnosis • Pattern of deviation must be evident in two or more of the following domains: cognition, emotional responses, interpersonal functioning, or impulse control • Pattern must be inflexible and pervasive across a broad range of personal and social situations • Must be a source of clinically significant distress or impairment in social, occupational or other important areas of functioning • Must be stable and of long duration, with an onset that can be traced back to at least adolescence of early adulthood

3. Ways of Understanding • Personality Disorders are a construct (clinical) used to understand, describe and communicate about the complex phenomena that result when the personality system is not functioning optimally • Categorical Classification (DSM-IV) – Axis II Disorders • Cluster A: odd or eccentric behaviour including paranoid, schizoid, schizotypal personalities • Cluster B: erratic, emotional and dramatic presentations including antisocial, borderline, histrionic and narcissistic personalities • Cluster C: characterised by anxiety and fearfulness including avoidant, dependent and obsessive-compulsive personalities

4. Contd… • Dimensional Classification: personality disorders are normal traits amplified to the extreme • E.g. Five-Factor Model of Personality: neuroticism, extraversion, openness to experience, agreeableness and conscientiousness • Facilitates assessment and research

5. Neuroticism Very Low Very High Extraversion Very Introverted Very Extraverted Openness Very Low Very High Agreeableness Very Low Very High Conscientiousness Very Low Very High

6. Aetiology • Aetiology Models: • Biopsychosocial Model: holistic and inclusive • Diathesis-Stress Model: individual levels of tolerance • Psychodynamic theory: driven by the unconscious • General Systems Theory • Aetiology Factors: • Genetic Predisposition • Attachment Experience • Traumatic events • Family factors and dysfunction • Sociocultural and political forces

7. Prevalence • Varies according to gender, social factors and type • Approx. 10-14% overall • Most prevalent = Obsessive Compulsive, Dependent, Schizotypal • Least prevalent = Narcissistic, Schizoid • Most visible = Borderline, Antisocial • Assumption of stability over time, but some more than others (e.g. schizotypal > borderline)

8. Major Personality Disorders • Cluster A: odd/eccentric • Paranoid: pervasive distrust and suspicion of others • Schizoid: Social detachment/indifference and limited emotional experience & expression • Schizotypal: cognitive and perceptual distortions; eccentric behaviour; discomfort with close relationships

9. Contd. • Cluster B: dramatic/emotional/erratic • Antisocial: disregard for and violation of (the rights of) others • Borderline: instability of interpersonal relationships, self-image, emotions, and control over impulses • Histrionic: excessive emotionality and attention-seeking • Narcissistic: grandiosity; inflated sense of self-importance; need for attention; lack of empathy

10. Contd. • Cluster C: anxious or fearful • Avoidant: social withdrawal; feelings of inadequacy, hypersensitive to criticism • Dependent: excessive need to be taken care of; clinging and submissive • Obsessive-compulsive: preoccupation with orderliness, perfection and control at the expense of flexibility

11. Examples • Borderline: Fatal Attraction • Narcissistic: The Talented Mr. Ripley, Capote • Paranoid: Conspiracy Theory • Antisocial: Wall Street • Histrionic: Being Julia

12. Issues and Concerns • Socially and culturally sensitive diagnoses • Can be adaptive? • Gender biases • Clinically arbitrary thresholds for diagnosis (who decides?) • Stigma • Clinical hopelessness

13. Treatment • Traditionally PDs considered very difficult to treat because of their pervasive, entrenched nature • Psychoanalysis (esp. Cluster B: Borderline, Dependent, Antisocial etc.) • Cognitive Behavioural Therapy • Other psychotherapies: RET, Gestalt, Narrative etc. (individual and group) • Medication

14. Antisocial Personality Disorder • More studied than any other personality disorder • Origins usually traced back to earlier periods in development (Conduct Disorder), although can not be diagnosed until late adolescence (DSM criteria) • Has the distinction between ASPD and criminality been blurred? Not all psychopaths are criminals, and not all serious offenders are psychopaths. • Psychopathy includes ”shallow, deceitful, unreliable and incapable of learning from emotional experience” and seemingly lacking in basic emotions: shame, guilt, anxiety, remorse (conscience). • Increasing age can bring a change (lessening) in overt antisosial behaviours: less obvious impulsivity, recklessnes, social deviance. Some argue that the behaviours merely go ”underground”.

15. Causes • Biological Factors: seems to be a genetic loading, esp. Father-son, but outcome strongly determined by environment (adoption studies) • Temperament and family environment interaction: parenting (punitive, inconsistent, low warmth), peers, school • Behavioural and social reinforcers: learned behaviour resistant to change, modelling, consequence ”trap”, peer support

16. Born bad? • Psychological factors: inability to anticipate punishment, lack of anxiety regarding punishment/negative consequences. Does moral judgement cause anxiety or vica versa? • Consequent participation in risk-taking, self-promoting behaviour with reduced ability to interpret (or pay attention to) nonverbal cues esp. fear, distress, anger, anxiety. Deficit or decision? • Some people ”born bad”? (GSR, emotional responsiveness, empathy studies)

17. Treatment • Seldom seek treatment • Often coerced into treatment by the legal system, however, participation does not always equate with success • Difficulty building a therapeutic relationship • Very high recurrance of behaviour • Limited success with behavioural techniques

18. Borderline Personality Disorder • Often present due to other complaints (e.g. somatic, self-harm, anxiety, depression, abuse history). Large degree of comorbidity • Initially conceptualised as the ”borderline” between neurosis and schizophrenia but this no longer the case • Very poor sense of/integration of self leads to uncertainty about personal values, identity, worth and choices = erratic, impulsive and self-damaging behaviour

19. More cognitive/behavioural features • Fear abandonment and crave relationships but are incapable of maintaining these due to unrealistic expectations and lack of self-cohesion • Subject to chronic feelings of depression, worthlessness, ’emptiness’ leading to self-harm and self-deprecating behaviour (e.g. sexual activity, substance abuse, eating) • May demonstrate dissociation during intense distress • ”Splitting” – tend to see people and events as either all good or all bad, and can shift rapidly between these.

20. Causes • Biological/genetic: seems to run in families and may be associated with genes that contribute to anxiety, frontal lobe dysfunction • Object Relations: the internalisation of early caregiving relationships (e.g. inconsistency = insecurity & ego confusion leads to ego defence such as splitting) • Diathesis-stress: vulnerability thresholds overwhelmed e.g. by abuse & trauma

21. Treatment • Perceived as very difficult clients • Therapeutic relationship is key but threatening to person with BPD therefore attrition is high, and therapy is made very challenging • Psychoanalysis uses the transference relationship to interpret and integrate

22. Dialectical Behavior Therapy • Developed by Marsha Linehan (1993) • Based on strategies of both behaviour therapy and supportive psychotherapy • ”Dialectic” refers to strategies used by therapist to help client balance contradictory needs • Rogerian acceptance is first established • Aim is to become more comfortable with difficult emotions, followed by helping to re-interprete these and then regulate • Other CBT strategies also employed • Contracts are made about self-harm to communicate support without acceptance. • Some preliminary evidence to support this treatment model