Survey of Modern Psychology

Survey of Modern Psychology Fall 2010 Personality Disorders

Personality DisordersAs they currently appear in the DSM-IV-TR • Cluster A “Odd or Eccentric” • Paranoid Personality Disorder • Schizoid Personality Disorder • Schizotypal Personality Disorder • Cluster B: “Dramatic, emotional, or erratic” • Antisocial Personality Disorder • Borderline Personality Disorder • Histrionic Personality Disorder • Narcissistic Personality Disorder • Cluster C “Anxious or fearful” • Avoidant Personality Disorder • Dependent Personality Disorder • Obsessive-Compulsive Personality Disorder

Proposed Changes for DSM-V • Will likely include “Personality Disorder Types” • This would use a system of “graded membership” – to what degree does the person have this type of personality • Antisocial/Psychopathic Type • Avoidant Type • Borderline Type • Obsessive-Compulsive Type • Schizotypal Type

Proposed Changes for DSM-V A. Type rating. Rate the patient’s personality using the 5-point rating scale shown below. Circle the number that best describes the patient’s personality. 5 = Very Good Match: patient exemplifies this type 4 = Good Match: patient significantly resembles this type 3 = Moderate Match: patient has prominent features of this type 2 = Slight Match: patient has minor features of this type 1 = No Match: description does not apply B. Trait ratings. Rate extent to which the following traits associated with the [whichever] Type are descriptive of the patient using this four-point scale: 0 = Very little or not at all descriptive 1 = Mildly descriptive 2 = Moderately descriptive 3 = Extremely descriptive

Defining a Personality Disorder • Enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts • Only when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute Personality Disorders

Defining a Personality Disorder • The essential feature of a Personality Disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture and is manifested in at least two of the following areas: • Criterion A • Cognition • Affectivity • Interpersonal functioning • Impulse control

Defining a Personality Disorder • Criterion B: • The enduring pattern is inflexible and pervasive across a broad range of personal and social situations • Criterion C: • The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning

Defining a Personality Disorder • Criterion D: • The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood • Criterion E: • The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder • Criterion 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)

Defining a Personality DisorderDSM-V Proposed Changes Personality disorders represent the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual’s cultural norms and expectations. • Impaired sense of self identity • Failure to develop effective interpersonal functioning

Diagnosing a Personality Disorder • Requires evaluation of the individual's long term patterns of functioning • The personality traits must be distinguished from those that emerge in response to specific situational stressors or more transient mental states • The clinician should address the stability of the personality traits over time and across different situations • The individual may not consider these traits problematic; they are often ego-syntonic

Diagnosing a Personality Disorder • Evaluation must take into account the individual's ethnic, cultural, and social background • Traits of a personality disorder that appear in childhood do not always continue to adulthood; to diagnose a person under 18 with a personality disorder requires that the trait has been present at least 1 year • Antisocial Personality Disorder cannot be diagnosed until 18 years of age • May be exacerbated by the loss of a significant support or stabilizing situation (e.g., a job)

Personality Disorders: Notes • Antisocial Personality Disorder and Borderline Personality Disorder tend to become less evident or remit over time • Antisocial Personality Disorder is more frequently diagnosed in males; Borderline, Histrionic, and Dependent Personality Disorders are more often diagnosed in females. It is unclear whether there is a real difference in prevalence, or if there’s a tendency to over/under diagnose based on traditional gender roles and behaviors

Paranoid Personality Disorder • A pervasive distrust and suspiciousness 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:

Paranoid Personality Disorder(4 or more) • 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 hidden demeaning or threatening meanings into benign remarks or events

Paranoid Personality Disorder(4 or more) • Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights • Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack • Has recurrent suspiciousness, without justification, regarding fidelity of spouse or sexual partner

Paranoid Personality Disorder • Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, or another Psychotic Disorder and is not due to the direct physiological effects of a general medical condition Note: if criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g., “Paranoid Personality Disorder (Premorbid).”

Paranoid Personality Disorder: Notes • More common in males • Should not be confused with behaviors that are influenced by sociocultural factors or life circumstances • Increased prevalence in relatives of people with Schizophrenia

Paranoid Personality Disorder: Notes • Prevalence: • General population: .5% - 2.5% • Inpatient settings: 10% - 30% • Outpatient settings: 2% - 10% • More likely to experience Major Depressive Disorder, Agoraphobia, OCD, Substance Abuse

Schizoid Personality Disorder • 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:

Schizoid Personality Disorder(4 or more) • Neither desires nor enjoys close relationships, including being part of a family • Almost 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 affectivity

Schizoid Personality Disorder: Notes • Often prefer mechanical or abstract tasks • Reduced experience of pleasure from sensory or interpersonal experiences • May be oblivious to normal subtleties of social interactions and do not respond appropriately to social cues • May seem socially inept, superficial, or self-absorbed • Often seem aloof or cold • Often react passively to adverse events and seem directionless

Schizoid Personality Disorder: Notes • May be comorbid with Major Depressive Disorder • May experience brief Psychotic Episodes (lasting minutes to hours) • Is sometimes an antecedent of Delusional Disorder or Schizophrenia • Slightly more common in males and may cause more impairment in males • Uncommon in clinical settings

Schizotypal Personality Disorder • 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) of the following:

Schizotypal Personality Disorder(5 or more) • Ideas of reference (excluding delusions of reference) [a less firmly held idea] • Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations) • Unusual perceptual experiences, including bodily illusions • Odd thinking and speech (e.g., vague, circumstantial, metaphorical, over-elaborate, or stereotyped)

Schizotypal Personality Disorder(5 or more) • Suspiciousness or paranoid ideation • Inappropriate or constricted affect • Behavior or appearance that is odd, eccentric, or peculiar • Lack of close friends and confidants other than first-degree relatives • Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

Schizotypal Personality Disorder: Notes • May express unhappiness about their lack of relationships • Tend to feel like, and behave like, outsiders • Often seek treatment for associated features • Anxiety, depression, etc. • 30% - 50% who are diagnosed also have a diagnosis of Major Depressive Disorder • In response to stress, may experience transient psychotic episodes • Slightly more common in males

Schizotypal Personality Disorder: Notes • Occurs in about 3% of the general population • Usually is relatively stable, very few develop a Psychotic Disorder • More prevalent among first degree relatives of Schizophrenics • Symptoms may appear transiently in adolescents

Avoidant Personality Disorder • 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:

Avoidant Personality Disorder(4 or more) • 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 within intimate relationships because of the fear of being shamed or ridiculed • 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 might prove embarrassing

Avoidant Personality Disorder: Notes • May decline offers of job promotions because of a fear of criticism • Low threshold for criticism; feel extremely hurt at any slight disapproval • Tend to be shy, quiet, inhibited, and “invisible” because of a fear that any attention would be bad • Expect that whatever they say will be wrong, so tend to stay mute • Want to have social relationships, but are fearful

Avoidant Personality Disorder: Notes • Because of a fearful and tense demeanor, might be more likely to be noticed and ridiculed (hence confirming fears) • May fantasize about idealized relationships with others • High comorbidity with mood and anxiety disorders (especially Social Phobia, Generalized Type) • Become overly attached to anyone with whom they are close

Avoidant Personality Disorder: Notes • Equally prevalent in males and females • Prevalence: • General population: .5% - 1% • Outpatients: 10% • Avoidant behavior often starts in infancy or childhood • Usually shyness decreases with age, with Avoidant Personality Disorder, it increases • Avoidant Personality Disorder may remit slightly with age

Dependent Personality Disorder • A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

Dependent Personality Disorder(5 or more) • Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others • Needs others to assume responsibility for most major areas of his or her life • Has difficulty expressing disagreement with others because of fear of loss of support or approval Note: Do not include realistic fears of retribution • Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)

Dependent Personality Disorder(5 or more) • Goes to excessive lengths to obtain nurturance and support form others, to the point of volunteering to do things that are unpleasant • Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself • Urgently seeks another relationship as a source of care and support when a close relationship ends • Is unrealistically preoccupied with fears of being left to take care of himself or herself

Dependent Personality Disorder: Notes • May occur in an individual with a general medical condition or disability, but the difficulty in taking responsibility goes beyond what would normally be associated with that condition/disability • Will agree with something he or she feels is wrong rather than risk losing the person • Often do not learn skills of independent living • May tolerate abuse (when there are clear options/ways to leave the relationship) • Increased risk of Mood and Anxiety Disorders • Chronic illness or childhood Separation Anxiety Disorder may be predisposing conditions • Among the most frequently reported Personality Disorders in clinics

Obsessive-Compulsive Personality Disorder • A 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:

Obsessive-Compulsive Personality Disorder(4 or more) • 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)

Obsessive-Compulsive Personality Disorder(4 or more) • Is unable to discard worn-out or worthless objects even when they have no sentimental value • Is 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

Obsessive-Compulsive Personality Disorder: Notes • Attempt to maintain control through painstaking attention to rules, trivial details, procedures, lists, schedules, etc. • Excessively careful and prone to repetition • Extraordinary attention to detail and repeatedly checking for possible mistakes • Oblivious to the fact that other people tend to be annoyed by the delays and inconveniences from this behavior • Time is poorly allocated, the most important tasks are often left to the last minute

Obsessive-Compulsive Personality Disorder: Notes • May pay so much attention to making every detail of a project perfect that the project is never completed • Hobbies and recreational tasks are approached as serious tasks requiring organization • Rigidly deferential to authority and insist on literal compliance to rules with no rule-bending for extenuating circumstances • May be very self-critical • “Pack rats” because “you never know when you might need something”

Obsessive-Compulsive Personality Disorder: Notes • May show surprise or annoyance if others suggest that an activity or task may be done a different way • Even if the individual recognizes that compromise might be in their best interest, they refuse to do so because of “the principle of the thing” • Prone to anger when they cannot maintain control or there is no clear rule • Preoccupation with logic and intellect

Obsessive-Compulsive Personality Disorder: Notes • High comorbidity with Anxiety Disorders • The majority of people with OCD do not have OCPD • May be an association between Eating Disorders and OCPD • Prevalence: • 1% of general population • 3% - 10% in mental health clinics In OCPD, there are no actual obsessions or compulsions

Histrionic Personality Disorder • 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:

Histrionic Personality Disorder(5 or more) • 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

Histrionic Personality Disorder(5 or more) • Has a style of speech that is excessively impressionistic and lacking in detail • Shows self-dramatization, theatricality, and exaggerated expression of emotion • Is suggestible, i.e., easily influenced by others or circumstances • Considers relationships to be more intimate than they actually are

Histrionic Personality Disorder: Notes • Need to be “the life of the party” and will do something dramatic to get attention • In treatment, will tend to be overly flattering, bring gifts, give dramatic descriptions of symptoms and replace them with new symptoms each visit • Excessively use physical appearance to draw attention • Fish for compliments and be excessively upset by critical comments • Express strong and dramatic opinions, but have no information or reasons to back them up • Excessively emotional

Histrionic Personality Disorder: Notes • Emotions may appear to be turned on and off too quickly to be authentic • Will often accuse others of faking their feelings • Opinions and feelings are overly influenced by others • May be overly trusting, especially of authority figures • Difficulty achieving real emotional intimacy • Often control partners through emotional manipulation • May alienate others because of constantly demanding attention • Manipulate others to gain nurturance

Histrionic Personality Disorder: Notes • Thought to be more common in women • Behavioral expression does seem to be strongly influenced by social norms and stereotypes • A man might present as particularly “macho” and seek attention by bragging about his athleticism • More prone to suicidal gestures and threats; unclear what the risk of suicide is • Prevalence: • General population: 2% - 3% • Mental health clinics: 10% - 15%

Narcissistic Personality Disorder • 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:

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