Personality Disorders

1. Personality Disorders

2. Bo r d e r l i n e Neurotic Beh • Anxiety-based • No distortions in reality • Recognizes problem • No great personality disorganization Psychotic • Gross distortions in reality (e.g., perception) • Some personality disorganization • Does not recognize problem

3. Personality Disorders • When behaviour patterns become inflexible and maladaptive to the point of causing distress or social/occupation impairment can say have Personality Disorder

4. Personality Disorders • Don’t stem from reactions to stress but from gradual development of inflexible and distorted personality • Maladaptive ways of perceiving, thinking, relating to world

5. Personality Disorders • Excessively rigid patterns of behaviour or ways to relating to others that prevents people from adjusting to external demands and, thus, become self-defeating. • Have always been there for an individual

6. Personality Disorders • Mild: Function reasonably well, viewed as troublesome, eccentric, etc. • Severe: Extreme or unethical behaviour, may be incarcerated.

7. Quote From Lorna Benjamin (1996) “A great way to come down with a case of “medical student disease (syndrome)” is to read a survey of personality disorders”

8. Some Trait Pattern Example • Suspiciousness • Excessive Self-regard • Fear of Rejection • Come to dominate reactions to new situations • Repetitive maladaptive behaviour

9. Difference between DSM’s Clinical Syndromes & PD • Clinical Syndrome specific symptom clusters, time limited, ego-distonic (viewed as separate from self, unacceptable, objectionable and alien) • E.g., depression, anxiety disorders, psychotic disorders

10. Continued Personality Disorder Individual with PD are perceived as ego-syntonic (e.g., personality issues are acceptable, unobjectionable and part of the self). Tend to blame others for problems in their lives.

11. Difficulties with Diagnosis of Personality Disorder • Need to infer traits to make diagnosis, do not have specific behaviours clinician can judge • Disorders and criteria are relatively new, therefore not as much research has been done on them • Great deal of overlap among the disorders • Hard to draw a line between disorder and normal behaviour

12. Personality Disorder Clusters • Cluster One: Odd-Eccentric: • Behaviours similar to schizophrenia, suspiousness, withdrawal, peculiar thinking

13. The Odd Eccentric PD Group 1. Paranoid Personality Disorder 2. Schizoid Personality Disorder 3. Schizotypal Personality Disorder

14. Paranoid Personality Disorder Reverend Jim Jones People’s Temple

15. Paranoid Personality Disorder • suspicious of other’s motives • interprets actions of others as deliberately demeaning/threatening • expectation of being exploited • see hidden messages in benign comments • easily insulted/ bears grudges • appear cold and serious

16. Paranoid Personality Disorder Example • Undergraduate student/patient who followed

17. Schizoid Personality Disorder Theodore Kaczynski: Unabomber

18. Schizoid • indifferent to relationships • limited social range (some are hermits) • aloof, detached, called loners • no apparent need of friends, sex • solitary activities • seem to be missing the “human part”

19. Schizotypal • peculiar patterns of thinking and behaviour • perceptual and cognitive disturbances • magical thinking • not psychotic • perhaps a distant “cousin” of schizophrenia

20. Personality Disorder Clusters • Cluster Two: Dramatic-Emotional: • Behaviours are so dramatic, emotional, or erratic that it is almost impossible to have truly giving and satisfying relationships • More commonly diagnosed than other PD’s

21. The Dramatic-Emotional PD Group 1. Antisocial Personality Disorder (Dissocial) 2. Borderline Personality Disorder 3. Histrionic Personality Disorder 4. Narcissistic Personality Disorder

22. Antisocial Personality Disorder • pattern of irresponsibility, recklessness, impulsivity beginning in childhood or adolescence (e.g., lying, truancy) • adulthood: • criminal behaviour • little adherence to societal norms, • little anxiety • conflicts with others • callous/exploitive

23. Difficulties in establishing secure identity • Distrust • Impulsive and self-destructive behavior • Difficulty in controlling anger and other emotions

24. Narcissistic Personality Disorder • grandiose, sense of self-importance • lack of empathy • hyper-sensitive to criticism • exaggerate accomplishments/ abilities • special and unique • entitlement • below surface is fragile self-esteem

25. Armand Hammer • “There has never been anyone like me, and my likes will never be seen again.”

26. Armand Hammer - Again “The brilliance of my mind can only be described as dazzling. Even I am impressed by it.”

27. Histrionic Personality Disorder • excessive emotional displays/ dramatic behaviour • attention-seeking, victim stance • seek re-assurance, praise • shallow emotions, flamboyant, self-centred • very seductive, “life of the party”

29. Personality Disorder Clusters • Cluster Three: Anxious-Fearful: • Display anxiety and fear typically • Similar to anxiety and depressive disorders but no real connection

30. The Anxious-Fearful Group 1. Avoidant Personality Disorder 2. Dependent Personality Disorder 3. Obsessive-Compulsive Personality Disorder (Anankastic)

31. Avoidant Personality Disorder • over-riding sense of social discomfort • easily hurt by criticism • always need emotional support • occasionally try to socialize • so distressing they retreat into loneliness

32. Dependent Personality Disorder • submissive, clingy behaviour • fear of separation • easily hurt by criticism

33. Obsessive Compulsive Personality Disorder • excessive control and perfectionism • inflexible • preoccupied with trivial details • judgmental/moralistic • workaholic/ignore family members • often humourless

34. Focus on Borderline PD

35. Borderline Personality Disorder • marked instability of mood, relationships, self-image • intense, unstable relationships • uncertainty about sexuality • everything is “good” or “bad” • chronic feeling of “emptiness • recurrent threats of self-harm/ “slashers”

36. Single White Female (Jennifer Jason Leigh) or Fatal Attraction (Glen Close).

37. Good Depictions of BPD

38. Borderline Personality Disorder • Therapist “killers” (not really killers) • Very difficult to treat • Tend to be avoided by many clinicians • Takes lots of training and experience to treat effectively • Lots of turmoil in treatment

39. Borderline Personality Disorder: Four Core Elements • Difficulties in establishing secure self- identity • Distrust & Splitting • Impulsive and Self Destructive Behaviour • Difficulty in controlling anger and other emotions

40. Borderline Examples: From Therapist • First experience with BPD under my supervision

41. Identity Disturbance • In terms of identity disturbance, she relied heavily on a sort of reflected identity from others and saw herself as she believed others saw her. • With respect to her poor ego boundaries and the melding of her identity with my own, one particularly surprising thing she said to me was that she had googled my name on the internet and found out that I had won a presitious academic award. She said she felt really sad because she did not have an award herself.

42. Distrust and Splitting • She vascillated quite wildly between idealizing me (including telling me that she loved me and at times wanted us to sit together on the couch so I could hold her) and devaluing me (lots of anger in session, and a fairly caustic email that said "Ain't it so nice and easy. Tell you what M***, go out and get ourself abused, loose that charming smile of yours and come back and tell me who's mentally ill", which was followed shortly after by an apologetic one.)

43. Continued • It was difficult for me to predict from week to week whether she would tell me I was dirt  or idealized. She was a good example of someone who used splitting defenses where she saw other people (me in particular) in all good or all bad terms and made rapid shifts between these two positions.

44. Affective Instability • Affective instability (went along with the wild swings between this sort of coy, coquettish behavior and the pronounced anger in session), but also exhibited shallow affect and incongruent affect. • For example, she often smiled or giggled when she told me about her difficulties and began to ocassionally exhibit sadness in session by crying. However, a little later in therapy she told me that in fact the tears were fake and that she was using them because she felt closer to me when I responded to her tears.

45. More on Distrust • She had a long history of interpersonal problems and difficulty connecting with people. She was quite paranoid about what others thought of her and this was quite evident in her comments about her co-workers whom she felt were against her (and, frankly, she may have been right) and in her desire to see her chart in the hopes that it would finally reveal the intense dislike for her that she imagined I felt.

46. Termination: Always difficult • We spent about 2 months preparing for and discussing termination and it still went poorly. She was angry and her parting gift to me was a plant that contained a set of tiny clay pots (sort a decorative thing) partially submerged in the soil. She gave the clinic secretary the same thing, but she was careful to say "this one is for the secretary, and this one is for you", when I looked at the two later, the one that she gave me had the tiny clay pots smashed, while Geraldine's were intact. A final parting message.

47. Self-Destructive Behaviour • Drug abuse • Suicide threats • Lots of promiscuity

48. Classification Models with respect to PD • Classical Categorical Model: Used by DSM - - Views disorders as discrete syndromes (i.e., distinct boundaries between PD’s and homogeneous within the boundaries) • Consistent with traditional conception of medical disorders

49. Dimensional Assessment of Personality Pathology • W. John Livesley at the University of British Columbia • Dimensions of PD and their traits: • Emotional dysregulation • Dissocial behaviour • Inhibitedness • Compulsivity

50. Epidemiology • gender: similar prevalence rates overall • consistent differences across disorders • bias in diagnoses? • temporal stability • culture • Wide variations in cultural expectations