Personality Disorders

1. Personality Disorders Pertemuan ke-8

2. Personality Disorders (PD) • Longstanding, pervasive, inflexible patterns of behavior and inner experience • Coded on Axis II • Patterns present in at least 2 areas: • Cognition • Emotions • Relationships • Impulse control • Patterns are not the effects of substance abuse nor general medical condition • Patterns are not necessarily comorbid with Axis I disorders. Even though comorbidity with Axis I is more often than not • More severe symptoms and poorer outcome when comorbid • 50+% of people diagnosed with a personality disorder meet criteria for another personality disorder • More than two-thirds meet lifetime criteria for an Axis I disorder (Lenzenwenger et al., 2007)

3. Personality Disorders (PD) • Patterns are not necessarily comorbid with Axis I disorders. Even though comorbidity with Axis I is more often than not • More severe symptoms and poorer outcome when comorbid • 50+% of people diagnosed with a personality disorder meet criteria for another personality disorder • More than two-thirds meet lifetime criteria for an Axis I disorder (Lenzenwenger et al., 2007) • Initial onset: adolescence or young adulthood • Nature of symptoms: ego-syntonic and alloplastic  “problems are not with me, they are with people”

4. Key Features of the DSM-IV-TR Personality Disorders

5. Rates of DSM-IV Personality Disorders in the Community and in Treatment Settings

6. Classifying Personality Disorders • DSM-IV-TR categorical approach • Classifies in 3 clusters: • Cluster A Odd/Eccentric • Cluster B Dramatic/Erratic • Cluster C Anxious/Fearful • Diagnostic reliability • Initially poor; improved since DSM-III • Test-retest reliability (diagnostic stability) • ½ of those initially diagnosed with PD did not receive same diagnosis 1 year later (Shea et al., 2002) • Gender bias • Certain diagnoses applied more often to men, others to women

7. Dimensional Approach: Five-Factor Model • Five-factor model (McCrae & Costa, 1990) • Neuroticism, extraversion/introversion, openness to experience, agreeableness/antagonism, and conscientiousness • Five factors are heritable • Personality traits form a continuum • Individuals with PDs endorse the extremes • Dimensional approach involves rating each individual on the five factors • Avoids applying a categorical label which may not completely fit

8. Dimensional Approach: Five-Factor Model • Most personality disorders are characterized by high neuroticism and antagonism. • High extraversion tied to histrionic and narcissistic disorders (involve dramatic behavior) • Low extraversion linked to disorders that involve social isolation, such as schizoid, schizotypal, and avoidant personality disorders

9. Table 12.4 Sample Items from the Revised NEO Personality Inventory assessing Five-Factor Model

10. Suspicious Secretive; reluctant to confide in others Expects to be mistreated/exploited Vigilant for hints of abuse Blames others when things go wrong Easily feel threatened Questions loyalty No hallucinations or full blown delusions More common in men than women Cormorbidity high for Schizotypal Borderline Avoidant Odd/Eccentric (A) Cluster: Paranoid Personality Disorder

11. Avoids close interpersonal relationships Few close friends Aloof & distant Loner Likes solitary activities Rarely report strong emotions Little interest in sex Experiences anhedonia Comorbidity high for Schizotypal Avoidant Paranoid Odd/Eccentric (A) Cluster: Schizoid Personality Disorder

12. Odd/Eccentric Cluster: Schizotypal Personality Disorder • Interpersonal difficulties similar to schizoid • Odd beliefs or magical thinking • Superstitious • Telepathic • Illusions • Feels the presence of a force or person not actually present. • Odd/eccentric behavior or appearance • Wears strange clothes • Talks to self • Ideas of reference

13. Etiology of the PDS in Odd/Eccentric Cluster • Highly heritable • Links to schizophrenia • Relatives of individuals with schizophrenia at greater risk for schizotypal • Individuals with schizotypal PD show problems similar to those found in schizophrenia • Cognitive and neuropsychological deficits • Enlarged ventricles • Less temporal gray matter

14. Dramatic/Erratic (B) Cluster: Borderline Personality Disorder (BPD) • Impulsive, self-damaging behaviors • Unstable, stormy, intense relationships • Emotional reactivity • Frantic efforts to avoid abandonment • Unstable sense of self • Anger control problems • Chronic feelings of emptiness • Recurrent suicidal gestures • Transient psychotic or dissociative symptoms

15. Dramatic/Erratic Cluster: Borderline Personality Disorder (BPD) • Onset during adolescence or early adulthood • Prognosis poor within 10 years of diagnosis • Later in life, most no longer meet diagnostic criteria (Paris, 2002) • Cormorbidity high with PTSD, MDD, substance-related, and eating disorders • Comorbidity predicts symptoms 6 years later • Suicide rates high • Self-mutilation also a problem

16. Etiology of Borderline Personality Disorder (BPD): Neurobiological factors • Genetic component • Highly heritable • May play a role in impulsivity and emotional dysregulation • Decreased functioning of serotonin system • Frontal lobe dysfunction • Increased activation of amygdala

17. Etiology of Borderline Personality Disorder (BPD): Social Environmental Factors • Parental separation • Verbal and emotional abuse during childhood • Object-Relations Theory (Kernberg, 1985) • Introjection • Object-representation • BPD involves disturbed object representations, possibly due to inconsistent parenting • Conflict between introjected values and current needs • Splitting

18. Etiology of Borderline Personality Disorder (BPD): Social Environmental Factors • Linehan’s Diathesis-Stress Theory • Individuals with BPD have difficulty controlling their emotions • Possible biological diathesis • Family invalidates or discounts emotional experiences and expression • Interaction between extreme emotional reactivity and invalidating family → BPD

19. Linehan’s Diathesis-Stress Theory of BPD

20. Dramatic/Erratic (B) Cluster:Histrionic Personality Disorder • Formerly known as hysterical personality • Overly dramatic and attention seeking behavior • Craves attention • Loves to be in the spotlight • Emotionally shallow despite strong displays of emotion • Easily influenced by others • Overly concerned with physical attractiveness • May be sexually provocative and seductive

21. Etiology ofHistrionic Personality Disorder • Psychoanalytic theory • Emotional displays and seductiveness result from parental seductiveness • Father’s sexual attention towards daughter • Conflicting family attitudes towards sexuality • Negative attitudes towards sex while simultaneously acknowledging titillation • Theory untested

23. Dramatic/Erratic (B) Cluster:Narcissistic Personality Disorder • Grandiose view of self • Preoccupied with fantasies of success • Self-centered • Demands constant attention and adulation • Feelings of entitlement and arrogance • Envious of others • Little concern for needs and well being of others • Lacks empathy • Sensitive to criticism • Seeks out high-status partners

24. Etiology ofNarcissistic Personality Disorder • Kohut’s Self-Psychology Model • Characteristics mask low self-esteem • In childhood, narcissist valued as a means to increase parent’s own self-esteem • Not valued for his or her own competency and self worth • People with high levels of narcissism report cold parents who overemphasized child’s achievement • Social cognitive model • Narcissist has low self esteem • Sense of self depends on “winning” • Interpersonal relationships are a way to bolster sagging self esteem rather than increase closeness to others • Lab studies reveal cognitive biases that maintain narcissism

25. Dramatic/Erratic Cluster:Antisocial Personality Disorder • Pervasive disregard for the rights of others since age 15 • Lies • Aggression • Impulsiveness • Violates the law • Irresponsible • Lacks remorse • Conduct disorder before age 15 • Truancy, running away, lying, theft, arson, destruction of property • Substance abuse most common comorbid disorder • Culture plays a role • More common in US than Scotland • More common among lower SES groups

26. Psychopathy (sociopathy) (Cleckley, 1941) Predates DSM-IV-TR category Focuses on internal thoughts and feelings Poverty of emotion Negative emotions Lacks shame and anxiety Positive emotions Used to manipulate others Impulsivity Behave irresponsibly for thrills Psychopathy Checklist – revised (Hare, 2008) Interpersonal symptoms Pathological lying, manipulativeness, and charm Affective symptoms Lack of remorse and empathy, shallow affect Onset before age 15 not required. Dramatic/Erratic (B) Cluster:Antisocial Personality Disorder

27. Etiology ofAntisocial Personality Disorder • Genetics • Antisocial behavior heritable • Estimates as high as .96 • Genetic risk for APD, psychopathy, conduct disorder, and substance abuse related. • Family environment • Lack of warmth, negativity, and parental inconsistency predict APD • Poverty, exposure to violence • Family environment interacts with genetics

28. Emotion and psychopathy Lack of fear or anxiety Low baseline levels of skin conductance Skin conductance reactivity at age 3 predicted APD at age 28 (Glenn et al., 2007) Makes it difficult for them to avoid behavior that leads to punishment Also show less SCR to other’s distress Lack empathy Etiology ofAntisocial Personality Disorder Figure 12.3

29. Anxious/Fearful (C) Cluster: Avoidant Personality Disorder • Avoids interpersonal situations • Fears criticism or rejection • Hesitant about involvement with others • Wants to be certain of acceptance • Restrained and inhibited in interpersonal situations • Fears ridicule • Feelings of inadequacy • Avoids taking risks or trying new activities • Doesn’t want to risk embarrassment • High comorbidity with major depression and generalized social phobia • Related toJapanese syndrome called taijin kyofusho (taijin means “interpersonal” and kyofusho means “fear”).

30. Anxious/Fearful (C) Cluster: Dependent Personality Disorder • Lack of self confidence • Excessive reliance on others • Intense need to be cared for • Uncomfortable when alone • Feels helpless to care for self • Behavior focused on maintaining relationships • Quickly initiates new relationship if current one fails • Prevalence higher in India and Japan than US

31. Anxious/Fearful Cluster: Obsessive-Compulsive Personality Disorder • A perfectionist • Preoccupied with rules, details, & organization • Rigid and inflexible • Overly focused on work • Little time for leisure, family, & friends • Tendency to hoard • Difficulty discarding worthless items • Reluctant to delegate • Moral inflexibility • Does not have the obsessions/compulsions of OCD • Most frequently comorbid with Avoidant PD

32. Etiology of Personality Disorders in the Anxious/Fearful Cluster • Not much available research • Avoidant PD • Overly protective and authoritarian parents • Obsessive-Compulsive PD • Fixation at anal stage of development (Freud) • More recent theorists • Cope with fears of losing control by overcompensation • Dependent PD • Disruption of early childhood attachment by death, neglect, rejection, or overprotectiveness

33. Treatment of Personality Disorders • Axis I disorder usually drives individual to treatment • Presence of PD, reduces success of treatment for Axis I • Medications • Avoidant PD • Antianxiety medication or antidepressants • Schizotypal PD • Antipsychotic medications • Psychotherapy • Psychodynamic • Seek awareness of early childhood problem • Cognitive behavioral • Break personality disorder down into discrete problems • Treat sensitivity to criticism with social skills training

34. Maladaptive Cognitions Associated with PD

35. Treatment of Borderline PD • Difficult to treat • Interpersonal problems play out in therapy • Attempts to manipulate therapist • Object Relations Therapy (Kernberg et al., 1985) • Dialectical Behavioral Therapy (Linehan, 1987) • Acceptance and empathy plus CBT, emotion regulation, and social skills • Schema-Focused Cognitive Therapy for BPD • Identify maladaptive assumptions that underlie cognitions • Medications • Antidepressants • Antipsychotics • Olanzapine

36. Treatment of Psychopathy • Intensive psychoanalytic therapy • Cognitive behavioral therapy • Issue remains • Are therapy successes ‘faking good’ or genuinely improved?