Personality Disorders

1. PersonalityDisorders Personality features versus Disorder Categorical versus Dimensional Approaches Overview of major disorders Cato Grønnerød PSY2600

2. Definitions • Personality • “The enduring patterns of thinking, feeling and reacting that define a person” • Personality Disorder • “An enduring pattern of inner experience and behavior 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

3. Definitions • Personality Disorder • Pattern of deviation must be evident in two or more of the following domains • Cognition • Emotional responses • Interpersonal functioning • Impulse control • Pattern must be inflexible and pervasive across a broad range of personal and social situations

4. Definitions • Personality Disorder • 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 or early adulthood • Clinical constructs used to • understand, describe and communicate about • the complex phenomena that result when • the personality system is not functioning optimally

5. Ways of Understanding • Categorical Classification • DSM-IV – Axis II Disorders • Cluster A: odd or eccentric behaviour • Paranoid, schizoid, schizotypal personalities • Cluster B: erratic, emotional and dramatic • Antisocial, borderline (unstable), histrionic and narcissistic personalities • Cluster C: anxiety and fearfulness • Avoidant, dependent and obsessive-compulsive personalities

6. Ways of Understanding • Categorical Classification • ICD-10 – F60: Specific Personality Disorders • PDM, MCMI-III: Sadistic, Masochistic, Depressive, Passive-Aggressive • 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 • Psychodynamic Diagnostic Manual (PDM)

7. Ways of Understanding 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

8. Aetiology • Genetic predisposition • Varies among PDs • Childhood experience • Attachment experience • Traumatic events • Family factors and dysfunction • Sociocultural and political forces • Variations between nations • More Antisocial PD in the US • Presentation of symptoms may vary

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

10. Cluster A: Paranoid • Pervasive distrust and suspicion of others • Argumentative, tense and humourless • Become preoccupied with their distrust in others, causing relational problems • Attributional style: blames other for everything that is wrong

11. Cluster A: Paranoid • Normal trait: Suspicious,sceptical • Comorbid: anxiety, psychosis, mood disorder

12. Cluster A: Schizoid • Social detachment/indifference • Limited emotional experience and expression • Strong fantasy life • Takes pleasure in few activities • Appears indifferent to praise or criticism • Modest genetic link to autism

13. Cluster A: Schizoid • Normal trait: Retiring, introvert • Subclinical: asocial

14. Cluster A: Schizotypal • Cognitive and perceptual distortions • Derealisation and depersonalization • Suspicion, magical thinking, illusions • Eccentric behaviour • Discomfort with close relationships • Not serious enough to warrant a schizophrenia diagnosis • Genetically related to schizophrenia

15. Cluster A: Schizotypal • Normal trait: Eccentric • Extreme: Schizophrenia?

16. Cluster B: Narcissistic • Grandiosity, inflated sense of self-importance • Need for attention, lack of empathy • Fragile, unstable self image

17. Cluster B: Narcissistic • Normal trait: Confident • Subclinical: Egoistic • Examples: Capote, American Beauty

18. Cluster B: Antisocial • Disregard for and violation of (the rights of) others • Includes sociopaths and psychopaths • Emotional detachment • Antisocial life style • Charming and even charismatic

19. Cluster B: Antisocial • Normal trait: Nonconforming • Subclinical: Grandiose, conning • Examples:Reservoir Dogs, Silence of the Lamb, Wall Street

20. Cluster B: Borderline • Instability of interpersonal relationships, self-image, emotions, and control over impulses • Frantic efforts to avoid real or imagined abandonment • “Borrowing” identity from others • High comorbidity with other disorders

21. Cluster B: Borderline • Normal trait: Capricious (NO: lunefull) • Extreme: biploar? • Example: Fatal Attraction

22. Cluster B: Histrionic/Dramatizing • Excessive emotionality and attention-seeking • Superficial charm, viewed as shallow • Demanding, inconsiderate and egocentric in relationships • Some overlap with Antisocial PD • Less severe form of Borderline PD?

23. Cluster B: Histrionic/Dramatizing • Normal trait: Sociable • Subclinical: affect ridden (NO: affektert) • Example: Being Julia

24. Cluster C: Avoidant • Social withdrawal • Feelings of inadequacy, low self-esteem • Hypersensitive to criticism, disapproval or rejection • Overlap with social phobia • Normal trait: shy • Subclinical: withdrawn

25. Cluster C: Dependent • Excessive need to be taken care of • Clinging and submissive behaviour • Relies on others for important decisions • Will often tolerate abuse • Subtypes • Attachment/abandonment • Dependency/incompetence • Normal trait: cooperative • Subclinical: attached

26. Cluster C: Obsessive compulsive • Preoccupation with orderliness, perfection and control at the expense of flexibility • Sticks to plans and rules to an extent that the original purpose of the activity is lost • Demands perfection from themselves and others • Very little overlap with OCD • Normal trait: conscientious • Subclinical: restricted

27. Treatment • Traditionally PDs considered very difficult to treat because of their pervasive, entrenched nature • Psychoanalysis/psychodynamic therapy • Esp. Borderline, Histrionic, Dependent, Narcissistic, etc. • Cognitive Behavioural Therapy • Medication

28. Antisocial Personality Disorder (APD) • More studied than any other personality disorder • Origins usually traced back to earlier periods in development (Conduct Disorder), • 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

29. Antisocial Personality Disorder (APD) • Psychopathy includes • ”Shallow, deceitful, unreliable and incapable of learning from emotional experience” • Seemingly lacking in basic emotions: shame, guilt, anxiety, remorse (conscience). • Increasing age can bring a change (lessening) in overt antisocial behaviors • Less obvious impulsivity, recklessness, social deviance • Some argue that the behaviors merely go ”underground”

30. APD: 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 • Behavioral and social reinforcers • Learned behavior resistant to change, modeling, consequence ”trap”, peer support

31. APD: Born bad? • Psychological factors • Inability to anticipate punishment • Lack of anxiety regarding punishment/negative consequences • Consequent participation in risk-taking, self-promoting behaviour with reduced ability to interpret (or pay attention to) nonverbal cues • Esp. fear, distress, anger, anxiety • Some people ”born bad”? • GSR, emotional responsiveness, empathy studies

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

33. Borderline Personality Disorder (BPD) • Often present due to other complaints • E.g. somatic, self-harm, anxiety, depression, abuse history; large degree of comorbidity • Initially conceptualized as the ”borderline” between neurosis and schizophrenia • Very poor sense of/integration of self leads to uncertainty about personal values, identity, worth and choices • = erratic, impulsive and self-damaging behavior

34. BPD: Cognitive/behavioural features • Fear abandonment and crave relationships • 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 behavior • E.g. sexual activity, substance abuse, eating • 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.

35. BPD: 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 and trauma

36. BPD: Treatment • Perceived as very difficult clients • Therapeutic relationship is key but threatening to person with BPD • Attrition is high, and therapy is made very challenging • Psychoanalysis uses the transference relationship to interpret and integrate • Ego-supportive therapy