Personality Disorders and Impulse Control Disorders

1. Personality Disorders and Impulse Control Disorders http://www.banow.ca/images/Gallery/Misc/Lampshade.jpg http://www.fixingyourwebsite.com/assets/flasher.gif

2. Personality disorders • Characteristics • Inflexible and maladaptive behaviors • Social difficulties, subjective distress, or dysfunction • 5-15% of admissions • 10-15% lifetime prevalence

3. Gender Distribution • Men • More paranoid, OCPD and antisocial • Women • More borderline, dependent, and histrionic

4. Diagnostic Challenges • Recorded on Axis II of DSM • Categorical approach e/o • Extreme versions of normal personality traits • Dimensional approach • Concerns • Number of factors • Are personality quirks disorders • High degree of comorbidity • Cross over to Axis I

5. Etiological and treatment considerations • Use – FFM of personality and see disorders as extremes of personality traits • Neuroticism • Extraversion • Openness • Agreeableness • Conscientiousness http://www.researchcommunication.com/Pics/BIGFIVEWHEEL2.gif

6. Causes • Genetics • Some correlates • Some evidence of differences in neuro-activity • Some evidence of neuro-structural differences • Environment • Family • Society • Damage to brain

7. Treatment • Varied approaches • Cognitive behavioral treatments • Drug treatments • Clinicians are somewhat pessimistic about the prognosis • Help is often not sought • Behavior rarely results in involuntary treatment • Research to verify efficacy of treatments is needed

8. Three clusters of personality disorders • Odd or eccentric • Paranoid, schizoid, schizotypal • Dramatic, emotional, or erratic • Histrionic, narcissistic, antisocial, borderline • Anxious or fearful • Avoidant, dependent, obsessive-compulsive

9. Odd or Eccentric

10. Paranoid • Suspiciousness, lack of emotion, hypersensitivity • Higher among males • Tend to externalize blame and guilt • Not inclined to seek out treatment • Psychoanalytic view suggests projection: self onto others • Cognitive-behavioral therapy aimed at reducing paranoid tendencies

11. Schizoid • Desired social isolation • Defect in the capacity to form social relationships • Does not involve abnormal ideas or perceptions • Treatment focuses on facilitating the development of intimate relationships by fostering the building of networking

12. Schizotypal • Oddities of thinking • Ideas of reference • Magical thinking • Social isolation • Communication symptoms • Vague, digressive, tangential, overly elaborate • Not incoherent • Schizophrenic like symptoms • Does correlate with onset of schizophrenia • Do not lose contact with reality • Treatment focuses on teaching clients to evaluate their environment objectively

13. Dramatic, Emotional, or Erratic

14. Histrionic • Self-dramatizing, attention seeking, exaggerated emotions • Higher among women • Superficially charming, • Viewed by others as insincere and shallow • Egocentric • Flirtatious, seductive, yet non-committed • Strong correlations with APD • May be related to Inconsistent patterns of reinforcement by parents • Treatment should focus on defensiveness of client

15. Narcissistic • Exaggerated self-importance • Denial and devaluation of others to prop up self-concept • More prevalent in males • More critical of others than self • Entitlement • Fragile self-esteem and deep seated fear of failure • View dependency as dangerous, relies on self for evaluation • Histrionics depend on others for aproval

16. Antisocial Personality Disorder • No guilt • Little loyalty • Predominantly male • Crossover between • Antisocial personality disorder (behaviors) • Those who score high on psychopathy (personality traits) • Criminality • Criminality aspect of APD spurs research

17. Borderline Personality Disorder • Fluctuations in mood, angry outbursts, identity problems, emptiness, capriciousness • Most commonly diagnosed personality disorder • More common in women • Lack of purposefulness • Etiological theories • Psychodynamic: others are either all good or all bad • Social learning: poor coping skills • Cognitive: mistaken assumptions and attributions • Treatment focuses on motivational issues, skill training, supportive acceptance • High attrition rates • Effectiveness of treatments is difficult to determine

18. Anxious or Fearful • Avoidant • Desires attention from others but sensitive to disapproval: fear of appearing foolish • Strong similarity to social phobia • Fantasies of intimacy • Depression and inadequacy • Some evidence of hypersensitivity to sensory stimuli • Behavioral treatments show some success

19. Dependent • Characteristics • Unwilling to assume responsibility • Low self confidence • Let others decide • Subordinate their needs to the needs of others • Even in the face of abuse • Fundamental beliefs • See selves as inadequate • Solution is to depend on another • More common 7% (culture) • More women • High rate of comorbidity with mood disorders • Associated with overprotective, authoritarian parenting styles • More responsive to therapy than other PDs • Caution regarding drug treatments and therapist/client relationship http://www.nomoremrniceguy.com/selfassess.php

20. OCPD • Characteristics • Perfectionism • No expression of warmth • Demanding of others (controlling) • Detail oriented • Rigidity • Indecisive • Impaired functioning at work or in relationships • Twice as common in men • Somewhat responsive to cognitive behavioral therapy

21. Antisocial Personality Disorders • Historical Views • Moral insanity, moral imbecility, moral defect, psychopathic inferiority • Current diagnosis is less oriented on “morals”

22. Cleckley’s Characteristics • Superficial charm • Intelligence • Shallow emotions • Little plan of order • Failure to learn from experience • Unreliability • Dishonesty

23. Three Central Themes • Inadequately motivated antisocial behaviror • Absence of a conscience and a sense of responsibility to others • Emotional poverty

24. DSM-IV-TR on APD • Characteristics • Over 18 • History of truancy/delinquency before age 15 (conduct disorder • Egocentricity • Impulsivity • Antisocial behavior • Prevalence • 3% of population • Predominately men • Primary type lacks guilt, secondary type some remorse

25. Explanations of APD • Psychodynamic • Faulty superego development • Lack of parental identification: Oedipal Complex • Family and socialization perspectives • Divorce and socioeconomic indicators weak predictors • Poor parental involvement and prenatal hostility good predictors • Antisocial father that is manipulative is good predictor

26. Genetic influences • 5 times more common among first – degree biologic relatives of males • MS twins’ concordance rates higher than DZ twins • Greater likelihood among adoptees with APD biologic parents, still some environmental factors may be involved

27. Central nervous system abnormality • Diminshed brain wave activity • Similar to the activity of the brain of a child • Limited evidence

28. Autonomic nervous system abnormalities • Inability to learn from experiences • Reduced ability to learn from shocks: less galvanic skin response to potential shock • Absence of anxiety, • Thrill- seeking behaviors

29. Fearlessness or lack of anxiety • Failure to learn avoidance because of under-arousal • Fewer inhibitions about engaging in antisocial behavior

30. Arousal, sensation seeking, and behavioral perspectives • Big thrill seekers • Constructive: test pilot • Destructive: ASP • Type and certainty of punishment • Ineffective • Physical, social, material • Effective • Loss of memory, certain punishment http://www.unixgods.org/~tilo/images/NZL/bungee.jumper.jpg

31. Treatment of APD • Poorly motivated to change themselves • Behavior controls • Behavioral and cognitive approaches are not very effective • Prevention: since treatments are not very effective, work to redirect youth with APD tendencies http://www.dc.state.fl.us/oth/timeline/images/1987/bundy.jpg http://www.sencis.com/gjoulin/Pix/drlecter2.JPG

32. Disorders of Impulse Control • Characteristics • Failure to resist temptations • Tension before committing act • Release after committing act • Guilt may or may not be felt

33. Types of Impulse Control Disorders • Intermittent explosive disorder: episodes of uncontrolled aggression • Kleptomania: failure to resist impulses to steal • Pathological gambling: inability to resist gambling • More common in males • Manic when winning, depressive after • Cognitive treatment focuses on “chance” aspect of gambling

34. Types of Impulse Control Disorders (Cont.) • Pyromania: deliberate fire setting • Pleasure in observing the fires • Hostile and impulsive • More common in males • Trichotillomania: urge to pull out one’s own hair • More common in women • 1% of college students report current or past history http://www.goodgulf.demon.co.uk/CCDE.FIRE.JPG http://www.bbc.co.uk/science/humanbody/mind/selfcontrol/morescience_selfcontrol.shtml

35. Etiology and treatment of ICD • Little information on causes • Similar to OCD, substance abuse, sexual deviance • Psychoanalytic theory stresses sexual symbolism • Behaviorists stress variable reinforcement schedule • Lesieur • Impulse control problems on a continuum • Impulse control disease • Treatments often include behavioral and cognitive methods