Chapter 13 Personality Disorders

1. Chapter 13 Personality Disorders Ch 13

2. Personality Disorders • Personality Disorders refer to long-standing, pervasive and inflexible patterns of behavior • Depart from cultural expectations • Impair social and occupational functioning • Cause emotional distress • Personality disorders are coded on Axis II of the DSM • Personality disorders can be a co-morbid condition for an Axis I disorder Ch 13.1

3. Personality Disorders: Facts and Statistics • Prevalence of Personality Disorders • About 0.5% to 2.5% of the general population • Rates are higher in inpatient and outpatient settings • Origins and Course of Personality Disorders • Thought to begin in childhood • Tend to run a chronic course if untreated • Co-Morbidity Rates are High • Gender Distribution and Gender Bias in Diagnosis • Gender bias exists in the diagnosis of personality disorders • Such bias may be a result of criterion or assessment gender bias

4. Personality Disorder Clusters • Personality disorders fall into three general clusters: • Persons in cluster A seem odd or eccentric • Paranoid, schizoid, schizotypal • Persons in cluster B seem dramatic, emotional or erratic • Antisocial, borderline, histrionic, narcissistic • Persons in cluster C appear as anxious or fearful • Avoidant, dependent, obsessive-compulsive Ch 13.2

5. Odd/Eccentric Cluster • Paranoid personality disorder (PD) involves suspicion of others, hostility, jealousy • No hallucinations and no full-blown delusions are present in paranoid PD • Paranoid PD occurs more frequently in men than in women • Lifetime prevalence is about 2 percent (D&N, 9th edition, p. 412) Ch 13.3

6. Odd/Eccentric Cluster • Schizoid personality disorder (PD) involves • Reduced social relations and few friends • Reduced sexual desire and few pleasurable activities • Indifference to praise or criticism • Lonely life style • Prevalence of schizoid PD is less than 2 percent and occurs more commonly in men than women Ch 13.4

7. Odd/Eccentric Cluster • Schizotypal personality disorder (PD) involves • An attenuated form of schizophrenia • Odd beliefs and magical thinking • Recurrent illusions (things not present) • Ideas of reference (hidden meaning) • Behavior and appearance is eccentric • Prevalence of schizotypal PD is less than 1 percent. Ch 13.5

8. Etiology of the Odd/Eccentric Cluster • These disorders are linked to schizophrenia and may represent a less severe form of the disorder • Schizophrenia has clear genetic determinants • Family studies reveal that relatives of schizophrenic patients are at increased risk for developing schizotypal PD as well as paranoid PD • No clear pattern for schizoid PD • Additional similarities for Schizotypal PD • Have cognitive and neuropsychological problems similar to those found in individuals with schizophrenia. • Have enlarged ventricles and less temporal lobe gray matter. Ch 13.6

9. Dramatic/Erratic Cluster • Borderline personality disorder (PD) involves • Impulsivity (gambling, spending, sexual sprees) • Instability in relationships, mood and self-image • Borderline PD persons are argumentative and difficult to live with • Prevalence of Borderline PD is about 1 percent and occurs more commonly in women than men • Linehan’s diathesis-stress theory • Difficulty controlling emotions (biological diathesis) • Raised in “invalidating” family environment Ch 13.7

10. Figure 13.1 Linehan’s Diathesis-Stress theory: Etiology of borderline personality disorder • Emotional dysregulation in child (diathesis) and a failure to • validate the child’s feelings by the parents (stress) leads to a • vicious cycle. • The emotional dysregulation may be inadvertently • reinforced by parents if it becomes one of the only times the • child receives parental attention.

11. The Cluster B Personality Disorders • Borderline Personality Disorder • Unstable Relationships • Avoid Abandonment • Poor Self-Image • Mood Swings, Feel Empty • Impulsivity • Substance Abuse, Sex, Suicidality

12. The Cluster B Personality Disorders • Borderline Personality Disorder • Causes • Runs in Families • Connection With Mood Disorders • Contribution of Early Abuse

13. The Cluster B Personality Disorders • Borderline Personality Disorder • Treatment • Few Controlled Studies • Dialectical Behavior Therapy (DBT) • Medications • Antidepressants , Mood Stabilizers, Antipsychotics

14. Dramatic/Erratic Cluster • Histrionic personality disorder (PD) involves • People who are overly dramatic and attention seeking • People who exhibit emotional displays but are emotionally shallow • People who are self-centered and overly concerned about physical attractiveness • Prevalence of histrionic PD is about 2 percent and occurs slightly more commonly in women than men Ch 13.8

15. Dramatic/Erratic Cluster • Narcissistic personality disorder (PD) involves • A grandiose view of the person’s own importance • A strong sense of entitlement • A lack of empathy for others • Prevalence of narcissistic PD is less than 1 percent and this disorder co-occurs with borderline PD Ch 13.9

16. Dramatic/Erratic Cluster • Antisocial personality disorder (PD) involves • The presence of conduct disorder before the age of fifteen • Conduct disorder includes truancy, lying, theft, arson, running away from home and destruction of property • The continuation of these behaviors into adulthood • Prevalence of antisocial PD is about 3% of men and 1 % of women Ch 13.10

17. Etiology of Antisocial PD • Family issues may play a role in the development of antisocial PD • Lack of affection • Severe parental rejection • Inconsistent (or no) discipline • Twin studies show a greater concordance for antisocial PD in MZ twins relative to DZ twins • Adoption studies (e.g., Cadoret et al., 1995) • Adverse adoptive environment may be the stressor triggering the ASPD biological diathesis • Psychopaths • Have reduced gray matter in frontal lobes • Perform more poorly on tests of frontal lobe functioning • These findings are supportive of a key role for impulsivity in psychopathy Ch 13.11

18. Cluster B: Antisocial Personality Disorder Figure 12.2 Barlow/Durand, 3rd. Edition Overlap and lack of overlap among antisocial personality disorder, psychopathy, and criminality

19. Cluster B: Antisocial Personality Disorder (cont.) Figure 12.3 Barlow/Durand, 3rd. Edition Lifetime course of criminal behavior in psychopaths and non-psychopaths

20. Figure 13.2 Skin-conductance responses of psychopathic and non-psychopathic men. Psychopathic men's response to distress stimuli is evidence of a lack of empathy Fig 13.2

21. The Cluster B Personality Disorders • Antisocial Personality Disorder • Neurobiological Influences • Underarousal Hypothesis • Low Corical Arousal or “Tuning it Out”? • Fearlessness Hypothesis • Fail to Show Normal Fear • Fail to Avoid Punishment

22. The Cluster B Personality Disorders • Antisocial Personality Disorder • Treatment • Many Do Not Seek Treatment • Poor Prognosis • Focus on Prevention

23. Anxious/Fearful Cluster • Avoidant personality disorder (PD) involves • People who are fearful in social situations • People who are keenly sensitive to criticism, rejection or disapproval • People whose lives and job are restricted by their fear of negative interactions • Prevalence of Avoidant PD is about 5 percent and this disorder is co-morbid with dependent PD and borderline PD Ch 13.12

24. The Cluster C Personality Disorders • Avoidant Personality Disorder • Treatment • Several Well Controlled Studies • Target Anxiety and Social Skills • Treatment Similar to Social Phobia • Systematic Desensitization • Behavioral Rehearsal

25. Anxious/Fearful Cluster • Dependent personality disorder (PD) involves • A lack of self confidence • A lack of a sense of autonomy • A view that others are powerful while they are weak • Prevalence of Dependent PD is about 1.5 percent and occurs slightly more commonly in women than men • May be related to insecure “anxious” attachment Ch 13.13

26. Anxious/Fearful Cluster • Obsessive-Compulsive personality disorder (PD) involves a person who • Is a perfectionist, but who does not complete projects • Is a ‘control freak” who must have their own way • Prevalence of Obsessive-Compulsive PD is about 1 percent and this disorder is co-morbid with avoidant PD Ch 13.14

27. The Nature of Personality Disorders • Dimensional vs. Categorical • Problem of Degree? • Problem of Kind? • DSM-IV • Categorical View • Axis II • Ten Types

28. Dimensional Approach to Personality Disorders • Five-Factor Model (McRae & Costa, 1990) • Neuroticism / emotional stability • Extroversion/introversion • Openness to experience • Agreeableness/antagonism • Conscientiousness • Relationship of PDs to FFM (Widiger & Costa, 1994) • Advantages of dimensional model • Handles the comorbidity problem • Makes a link between normal and abnormal personality • Supported by behavior-genetic and statistical techniques

29. Therapies for Personality Disorders • Therapists treating PD patients are concerned about co-morbid Axis I disorders • Therapy modalities include: • Antianxiety or antidepressant drugs • Psychodynamic therapy aims to change the person’s understanding of the childhood problems that underlie the PD • Behavioral and cognitive therapy focuses on specific symptoms and issues (e.g. social skills) • Overall therapeutic goal: change the “disorder’ into a “style”, except for ASPD (D&N, p.431) • Recent meta-analysis (Salekin, 2002) shows promising results with CBT for younger psychopaths. Ch 13.15