The Personality Disorders

1. The Personality Disorders Troubling, mysterious, untreatable?

2. Over-arching characteristics • The 3 P’s • Pervasive – their problems cut across settings • Persistent – difficulties don’t go away or wax and wane, last for decades • Pathological – behaviors are destructive and maladaptive

3. More characteristics • Tremendous problems with relationships hot and then ice-cold don’t last long few, if any, friends • Identity issues – don’t form a stable, positive sense of self

4. Worse yet • Lots of them • Notoriously hard to treat • Great burden on society crime family issues general chaos

5. Classification – DSM5 • Recognizes 10 types divided into three clusters • Odd/eccentric – Schizoid, Schizotypal, Paranoid • Erratic/emotional/dramatic – Histrionic, Antisocial, Borderline, Narcissistic • Fearful/anxious – Avoidant, Obsessive-compulsive, Dependent

6. Comorbidity • Many have other disorders – 50%! • The presence of a pd has a great influence on symptoms, social functioning and treatment options • More severe symptoms • More frequent in treatment settings

7. Reliability • Since DSMIII commenced listing specific behavioral criteria, interrater reliability has greatly improved, typically >.8 • At least if structured interviews are used • Exception – schizotypal • Gender expectations

8. Self reports as basis? • Huge reliability concern • By definition, pd involves an unstable self-view • Can they accurately describe their behaviors? • Another perspective is crucial, though rarely obtained

9. An alternative DSM5 model • Described in appendix to DSM5 • Reduces disorders • Heavy reliance on the Big 5 personality traits • Provides more detail • Stability • Better predictions • Aids research

10. Odd/Eccentric Cluster • Characterized by weird, bizarre behaviors • Somewhat similar to schiz, but less severe • Paranoid • Schizoid • Schizotypal • Lots of comorbidity between disorders

11. Paranoid • Suspicion • Great effect on all types of relationships • Expectation of betrayal • Attend to and exaggerate threats & ill will • Hostility • Not as severe or as profound as Schiz – lack hallucinations & full-blown delusions

12. Schizoid • Don’t want or maintain relationships • Lifeless, bland • Little joy or fun • No interest in sex • Indifferent to other people, no warm feelings for others

13. Schizotypal – “Schiz lite” • Strange, unusual thoughts and behaviors • Magical thinking – think they can read minds • Ideas of reference – everything is about them • Illusions – strange, impossible sensory perceptions • Strange appearance • Flat or out of place affect • Paranoia • Limited social contacts

14. Cause? • Highly heritable • Beyond that, much uncertainty • Schizotypal – high genetic overlap w/ schiz • Also share same cognitive and neuro functioning issues w/ Schiz, just milder • Find enlarged ventricles and decreased grey matter like schiz

15. Dramatic/erratic • Extremely variable behavior • Excessive, unrealistic self-esteem • Emotional outbursts • Rule-breaking • Antisocial – no care or concern for others • Histrionic – drama kings and queens • Borderline – rollercoaster relations, fragile self image • Narcissistic – I’m perfect, you’re snot

16. Antisocial vs. Psychopathy • Related but distinct • Antisocial w/in DSM, Psychopathy not • Both involve flagrant disregard for rules/ laws

17. Antisocial • Long-standing pattern of behavior flouting the rights of others • Aggressive, impulsive, callous • DSM5 requires Conduct Disorder diagnosis • All sorts of nasty behaviors – fighting, stealing, lying, never planning ahead, impulsivity, failing to repay debts, temper outbursts • No remorse

18. Demographics • More men than women • Some seem to outgrow • More severe among young • ¾ comorbid • Substance abuse most common • ¾ of convicted felons meet criteria

19. Psychopathy • Came before antisocial • Cleckly (1976)’s classic – The Mask of Sanity • Focused on thoughts and feelings (or lack of) • Lack emotions, good or bad • No sense of shame • Any exhibited emotion just an act • No plan, just acting on whim or impulse

20. Differences in DSM 5 • DSM 5 requires onset before 15, many psychopaths didn’t • Antisocial often (80%) score low on Psychopathy Checklist

21. Causes • Lots of research and theories • Two limitations though, 1) findings include both psychopaths and antisocials = despite differences in diagnoses 2) samples drawn from convicts., some escape criminal penalties

22. Genetic factors • Follows biological children of APDs and substance abuse • Heritability estimates range from 40-50% • More aggression, more heritability • More thorough (reliable) studies, higher heritability • These run parallel with substance abuse • But very difficult to disentangle genetic, familial & behavioral influences

23. Social factors • Initial socialization from family key to building respect for others • Parenting red flags - high negativity, low warmth, inconsistency • Especially crucial if there is genetic risk • Also, poverty and exposure to violence predict even w/out genetic risk

24. Nothing scares them • Seem unable to profit from experience, even punishment • Don’t fear arrest, prison, social stigma • The opposite of anxiety disorders, don’t develop conditioned fear responses • Amygdala doesn’t get activated by stimuli which should trigger CRs • CC fail

25. Can’t resist • Impulsivity predicts • If they are pursuing something they want, they don’t respond to consequences • However, if they are forced to pause before responding, they do show learning

26. They just don’t feel others pain • Focus on lack of empathy – being able to walk in another’s shoes • Can’t even recognize other’s fear • Don’t respond to victimization scenes • Lack of arousal of ventromedial prefrontal cortex in brain-imaging studies

27. Borderline • Wild, inconsistent relationships • Rollercoaster moods • Rapidly changing, searingly hot to freezing cold • Typical behaviors – promiscuity, gambling, over-spending, substance abuse

28. Who am I? • Fail to develop a clear and coherent sense of self • Basic aspects of identity can change instantaneously • Career plans, hobbies, values, loyalties can shift from one moment to the next • Correspondingly, great fear of abandonment, rejection, emptiness

29. Self-harm, even suicide • Many engage in self-destructive behaviors • 2/3’s engage in self-mutilation at some point • 15% attempt and 7.5 % succeed in taking life • But these tendencies tend to decrease as they mature

30. Duration, comorbidity • Thankfully, many lose the diagnosis over 10-15 years, most by 40 • Many suffer from: 1) other pds 2) mood disorders 3) substance abuse • More conditions, longer duration

31. The many causes of Borderline • Neurobiological factors high, 60% heritability lower serotonin function hyper amygdala reactivity explains erratic emotions poor function of prefrontal cortex explains impulsivity also poor control of amygdala

32. Social factors – child abuse • Compared to other pds, Borderlines show more parental separation, verbal and emotional abuse • Similar to Dissociative Identity Disorder • On a continuum DID?

33. Diathesis- Stress model • If you have genetic difficulties in controlling your emotions (diathesis) and are raised in an invalidating environment (stress), you are likely to develop Borderline • Invaladating – no one pays attention to you or credits your expression of emotion • Abuse is even worse

34. Dynamics of DS • Interactive effect • Some children are difficult and demanding from the start • Children punish or ignore emotional outbursts • Child suppresses emotions • Child boils over, drawing attention (reinforcement) • Ongoing and escalating

35. Histrionic • Excessive need for attention • Overly dramatic behavior • Provocative dress • Seductive, theatrical behavior • Emotional volatility • Easily persuaded • Strange, shallow language • Exaggerated intimacy in relationships

36. Cause • Psychodynamic theory poses a father’s seductive behavior as cause for daughter’s actions • Parents ambivalent views towards sex cause child to approach but then withdraw • unverified

37. Narcissistic • Grandiose, unjustified opinion of achievements and talents • Demand attention and admiration • So special, only the truly gifted can understand them • Entitled, exploitative • Arrogant, envious • No empathy

38. Causes of Narcissisitic • Often comorbid with Borderline • Two distinct theories • Self-psychology – studies find parental coldness & excessive praise • Parents set this up by exaggerating child’s abilities to bolster their own self-esteem • Child feels shame with any failure

39. Social-cognitive model • Two basic premises 1)Narcissists desperately seek to prove their specialness due to precarious self-esteem, and 2) dealings with other people serve to bolster self-esteem, not warmth or fun

40. Support for social-cognitive model • In controlled settings, they exaggerate attractiveness and achievement • They falsely attribute success to special abilities rather than good fortune • Hyper sensitive to feedback because they need constant praise • Thirst to prove their specialness, rather than get close to people alienates others

41. The Anxious/Fearful Cluster • Preoccupied and functionally impaired by worry and distress • Avoidant – so terrified of social humiliation, they keep away from others • Dependent – need someone else for everything • Obsessive-Compulsive – rigid, inflexible, demanding perfection

42. Avoidant • Afraid of criticism, rejection and negativity, so they avoid social contact • Especially jobs or situations which will expose them to such • Very restrained face-to-face • Deep seated conviction that they are worthless and incompetent

43. Social Anxiety, & other connections • Often found together • On a continuum, with Avoidant just more severe? • Plenty of overlap w/ symptoms • Both similar to taijinkyofusho • Often found with MDD (80%!), borderline, and schizotypal pds • And, of course, alcohol abuse

44. Cause? • No one knows • Victims don’t want to discuss it • Fair heritability - ~30% • Maybe, through childhood modeling, they associated any social contact with humiliation and ridicule

45. Dependent • Desperate need for someone to take care of them and make decisions for them • No self-confidence • Grave fear of being alone • Willing to sacrifice anything for support • When one “guardian” leaves, another must be found

46. Other aspects • DSM might be wrong in requiring helpless passivity – can work to keep relationships • Found more frequently in eastern cultures like India and Japan where some passivity is expected • Found w/ many of PDs, mood and anxiety mds • Bulimia also

47. Cause of Dependent? • Parenting – authoritarian style – which prevents self efficacy, might be responsible • Also, maybe it arises from an attachment failure, infant didn’t get enough affection and attention

48. Obsessive-Compulsive • Wrapped up completely in details, rules, schedules, etc. to the point of impairing performance • Trouble with decisions and time-management • No fun, all work • “Control freaks” • Troubled relationships • Inflexible morally

49. Distinguishing from OCD • Not prey to obsessions and compulsions • Can appear together • But more likely found with Avoidant

50. Obsessive – compulsive cause? • Not much research • Twin studies produced differing heritability estimates • Some genetic overlap with OCD found • Especially with traits like Perfectionism