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Chapter 9_Personality Disorders %28compass%29

Chapter 9_Personality Disorders %28compass%29 - CHAPTER...

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Unformatted text preview: CHAPTER NINE CHAPTER Personality Disorders Personality Disorders • What are Personality Disorders? • Classification of Personality Disorders Categorical vs. Dimensional models • Features of Axis II Implications for Assessment • Specific Disorders: Cluster A Cluster B Cluster Cluster C Personality • Most mental disorders are Most defined in terms of states: episodes of symptoms episodes • Personality refers to enduring Personality traits that are fairly stable over traits fairly time or make a person who s/he is s/he What are Personality Disorders? • Enduring patterns of perceiving, Enduring relating to & thinking about the environment and oneself… environment – That are inflexible and pervasive across That inflexible pervasive a broad range of personal and social situations situations – That cause significant distress or That significant impairment in social, occupational, or impairment other important areas of functioning other • This pattern is stable and its onset This can be traced back to adolescence or Personality Disorders • What are Personality Disorders? • Classification of Personality Disorders Categorical vs. Dimensional models • Features of Axis II Implications for Assessment • Specific Disorders: Cluster A Cluster B Cluster Cluster C Categorical Classification of PDs: DSM-IV • Advantages – Familiar & convenient Familiar because it used by a majority of clinicians majority – Ease in communication – “Yes/No” format is Yes/No” consistent with clinical diagnoses (e.g., whether to go on meds or not, get hospitalized or not) hospitalized Categorical Classification of PDs: DSM-IV • Disadvantages – Arbitrary boundary between normal Arbitrary and abnormal personality and – Low inter-rater reliability – Very high comorbidity & high overlap Very among symptom criteria among – Not based on a theoretical model Not – Ambiguity occurs regarding the Ambiguity presence vs. absence of a PD presence – Most commonly diagnosed PD is PDNOS Dimensional Models of Personality • DSM-V is probably going to incorporate DSM-V a 6 Factor Dimensional model Factor Dimensional – All individuals have some degree of these All traits, but those with PDs have maladaptive levels levels Personality Tr a i t • Looks at a continuum of normal to Looks continuum abnormal personality Personality Disorder Normal Traits Five-Factor Model: “OCEAN” • Openness: willingness to consider and explore unfamiliar ideas, feelings, and activities activities • Conscientiousness: persistence in persistence pursuit of goals; organization; dependability dependability • Extraversion: interest in interacting with other people; positive emotions with • Agreeableness: willingness to willingness cooperate and empathize with others cooperate • Neuroticism: expression of negative expression emotions, emotional stability emotions, Dimensional Model • Advantages Advantages – Theoretical basis for these 5 factors Theoretical –Retention of information • Leads to less stereotyping • Both maladaptive and adaptive traits are Both highlighted highlighted – Resolution of a variety of categorical classification dilemmas • Avoids arbitrary assignment cut-off points Avoids • Addresses problems with comorbidity in the Categorical Model Categorical Dimensional Model • Disadvantages – Less familiar Less – Lacks clinical application • No explicit guidance how to assess – May be too complex • What kind of therapy or medication do What you recommend based on trait scores? you – Disagreement exists about Disagreement preference of which dimensional model to use model Personality Disorders • What are Personality Disorders? • Classification of Personality Disorders Categorical vs. Dimensional models • Features of Axis II Implications for Assessment • Specific Disorders: Cluster A Cluster B Cluster Cluster C Features of Axis II • Previously assumed to have a Previously different etiology than Axis I different – Not always true – Example of child abuse • More stable than Axis I disorders More or more resistant to treatment or – However, some Axis I disorders are However, also very stable also – And… some PDs are quite treatable Features of Axis II • Most other mental disorders are egoMost egodystonic – Personal distress, discomfort with one’s Personal symptoms symptoms – Disorder is something outside the norm Disorder outside • Personality disorders: ego-syntonic Personality ego-syntonic – The personality traits do not bother the person The not • The person may, however, experience a lot of The distress or impairment as a result of these traits distress • Traits = not distressing / Consequences = Traits distressing distressing Assessment of PDs • The ego-syntonic nature of The personality disorders can make them difficult to assess using traditional measures using • Others who have regular Others contact with an individual might be better judges of how that person’s behavior affects those around him/her affects Culture and Personality • Culture plays a large role in Culture determining what is appropriate or appropriate acceptable at a given time and place acceptable • Cultures may differ in: Degree of emotional expression expression Individualism vs. Individualism collectivism collectivism Personality Disorders • What are Personality Disorders? • Classification of Personality Disorders Categorical vs. Dimensional models • Features of Axis II Implications for Assessment • Specific Disorders: Cluster A Cluster B Cluster Cluster C Clusters of Personality Disorders • Cluster A: Odd and eccentric Paranoid PD Paranoid Schizoid PD Schizoid Schizotypal PD Schizotypal • Cluster B: Emotional, dramatic, or Cluster erratic erratic Narcissistic PD Antisocial PD Antisocial Histrionic PD Histrionic Borderline PD Borderline • Cluster C: Anxious or fearful Avoidant PD Avoidant Dependent PD Dependent Cluster A Personality Disorders • Characterized by odd, eccentric, Characterized and/or socially isolated behavior and/or – – – Paranoid PD Schizoid PD Schizotypal PD • Considered to be on the Considered less severe end of the spectrum of schizophrenia-related disorders disorders Paranoid Personality Disorder • A pervasive distrust and suspiciousness pervasive of others such that their motives are interpreted as malevolent interpreted – – – Reluctance to confide in others Persistently holding grudges Finds threatening hidden Finds meaning in benign comments meaning – Doubt the loyalty and trustworthiness of Doubt others others • Requires 4 of the 7 possible criteria Schizoid Personality Disorder • A pervasive pattern of detachment from social pervasive relationships and a restricted range of expression of emotions in interpersonal settings emotions - Neither desires nor enjoys close relationships relationships - Prefers solitary activities - Takes pleasure in few, if any, activities Takes - Is indifferent to praise and criticism Is - Lacks close friends other than 1st degree relatives degree - Shows emotional coldness, detachment, or flat affect detachment, • Requires 4 of the 7 possible criteria Schizotypal Personality Disorder • A pervasive pattern of interpersonal and social deficits marked by pervasive acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior behavior Cognitive-perceptual symptoms: – – – Ideas of reference Magical thinking Bodily illusions Interpersonal symptoms: – – – Suspiciousness/paranoid thinking Lack of close friends/confidants Social anxiety Disorganized symptoms: – Odd/eccentric behavior – Odd thinking and speech Epidemiology of Cluster A PDs Paranoid PD Schizoid PD Schizotypal PD 3% 2-3% More common in men Slightly more common in men 0.5 - 4.5% (among those seeking treatment, rates are higher: 2-30%) Some studies suggest it is slightly more common in men • Half of those with Schizoid PD also meet Half criteria for Schizotypal PD criteria Etiology of Cluster A PDs • Neurological Factors – Risk factors are similar to those in Risk schizophrenia (e.g., genetics and prenatal environment) environment) • Psychological Factors – Cognitive deficits, such as impaired Cognitive theory of mind in schizotypal PD: theory difficulty recognizing emotions in others difficulty • Social Factors – Childhood abuse/neglect, which leads to Childhood insecure attachment styles insecure Treatment of Cluster A PDs • Cluster A PDS are characterized by a Cluster reluctance to seek treatment reluctance • Treating Paranoid PD Treating Paranoid – Establish a trusting atmosphere – Challenge irrational thoughts – Clinician should try to be optimistic • Treating Schizoid PD Treating Schizoid – Focus on social skills • Treating Schizotypal PD Treating Schizotypal – Antipsychotic medications (at lower doses) – Similar to schizophrenia, use CBT, social skills Similar training, family therapy training, Compare and Contrast “Cluster A” PDs • Work in small groups – Will present on one section • What are key similarities? Key differences? • Based on your results, and using the textbook as a guide, what conclusions might you draw regarding overlap and difference of these disorders? Cluster B Personality Disorders • Characterized by overly dramatic, flamboyant, emotional, and/or erratic behavior behavior – – – – Antisocial PD Antisocial Borderline PD Histrionic PD Narcissistic PD Antisocial Personality Disorder • A pervasive pattern of disregard for and violation of pervasive the rights of others the – – – – – Repeatedly performing acts that are ground for arrest Deceitfulness Impulsivity Consistent irresponsibility Lack of remorse • Requires: – Age 18 or older – Evidence of Conduct Disorder by age 15 Antisocial Personality Disorder • Prevalence – General Population: 3% – Forensic Populations: 60% – About 3x more common among About men men • Course – Tends to have a chronic Tends course: delinquent behavior in childhood (e.g., conduct disorder) continues into adulthood adulthood – Middle age (around their 40s), Middle they “burn out” they Antisocial PD vs. Psychopathy • Psychopathy – The diagnosis of antisocial PD The focuses more on observable behaviors behaviors – In contrast, psychopathy In emphasizes both (1) personality traits (e.g., emotional deficits) and and (2) behaviors (e.g., socially deviant behaviors) behaviors) – May or may not engage in criminal May behavior behavior Criteria for Psychopathy Personality Traits QuickTime ™ and a decompressor are needed to see this picture. Socially Deviant Behaviors Antisocial PD vs. Psychopathy • Earlier conceptualizations of ASPD Earlier had a greater overlap with psychopathy psychopathy • However, due to DSM-IV’s focus However, on observable behaviors, ASPD is a distinct concept from psychopathy (there is still some overlap) overlap) • Psychopathy is a better predictor Psychopathy of recidivism than ASPD of Overlap between ASPD, Psychopathy, & Criminality 38% of people with ASPD are Psychopaths ASPD Psychopaths Criminals 50-85% of criminals have ASPD 15% of criminals are Psychopaths Special Topic: Does Psychopathy look the same in women as it does in men? • The gender difference in psychopathy The (and Antisocial PD) may be partly due to limitations of assessments limitations • Two Issues Created by Two Socialization Socialization – Socialization of Clinicians – Socialization of Clients • Physical aggression might be more common in men common • Women may be more likely to Women engage in relational aggression relational Antisocial PD & Psychopathy: Etiology Psychological Factors • Learning Deficits: – Hypothesis 1: Emotional deficits Hypothesis Emotional They lack fear & anxiety, so they can ignore the effects of punishment – Hypothesis 2: Impulsivity Hypothesis Impulsivity They have trouble shifting their attention to consider the negative consequences of their behavior consequences • These etiological factors apply to These people with psychopathic traits psychopathic (with or without ASPD) (with Antisocial PD & Psychopathy: Etiology Neurological Factors • Abnormal brain structure & function Abnormal – Evidence of smaller and hypoactive frontal lobes (i.e., Evidence hypo the area which governs EF processes) the – Deficits in EF: inhibition, planning • Genetically predisposed Genetically temperament temperament – High reward dependence: being High reward being highly motivated by the possibility of reward reward – Low harm avoidance: not being Low harm not strongly motivated by the possibility of punishment punishment Antisocial PD: Etiology Neurological Factors Cadoret et al. (1995) Study Cadoret 50 Criminal Behavior among Male Adoptees Had biological parents without AS PD 40 30 20 Had biological parents with AS PD 10 0 In adoptive family with no AS PD In adoptive family with AS PD Antisocial PD & Psychopathy: Etiology Social Factors • Inconsistent discipline (or complete lack of discipline) often seen in the prior family history of ASPD men – Kids with a “difficult temperament” are Kids especially irritating to parents especially – Parents respond inappropriately by giving Parents up or becoming severe in punishment up • Person selects friends who share Person antisocial interests and problems (‘skinheads’, gangs) (‘skinheads’, Antisocial PD & Psychopathy: Treatment • Little research on treatments – Effectiveness depends on whether or not the individual has Effectiveness psychopathy psychopathy • Psychopathy has poor prognosis – Personality traits interfere with therapeutic alliance – Feasibility of managing behavior vs. treating personality Feasibility traits traits • Treatments for individuals with antisocial PD who Treatments are not psychopathic are more successful not – Most likely to respond if they have a comorbid anxiety Most disorder (which indicates that they are not psychopathic) disorder – Treatment that targets behavior change and behavior Treatment behavior control (through CBT) is more effective than treatment that control targets empathy training targets Borderline Personality Disorder • A pervasive pattern of chaotic interpersonal relationships, pervasive unstable self-image, affective instability, and marked impulsivity unstable – – – – – – – Frantic efforts to avoid abandonment Recurrent suicidal behavior or self-mutilation Marked reactivity of mood Inappropriate, intense anger Chronic feelings of emptiness Impulsivity (e.g., binge eating, spending, sex) Chaotic interpersonal relationships that waver between extreme idealization and devaluation between • Requires 5 of the 9 possible criteria Borderline PD: Epidemiology • Prevalence – General population: 2% – Treatment-seeking populations: • Inpatient: 20% • Outpatient: 10% • According to the DSM, 75% of those diagnosed are According women women – Link to antisocial personality disorder: clinicians more likely to diagnose men with ASPD and women with BPD likely – Why? What are the similarities between the disorders? • High rate of suicide: 10% die by suicide Borderline PD: Etiology Psychological Factors • Core feature of the disorder is emotion Core dysregulation, meaning that they: dysregulation meaning – Have a lower threshold for emotional activation (i.e., their Have emotions shift quickly) emotions – Experience emotions intensely – Experience slow return to emotional baseline (i.e., it Experience takes them longer to self-soothe and come back down) takes • Engage in dangerous behaviors to self-soothe – – – – Operant conditioning: Operant Substance abuse Violence toward others these behaviors are negatively reinforcing Binging because they temporarily relieve temporarily Self-Injurious behavior emotional pain emotional Borderline PD: Etiology Neurological Factors • Differences in brain activity – Hyperactivity of the amygdala • Brain structure that generates strong emotions – Hypoactivity of the frontal lobes • Brain structure that allows for self-control of emotional Brain expression, as well as focusing attention and problemexpression, solving • Low serotonin levels – Associated with depression & Associated impulsivity impulsivity – Abnormal serotonin levels found more often among women with the disorder disorder Borderline PD: Etiology Social Factors • Invalidating Environments – In childhood, family members and friends In invalidated the child’s emotional experience (e.g., “You’re too sensitive) (e.g., – Generates a learning history wherein the Generates person views themselves as bad and punishable punishable • Childhood abuse – Especially sexual trauma Borderline PD: Treatment • Among the most challenging personality Among disorder to treat disorder – Medications • Used to treat comorbid Axis I disorders • May help with symptoms of emotional instability and impulsivity instability – Dialectical Behavior Therapy (DBT) • Most well-validated treatment for BPD Borderline PD: Treatment Dialectical Behavior Therapy (Linehan, 1993) • DBT falls under the umbrella of CBT, with an added DBT emphasis on Zen- and meditation-related components emphasis – Developed for use with clients with BPD, particularly those with Developed parasuicidal behavior parasuicidal • What is “dialectics?” – Refers to synthesizing opposing elements. For example, accepting Refers your current situation while at the same time recognizing that in order to feel better, change must occur order • Involves both individual therapy, as well as a skills training Involves group group – Skills training group involves 4 basic modules: • • • • Core Mindfulness Interpersonal Effectiveness Emotion Dysregulation Distress Tolerance Histrionic Personality Disorder • A pervasive pattern of excessive emotionality and pervasive attention seeking attention – – – – – – Inappropriately seductive or provocative behavior Uncomfortable in situations in which s/he is not the Uncomfortable center of attention center Impressionistic style of speech Suggestible, easily influenced by others Rapidly shifting and shallow expression of emotions emotions Considers relationships more intimate Considers than they really are than • Requires 5 of the 8 possible criteria Histrionic Personality Disorder • Prevalence – General Population: 2-3% – Treatment-Seeking Population: 10-15% • Etiology – Retrospective reports suggests they feel they did not get enough attention from parents – High in reward dependence: sensitive to negative High reward evaluation • Histrionic PD vs. Borderline PD vs. Antisocial PD? • Treatment – CBT or psychodynamic therapy – Get bored easily and continue to see other people as the primary Get problem problem Narcissistic Personality Disorder • A pervasive pattern of pervasive grandiosity, need for admiration, and lack of empathy and – Preoccupied with fantasies – Associates only with high-status Associates others others – Has a strong sense of entitlement – Is interpersonally exploitative – Is envious and thinks others are Is envious of him/her envious • Requires 5 out of 9 possible Requires Special Topic: Dimensions of Narcissism • Grandiose Narcissism – Characterized by inflated selfesteem, exhibitionism • Vulnerable Narcissism – Characterized by feelings of Characterized insecurity insecurity – Associated with depression and Associated reactive aggression reactive – More likely to show up for More treatment voluntarily treatment • DSM Classification for NPD puts DSM these dimensions together these Narcissistic Personality Disorder • Prevalence: <1% • According to the DSM, between According 50-75% of those diagnosed are male male • Hypothesized to have the same Hypothesized psychological and social factors that contribute to histrionic PD that Cluster C Personality Disorders • Characterized by anxious, fearful, or avoidant behaviors behaviors – – – Avoidant PD Dependent PD Obsessive-Compulsive PD Avoidant Personality Disorder • A pervasive pattern of social inhibition, feelings of pervasive inadequacy, and hypersensitivity to negative evaluation evaluation – Avoids interpersonal job activities Avoids – Unwilling to get involved with others unless certain of being liked others – Is preoccupied with criticism and rejection in social situations rejection – Views self as socially inept, personally unappealing, or inferior to others to – Won’t try new things in case they are embarrassing are Avoidant Personality Disorder: Epidemiology • Prevalence – – – – General Population: 0.5-2.5% Treatment-Seeking Population: 10% No consistent gender difference Early adulthood onset • Of all PDs, they report the lowest quality of life • Controversy over distinction Controversy between Avoidant PD and Generalized Social Phobia Generalized – Estimate that 43% of people diagnosed with social phobia are also diagnosed Is APD redundant with Generalized Social Phobia? • Social Phobia: an intense fear of public humiliation or embarrassment, together with the avoidance of social situations likely to cause this fear. May be specific to performances or generalized to most social situations. social • Avoidance PD: A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation evaluation • How are they How similar? similar? • How do they How Avoidant PD: Treatment • Treatment is similar to social phobia – Cognitive Behavioral Group Therapy • Exposure is built-in • Studies suggest it is the besttreated of the personality disorders Dependent Personality Disorder • A pervasive and excessive need to be taken care of that pervasive leads to submissive and clinging behavior and fears of separation separation – Has difficulty making everyday and major decisions major – Won’t express disagreement because of Won’t fear of loss or support or approval – Fails to initiate projects on own due to Fails lack of self-confidence – Feels uncomfortable or helpless when alone due to exaggerated fears of being alone unable to take care of him/herself – Urgently seeks another relationship when one ends when Dependent Personality Disorder: Epidemiology & Treatment • Prevalence – General Population: Less than 1% • More common among women in the general More population population • No gender difference in treatment-seeking No populations populations • Treatment – Clinicians must be cautious of not becoming Clinicians a “nurturer” and furthering problems “nurturer” – Treatments using homework will present a Treatments challenge challenge Obsessive-Compulsive PD • A pervasive pattern of preoccupation with orderliness, pervasive perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency expense – Preoccupied with rules, lists, details – Neglects family/friends because of devotion to work – Is overconscientious about rules, Is ethics, values ethics, – Cannot discard worthless objects – Hoards money in case of disaster – Refuses to delegate tasks to others • Requires 4 of the 8 possible criteria Obsessive-Compulsive PD: Epidemiology & Treatment • Prevalence – General Population: 1-8% – Treatment-Seeking: 3-10% – 2x more common in men • Don’t confuse with OCD – Most with OCPD do not have OCD Most not – Those with OCPD are not distressed by their traits/behaviors by • Treatment – – Often addresses their need for control Uses relaxation techniques and distraction Do Cluster C PDs belong together? • Although they all have feature of fear or anxiety in common, there Although is little diagnostic overlap between the criteria for the 3 disorders is • Neurological factors – The anxiety that characterizes the 3 disorders indicates that The the amygdala might be involved (but this is just speculation) the • Psychological factors – Temperament: high in harm avoidance – All 3 disorders have an avoidance component to them: All avoidance • Avoidant PD: patients avoid social situations • Dependent PD: patients avoid making decisions/having patients responsibilities responsibilities • Obsessive-compulsive PD: patients avoid making mistakes/ patients experiencing strong emotions experiencing • Research on how these disorders both do and do not overlap is Research how still sorely needed still ...
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