Personality Disorders Personality defined Stable, consistent

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Personality Disorders
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Personality defined

• Stable, consistent pattern of behavior
• across situations

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1960-70's Michel vs. Epstein

• Mischel-
• situations override concept of personality
• we cannot measure consistent acting
• Epstein-
• consistency in behavior is found looking across
  time
• the construct is there, we need to work on
  measurement

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Personality in the 1990's

• DSM-IV (APA, 1994)
• Trait- " enduring pattern of perceiving,
  relating to, and thinking about the environment
  and oneself that is exhibited in a wide range of
  social and personal contexts."
• Trait approach
• dimensional
• Big 5 (OCEAN)

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PERSONALITY DISORDERS

• Stable patterns of behavior that are
• maladaptive
• DSM-IV (APA, 1994)
• " enduring pattern of inner experience and
  behavior that deviates markedly from the
  expectation s of the individual's culture, is
  pervasive and inflexible, has an onset in
  adolescence or early adulthood is stable over
  time, and leads to distress or impairment."

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PD DSM-IV Criteria

• A. Enduring pattern of inner experience
  behavior 2 of
• 1. Cognition (i.e., perception)
• 2. Affectivity (i.e., range, intensity,
  lability, appropriateness)
• 3. Interpersonal functioning
• 4. Impulse control
• Inflexible and pervasive across situations
• Clinically sig. distress/impairment
• D. Stable, long-term, since at least early
• adulthood
• E. Not manifestation or consequence of other
  disorder or substance

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Classification system of DSM-IV

• A. Axis II PD and MR
• 1. 3 clusters
• a. Cluster A Odd and Eccentric PD
• b. Cluster B Dramatic, Emotional, Erratic
  PD
• c. Cluster C Anxious and Fearful PD
• 2. Prevalence
• lifetime 10 - 13
• (1 out of every 8-10 people)

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Cluster A Odd Eccentric PD

• 1. PARANOID PD
• Distrust, suspicious of others
• Interpret other's motives as malevolent
• Other's out to take advantage
• Doubt loyalties of friends
• Easily angered by perceived insults
• Resent others who have more
• Conceptualize self as faultless
• Secretive, jealous, rigid, unforgiving, hostile,
  sarcastic

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Cluster A Odd Eccentric PD

• 2. SCHIZOID PD (detached)
• Detachment from social relationships
• Restricted range of affect
• Form stable, but not close relationships
• Work settings- low social interaction
• Reclusive

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Cluster A Odd Eccentric PD

• SCHIZOTYPAL PD (social deficit)
• Intense discomfort in IP relationships
• Cognitive/perceptual distortions
• (reality testing intact)
• Eccentric behavior
• Loners, anxious, socially isolated

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Cluster B Dramatic, Emotional, Erratic PD

• 1. ANTISOCIAL PD (vs. Asocial)
• Disregard/violate rights of others
• Evidence of CD lt 15 years old
• Deceitfulness
• Impulsivity- disregard consequences
• Irritability
• Aggressiveness
• Disregard safety
• Irresponsible
• Lack remorse
• Failure to conform to social norms

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Cluster B Dramatic, Emotional, Erratic PD

• 2. BORDERLINE PD
• Instable relationships
• Instable self-image
• Instable affect
• Impulsive
• Fluctuating mood (snap!)
• Self-destructive acts
• Fear of abandonment

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Cluster B Dramatic, Emotional, Erratic PD

• 3. HISTRIONIC PD
• Excessive emotionality
• Attention seeking
• Dramatic
• Overreactive
• Impressionable
• Shallowness

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Cluster B Dramatic, Emotional, Erratic PD

• 4. NARCISSISTIC PD
• Grandiosity- sense of superiority
• Need for admiration- entitlement
• Lack empathy- self-centered

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Cluster C Anxious Fearful PD

• 1. AVOIDANT PD
• Soc. inhibition - avoid IP relationships
• Feelings of inadequacy
• Hypersensitivity to negative eval.
• Excessive worry about embarrassment
• Fear rejection
• Extreme social anxiety

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Cluster C Anxious Fearful PD

• 2. DEPENDENT PD
• Excessive need to be taken care of
• Submissive (clingy)
• Fear separation
• Reluctant to disagree
• Rely on others to make decisions

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Cluster C Anxious Fearful PD

• 3. Obsessive-Compulsive PD
• Preoccupation with details, rules, lists,
  organization, and schedules
• Perfectionistic
• High need for mental and IP control at the
  expense of efficiency, flexibility, openness
• Rigid, stubborn, controlled, controlling
• Devoted to work to detriment of leisure and
  friendships

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Issues in Classification

• 1. Interrater Reliability
• 2. Test - Retest Reliability (temporal)
• 3. Prototype
• 4. Dimensional vs. Categorical

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Problems with categorical diagnosis

• 1. Not stable over time
• 2. Individuals with different
• characteristics receive same diagnosis
• 3. Individuals with same characteristics
• receive different diagnosis
• 4. No clear boundary with normality
• 5. Most individuals diagnosed multiple,
• mixed, or atypical
• 6. Only fair agreement across methods

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Etiology

• Biological Factors (Siever Davis, 1991)
• 1. Cognitive/ Perceptual organization
• Sz spectrum
• 2. Impulsivity/ Aggression
• - ASPD and Borderline
• 3. Affective Instability
• - Histrionic and Borderline
• 4. Anxiety/ Inhibition
• - Avoidant, Dependent, ObComp

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Etiology

• B. Psychosocial Factors
• 1. Object Relations Theory
• Psychodynamic theory examining early parental
  relationships in development of personality and
  IP
• 2. Attachment Theory
• Emphasis on quality of relationship between child
  and primary caregiver

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Etiology

• C. Biopsychosocial Model
• Biological vulnerabilities and strengths interact
  with the psychosocial environment to create
  personality (and characteristic manner of
  interacting with others)

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GENETIC MATERIAL

• Strengths
• tendency to ponder and plan
• tendency toward moderate affect
• perceptually organized
• moderate arousal

• Weaknesses
• tendency to attack
• tendency to be flat, or dramatic
• perceptually disorganized
• low or high arousal

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PSYCHOSOCIAL ENVIRONMENT

• Chance - war zone, rape, geographically isolated
• Selected by individual - excitement, security
• Created by individual - manipulate, non-reactive
• Others seeking individual- exciting, predictable

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Pharmacotherapy

• Mostly Borderline PD
• Neuroleptics, antidepressants,
• lithium, benzodiazepines, and others
• Appears useful in specific facets only,
• not in the complex of symptoms

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Psychodynamic Psychotherapy

• Mostly Narcissistic and Borderline (Kernberg,
  1993)
• Clear rules and boundaries
• Active therapist
• Tolerate patient's deep sadness and hostility
• Help patient see connections between actions and
  feelings
• Discourage self-destructive behavior through
  confrontation
• Set limit on patient's dangerous, risk-taking
  behavior
• Emphasis on therapeutic alliance, more than on
  the past
• Alert to counter - transference

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Interpersonal Psychotherapy

• Develop collaborative therapeutic alliance
• Gain understanding to one's destructive
  interaction patterns
• Decide to give up destructive patterns, AND deal
  with consequential emotions (sadness, fear, etc.)
• more adaptive IP behavior

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Cognitive Therapy

• Assume errors in thought ? problems
• Work to discover cognitive distortions
• Replace maladaptive thoughts with more realistic
  and adaptive thoughts

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Behavior Therapy

• e.g. Social Skills Training
• Graduated exposure techniques
• match Tx to characteristics (e.g., anxiety,
  trust, independent action)
• e.g. Dialectical Behavior Therapy (Linehan, 1993)
• Group Individual Therapy
• Group Therapy- social skills, boundary setting,
  calmly coping with conflict
• Individual Therapy- address maladaptive dynamics
  (e.g., threat of suicide) and emotion modulation