Chapter 12 Personality Disorders. Personality Disorders: An Overview Enduring and pervasive...

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Chapter 12

Personality Disorders

Personality Disorders: An Overview

Enduring and pervasive predispositions Perceiving Relating Thinking

Inflexible and maladaptive Distress Impairment

Coded on Axis II

Personality Disorders

10 specific personality disorders Several under review for DSM-V

3 clusters

High comorbidity with Axis I disorders Poorer prognosis

Therapist reactions Countertransference

Categorical vs. Dimensional Views “Kind” vs. “Degree”

DSM is categorical Reifies concepts Less flexible Loss of individual information Sometimes arbitrary

Five factor model of personality (“Big Five”) Openness to experience Conscientiousness Extraversion Agreeableness Emotional stability

DSM Personality Disorder Clusters

Cluster A Odd or eccentric Paranoid, schizoid, schizotypal

Cluster B Dramatic, emotional, erratic Antisocial, borderline, histrionic, narcissistic

Cluster C Fearful or anxious Avoidant, dependent, obsessive-compulsive

Personality Disorders: Facts and Statistics

Prevalence = 0.5 - 2.5%, may be closer to 10% Outpatient = 2 - 10% Inpatient = 10 – 30%

Origins and Course Begin in childhood Chronic course High comorbidity

Personality Disorders: Gender Differences

Differences in diagnostic rates Borderline (75% female)

Clinician bias Assessment bias

Measures Criterion bias

Histrionic = extreme “stereotypical female” No “macho” disorder

Personality Disorders: Gender Differences

Personality Disorders Under Study

Individual disorders Sadistic Self-defeating

Categories of disorders Depressive Negativistic

Passive aggressive

Cluster A: Paranoid Personality Disorder

Clinical Description Mistrust and suspicion

Pervasive Unjustified

Few meaningful relationships Volatile Tense Sensitive to criticism

Causes Possible relationship to schizophrenia Possible role of early experience

Trauma Abuse Learning

“World is dangerous”

Treatment Unlikely to seek on own

Crisis Focus on developing trust Cognitive therapy

Assumptions Negative beliefs

No empirically-supported treatments

Cluster A: Schizoid Personality Disorder

Clinical Description Appear to neither enjoy nor desire relationships

Limited range of emotions Appear cold, detached

Appear unaffected by praise, criticism Unable or unwilling to express emotion

No thought disorder

Causes Limited research Precursor: childhood shyness

Possibly related to: Abuse/neglect Autism Dopamine

Treatment Unlikely to seek on own

Crisis Focus on relationships Social skills therapy

Empathy training Role playing Social network building

No empirically-supported treatments

Cluster A: Schizotypal Personality Disorder

Clinical Description Psychotic-like symptoms

Magical thinking Ideas of reference Illusions

Odd and/or unusual Behavior Appearance

Socially isolated Highly suspicious

Causes Schizophrenia phenotype?

Lack full biological or environmental contributions

Preserved frontal lobes

Cognitive impairments Left hemisphere? More generalized?

Treatment Options Treatment of comorbid depression Multidimensional approach

Social skill training Antipsychotic medications Community treatment

Cluster B: Antisocial Personality Disorder

Clinical Description Noncompliance with social norms “Social Predators”

Violate rights of others Irresponsible Impulsive Deceitful

Lack a conscience, empathy, and remorse

Nature of psychopathy Glibness/superficial charm Grandiose sense of self-worth Proneness to boredom/need for stimulation Pathological lying Conning/manipulative Lack of remorse

Overlap with ASPD, criminality Intelligence

Developmental considerations Early histories of behavioral problems

Conduct disorder

Families history of: Inconsistent parental discipline Variable support Criminality Violence

Causes of Antisocial Personality

Gene-environment interaction Genetic predisposition Environmental triggers

Arousal hypotheses Underarousal Fearlessness

Gray’s model of brain functioning Behavioral inhibition system (BIS)

Low Reward system (REW)

High Fight/flight system (F/F)

Interactive, integrative model

Genetic vulnerability Neurotransmitters

Environmental factors Family stress Reinforcement of antisocial behaviors Alienation from good role models Poor occupational/social function

Antisocial Personality Disorder

Treatment Unlikely to seek on own High recidivism Incarceration

Early intervention Parent training

Prevention Rewards for pro-social behaviors Skills training Improve social competence

Cluster B: Borderline Personality Disorder

Clinical Description Patterns of instability

Labile, intense moods Turbulent relationships

Impulsivity Fear of abandonment Very poor self-image Self-mutilation Suicidal gestures

Comorbid disorders Depression – 24-74%

Suicide – 6% Bipolar – 4-20% Substance abuse – 67% Eating disorders

25% of bulimics have BPD

Causes Genetic/biological components

Serotonin Frontolimbic circuit

Cognitive biases

Early childhood experience Neglect Trauma Abuse

Treatment Highly likely to seek treatment Antidepressant medications Dialectical behavior therapy

Reduce “interfering” behaviors Self-harm Treatment Quality of life

Outcomes Demonstrated efficacy Cortical activation changes

Cluster B: Histrionic Personality Disorder

Clinical Description Overly dramatic Sensational Sexually provocative Impulsive Attention-seeking Appearance-focused Impressionistic Vague, superficial speech Common diagnosis in females

Causes Little research Links with antisocial personality

Sex-typed alternative expression?

Treatment Problematic interpersonal behaviors

Attention seeking Long-term consequences of behavior

Little empirical support

Cluster B: Narcissistic Personality Disorder

Clinical Description Exaggerated and unreasonable sense of self-importance Require attention Lack sensitivity and compassion Sensitive to criticism Envious Arrogant

Causes Deficits in early childhood learning

Altruism Empathy

Sociological view Increased individual focus “Me generation”

Treatment focuses on: Grandiosity Lack of empathy Hypersensitivity to evaluation Co-occurring depression

Little empirical support

Cluster C: Avoidant Personality Disorder

Clinical Description Extreme sensitivity to opinions Avoid most relationships Interpersonally anxious Fearful of rejection

Causes Sub-schizophrenia disorder?

Difficult temperament Early parental rejection

Interpersonal isolation and conflict

Treatment Similar to social phobia Increase social skills Reduce anxiety Importance of therapeutic alliance

Moderate empirical support

Cluster C: Dependent Personality Disorder

Clinical Description Rely on others for major and minor decisions Unreasonable fear of abandonment Clingy Submissive Timid Passive Feelings of inadequacy Sensitivity to criticism High need for reassurance

Causes Little research Early experience

Death of a parent Rejection Attachment

Treatment Limited empirical support

Caution: dependence on therapist

Gradual increases in: Independence Personal responsibility Confidence

Cluster C: Obsessive-Compulsive Personality Disorder

Clinical Description Fixation on doing things the “right way” Rigid Perfectionistic Orderly Preoccupation with details Poor interpersonal relationships

Obsessions and compulsions are rare

Causes Limited research Weak genetic contributions

Predisposed to favor structure?

Treatment Similar to OCD Address fears related to the need for orderliness Decrease:

Rumination Procrastination Feelings of inadequacy

Limited efficacy data

Personality Disorders: Future Directions

Completely rethinking personality disorders Dimensional models

Chapter 12 Personality Disorders. Personality Disorders: An Overview Enduring and pervasive...

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