Personality Disorders and Impulse Control Disorders

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Personality disorders

• Characteristics– Inflexible and maladaptive behaviors– Social difficulties, subjective distress, or

dysfunction– 5-15% of admissions

• 10-15% lifetime prevalence

Gender Distribution

• Men– More paranoid, OCPD and antisocial

• Women– More borderline, dependent, and histrionic

Diagnostic Challenges

• Recorded on Axis II of DSM– Categorical approach e/o

• Extreme versions of normal personality traits– Dimensional approach

– Concerns• Number of factors

• Are personality quirks disorders

• High degree of comorbidity– Cross over to Axis I

Etiological and treatment considerations

• Use – FFM of personality and see disorders as extremes of personality traits– Neuroticism– Extraversion– Openness– Agreeableness– Conscientiousness

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Causes• Genetics

– Some correlates– Some evidence of

differences in neuro-activity

– Some evidence of neuro-structural differences

• Environment– Family– Society– Damage to brain

Treatment

• Varied approaches– Cognitive behavioral treatments

– Drug treatments

• Clinicians are somewhat pessimistic about the prognosis

• Help is often not sought– Behavior rarely results in involuntary treatment

• Research to verify efficacy of treatments is needed

Three clusters of personality disorders

• Odd or eccentric– Paranoid, schizoid, schizotypal

• Dramatic, emotional, or erratic– Histrionic, narcissistic, antisocial, borderline

• Anxious or fearful– Avoidant, dependent, obsessive-compulsive

Odd or Eccentric

Paranoid• Suspiciousness, lack of

emotion, hypersensitivity– Higher among males

– Tend to externalize blame and guilt

– Not inclined to seek out treatment

– Psychoanalytic view suggests projection: self onto others

– Cognitive-behavioral therapy aimed at reducing paranoid tendencies

Schizoid

• Desired social isolation• Defect in the capacity to

form social relationships• Does not involve abnormal

ideas or perceptions• Treatment focuses on

facilitating the development of intimate relationships by fostering the building of networking

Schizotypal • Oddities of thinking

– Ideas of reference– Magical thinking

• Social isolation• Communication symptoms

– Vague, digressive, tangential, overly elaborate– Not incoherent

• Schizophrenic like symptoms– Does correlate with onset of schizophrenia– Do not lose contact with reality

• Treatment focuses on teaching clients to evaluate their environment objectively

Dramatic, Emotional, or Erratic

Histrionic• Self-dramatizing, attention seeking,

exaggerated emotions– Higher among women– Superficially charming,– Viewed by others as insincere and

shallow– Egocentric – Flirtatious, seductive, yet non-

committed– Strong correlations with APD

• May be related to Inconsistent patterns of reinforcement by parents

• Treatment should focus on defensiveness of client

Narcissistic• Exaggerated self-importance

– Denial and devaluation of others to prop up self-concept

– More prevalent in males– More critical of others than self– Entitlement– Fragile self-esteem and deep

seated fear of failure– View dependency as dangerous,

relies on self for evaluation• Histrionics depend on others for

aproval

Antisocial Personality Disorder • No guilt• Little loyalty• Predominantly male• Crossover between

– Antisocial personality disorder (behaviors)

– Those who score high on psychopathy (personality traits)

– Criminality

• Criminality aspect of APD spurs research

Borderline Personality Disorder• Fluctuations in mood, angry outbursts, identity

problems, emptiness, capriciousness• Most commonly diagnosed personality disorder• More common in women• Lack of purposefulness• Etiological theories

– Psychodynamic: others are either all good or all bad

– Social learning: poor coping skills– Cognitive: mistaken assumptions and

attributions

• Treatment focuses on motivational issues, skill training, supportive acceptance– High attrition rates– Effectiveness of treatments is difficult to

determine

Anxious or Fearful• Avoidant

– Desires attention from others but sensitive to disapproval: fear of appearing foolish

• Strong similarity to social phobia

– Fantasies of intimacy

– Depression and inadequacy

– Some evidence of hypersensitivity to sensory stimuli

– Behavioral treatments show some success

Dependent• Characteristics

– Unwilling to assume responsibility– Low self confidence– Let others decide– Subordinate their needs to the needs of others

• Even in the face of abuse• Fundamental beliefs

– See selves as inadequate– Solution is to depend on another

• More common 7% (culture)• More women• High rate of comorbidity with mood disorders• Associated with overprotective, authoritarian

parenting styles• More responsive to therapy than other PDs• Caution regarding drug treatments and

therapist/client relationship

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OCPD• Characteristics

– Perfectionism– No expression of warmth– Demanding of others

(controlling)– Detail oriented– Rigidity– Indecisive– Impaired functioning at work

or in relationships– Twice as common in men

• Somewhat responsive to cognitive behavioral therapy

Antisocial Personality Disorders

• Historical Views– Moral insanity, moral imbecility, moral defect,

psychopathic inferiority– Current diagnosis is less oriented on “morals”

Cleckley’s Characteristics

• Superficial charm• Intelligence• Shallow emotions• Little plan of order• Failure to learn from

experience• Unreliability• Dishonesty

Three Central Themes

• Inadequately motivated antisocial behaviror

• Absence of a conscience and a sense of responsibility to others

• Emotional poverty

DSM-IV-TR on APD

• Characteristics– Over 18– History of truancy/delinquency before age 15 (conduct

disorder– Egocentricity– Impulsivity– Antisocial behavior

• Prevalence– 3% of population– Predominately men

• Primary type lacks guilt, secondary type some remorse

Explanations of APD

• Psychodynamic– Faulty superego development

– Lack of parental identification: Oedipal Complex

• Family and socialization perspectives– Divorce and socioeconomic indicators weak predictors

– Poor parental involvement and prenatal hostility good predictors

– Antisocial father that is manipulative is good predictor

Genetic influences

• 5 times more common among first – degree biologic relatives of males

• MS twins’ concordance rates higher than DZ twins

• Greater likelihood among adoptees with APD biologic parents, still some environmental factors may be involved

Central nervous system abnormality

• Diminshed brain wave activity– Similar to the

activity of the brain of a child

– Limited evidence

Autonomic nervous system abnormalities

• Inability to learn from experiences– Reduced ability to learn

from shocks: less galvanic skin response to potential shock

• Absence of anxiety,

• Thrill- seeking behaviors

                                             

Fearlessness or lack of anxiety

• Failure to learn avoidance because of under-arousal

• Fewer inhibitions about engaging in antisocial behavior

Arousal, sensation seeking, and behavioral perspectives

• Big thrill seekers– Constructive: test pilot

– Destructive: ASP

• Type and certainty of punishment– Ineffective

• Physical, social, material

– Effective• Loss of memory, certain

punishment

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Treatment of APD

• Poorly motivated to change themselves

• Behavior controls• Behavioral and cognitive

approaches are not very effective• Prevention: since treatments are

not very effective, work to redirect youth with APD tendencies

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Disorders of Impulse Control

• Characteristics– Failure to resist temptations– Tension before committing act– Release after committing act– Guilt may or may not be felt

Types of Impulse Control Disorders

• Intermittent explosive disorder: episodes of uncontrolled aggression

• Kleptomania: failure to resist impulses to steal

• Pathological gambling: inability to resist gambling– More common in males

– Manic when winning, depressive after

– Cognitive treatment focuses on “chance” aspect of gambling

Types of Impulse Control Disorders (Cont.)

• Pyromania: deliberate fire setting– Pleasure in observing the

fires

– Hostile and impulsive

– More common in males

• Trichotillomania: urge to pull out one’s own hair– More common in women

– 1% of college students report current or past history

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Etiology and treatment of ICD

• Little information on causes– Similar to OCD, substance abuse, sexual deviance

• Psychoanalytic theory stresses sexual symbolism• Behaviorists stress variable reinforcement schedule• Lesieur

– Impulse control problems on a continuum– Impulse control disease

• Treatments often include behavioral and cognitive methods