L8 - Cognitive models and cluster C Flashcards
(41 cards)
1
Q
What personality disorders are in cluster C?
A
- Avoidant PD
- Dependent PD
- Obsessive-compulsive PD
2
Q
Why are these personality disorders challenging?
A
- The most common PDs but they can be very challenging during treatment as patients internalise lot of their feelings, so they don’t show they’re true feelings
- It’s difficult to break through the coping mechanisms they have
3
Q
What are the prevalence rates?
A
- Avoidant PD – 2.7%
- Dependent PD – 0.8%
- Obsessive-compulsive PD - 3.2%
↪ Found very often in the general population rather than other PD population - might be due to high adaptiveness of such traits (e.g. perfectionism is linked to higher occupational functioning)
Cluster C prevalence: 5%
4
Q
Criteria for Avoidant PD
A
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts
- Avoiding occupational activities involving significant interpersonal contact
- Unwilling to get involved with people unless certain of acceptance
- Restraint within intimate relationships
- Preoccupied with fears of receiving criticism or rejection in social situations
- Social inhibition new interpersonal situations
- Feelings of inferiority
- Reluctant to take personal risks or to engage in any new activities
Must have 4 out of the 7 symptoms
5
Q
Explanations of the criteria
A
- Avoiding occupational activities involving significant interpersonal contact
- Unwilling to get involved with people unless certain of acceptance (if they know for sure that the person likes them, they might do it but even then, it’s hard for them)
- Restraint within intimate relationships (not lot of mutual contact because they’re scared to show their vulnerable side and to express any uncertainties or difficulties they run into’ the relationships are not as deep which also confirms the idea that people will leave them and criticise them + they’re very socially awkward and self-aware which gives off bad vibe to people so it’s a viscious cycle)
- Preoccupied with fears of receiving criticism or rejection in social situations (all the time)
- Social inhibition new interpersonal situations (due to the criterion 4)
- Feelings of inferiority (not just on their social skills but also comparison with other people on intelligence, worth, everyone else is better, work better; while also believing that others will criticise them: ‘‘they won’t be good to me, they won’t like me’’ so they rather avoid the situations all together)
- Reluctant to take personal risks or to engage in any new activities
6
Q
What is not grasped by these criteria?
A
- They have avoidance as a general stretegy
- The criteria focus on avoidance of specific situations
- But what the criteria doesn’t grasp is that it’s a general tendency to avoid emotions, other kinds of thoughts and behaviours
- So the avoidance is not exclusive to social or occupational situations
7
Q
What challenges might arise during treatment with avoidant clients?
A
- The same dynamics might occur - the client might be avoid and reluctant to trust the therapist due to fear of criticism or judgment and inferiority
- Even with specific tools during treatment (e.g. exposure), their feelings of inadeqacy and failure make it difficult for the therapy to move forward and for the person to get better
8
Q
What are other features of avoidant PD?
A
- High amounts of stress
↪ depression, substance use, somatic symptoms, chronic mental health issues, sleep problems - Strong focus on own fear and stress - puts lot of strain on them as they feel the pressure of being social + the feeling of inferiority and never succeeding in anything and other can do it
- Isolation from friends, colleagues, romantic partners
↪ Lower social support - Negative impact on (academic) career
- Self-fulfilling prophecy - they are very self-involved with their fears and trying to avoid negative evaluation at all cost that people start to avoid them
- Lot of non-suicidal self-injuries - alleviate stress and emotion regulation (to avoid emotions)
9
Q
What are similarities betwen Avoidant PD (AVPD) and borderline PD (BPD)?
A
- Fear of criticism
- Both fear abandonment and that people are out to get you or hurt you
- E.g. I’m afraid to approach them because they will hurt me or leave me anyway
10
Q
Etiology of AVPD
A
- Low degree of (healthy) emotional expression in family
- Conflict avoidance in family
- Avoidant modeling by parents
- Ridicule by parents and rejection → Emotional abuse
- (preoccupied)-Avoidant attachment
11
Q
Which syndrome disorder shows possible overlap with AVPD?
A
Social anxiety disorder
12
Q
Which criteria are similar between these two disorders?
A
- Picture 1
- SAD: marked anxiety about one or more social situation (could be specifically public speaking but also more general) and avoidance of such situations and if they are in them, there is intense anxiety
- AVPD: avoidance of occupational activities because ‘‘I will be criticised anyway’’ and preoccupied with fears
13
Q
What are the differences between AVPD and SAD?
A
- AVPD: feelings of inferiority, restrain in relationships which continues when they know the person (in SAD the anxiety decreases when they get to know the people), initiation of new projects, ideas…
- AVPD: avoidance is a general strategy (also at work, whereever there is a possibility that people will criticise them), SAD: avoidance is of more specific situations
14
Q
What are the two hypotheses about SAD and AVPD?
A
- Continuum hypothesis - there is lot of overlap and similarities between SAD and AVPD, so they might be the same continuum, with AVPD being a more severe form of SAD (picture 2)
- Qualitative differences hypothesis - There is an overlap between SAD and AVPD but AVPD has overlap with other disorders as well but the two are qualitatively different in lot of ways (picture 3)
15
Q
What is the evidence for/against the continuum hypothesis?
A
- Studies showed that participants with AVPD have more severe symptoms so supporting the hypothesis that it’s a more severe form of SAD
However:
- You would expect all AVPD people to meet SAD symptoms as well (not the other way around of course)
- Avoidant PD is also present in samples without SAD
- 1/3 to 46% individuals with SAD also diagnosed with AVPD
- Between 40 and 88% in AVPD also have SAD
16
Q
What are the qualitative differences between AVPD and SAD?
A
- AVPD patients don’t recognise the situational fear response of SAD because they have this general preoccupation with worrying
- Feelings of inferiority and passivity, stronger fear of abandonment
↪ AVPD general avoidance strategy and inferiority, in SAD, more related to specific attributes - Feared (social) situations
↪ Interpersonal (all interpersonal situations feared in AVPD) vs. performance (SAD) - AVPD more strongly related to introversion, openness, agreeableness (Could be support for both hypothesis)
- Clinical experience: AVPD more early experiences of isolation and early onset; SAD has a later onset
- Restraint: In SAD, anxiety lessens as relationship develops
17
Q
What is the conclusion from these two hypothesis
A
- There is no clear answer because there is definitely some overlap but also lot of qualitative differences (this depends on how you define such differences)
18
Q
What are the criteria for dependent PD?
A
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts (5 out of 8 have to be met)
- Difficulty making daily decisions advice and reassurance
- Needs someone else to take over major life areas
- Difficulty disagreeing with others
- Difficulty starting projects on their own
- Go to great lengths to obtain support from others
- Feeling uncomfortable or helpless when alone
- Searches for new relationship after one ends
- Unrealistic preoccupation with being left alone and unable to care for themselves
19
Q
Explanations of the criteria
A
- Difficulty making daily decisions advice and reassurance - always rely on someone else, even with daily decisions that usually a person doesn’t need someone else to make a decision for them (if someone has only difficulty about what to eat, it doesn’t count, it has to be in multiple small contexts throughout the day)
- Needs someone else to take over major life areas (e.g. studies, housing, finances, job…)
-
Difficulty disagreeing with others - they fear that if they speak up or don’t agree with their partner, that person will leave and they will have to take care of themselves
↪ This can also be very dangerous because they do whatever the person wants to not lose them so they get caught in abusive relationships
↪ It’s very dangerous because when they do get in a relationship with an abusive partner, they feel like they can’t leave because they’re convinced that they need that person so they feel trapped - Difficulty starting projects on their own - they feel like they won’t be able to; similar to AVPD
- Go to great lengths to obtain support from others - they do things they don’t enjoy and wouldn’t want to do under normal circumstances (can be small, mundane things but also big that can get dangerous for them)
- Feeling uncomfortable or helpless when alone - they feel like they’re not able to function if they don’t have someone in life who can take over major areas for them, take care of things for them because they believe, they’re not able to do that on their own
-
Searches for new relationship after one ends - can be romantic, friendship, parents…
↪ they become very proactive to make sure they find someone else (it’s not about the quality of the relationship rather that they have someone) - they have a very specific goal so they have lot of motivation to fulfill this goal and go out of their way to find someone who will take care of them - Unrealistic preoccupation with being left alone and unable to care for themselves
20
Q
What would possible challenges be in contact with a person with DPD in therapy?
A
- The dependency is in the therapeutic relationship as well - they think the therapist will tell them what to do and how to do it
- Terminating therapy can be extremely difficult because then they have to do it by themselves
- Helping reflex on the therapist’s side - you have to trigger the input from the client
- It’s difficult for the client to set boundaries because they’re afraid of what migth happen
21
Q
Etiology of DPD
A
- Linked to autoritarian and overprotective parenting - not having the experience of developing independence
- Not always passive! - in the case of searching for a relationship to replace the lost one
- Emotional vs. Functional dependency - very strong functional dependency rather than emotional one (they’re quite capable of dealing with their own emotions; emotional dependency more in BPD)
- It’s very difficult to take cultural differences into account - especially because in western cultures, we value independent people so DPD may seem out of norm more than in collectivistic cultures where dependency and family reliance is valued more - so when evaluating you have to take this into account whether it’s not cultural
- Gender bias?
↪ More diagnoses in females
↪ Dsm is written from masculine perspective (most PDs are written how a female would behave)
↪ There might be reporting bias - men don’t want to report such problems as it’s seen as a typical feminine behaviour (In antisocial PD, it’s other way around)
↪ Therefore, it might be easier to diagnose in females since they’re more prone to answer yes to certain questions during screening
↪ This is an ongoing deabte whether it’s actually more prevalent in females or whether there is reporting bias or gender bias
22
Q
What are similarities and differences between DPD and AVPD?
A
- Similarities in how they view themselves - very negative feelings about themselves; inferiority, inadequacy…
- Differences in how they view others
↪ DPD - others will help me, support me, provide the care I can’t do myself
↪ AVPD - very self-aware in social situations and scared they will be ridiculed or criticised therefore they don’t want to approach others
23
Q
OCPD
A
- Main characteristics: need for control, obsessive about control, very strict and rigid
- They often seek treatment for depression or burnout
- Despite often knowing that their behaviour is dysfunctional, they really believe that this is the way they should work and behave and therefore others should also meet the high standards they have for themselves
24
Q
What are the criteria for Obsessive-Compulsive PD?
A
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts (4 out of 8)
- Preoccupation with details, rules, schedules, organization
- Perfectionism that interferes with the task completion
- Devotion to work and productivity to the
exclusion of leisure activities and friendships - Is overconscientious, scrupulous, and inflexible
about matters of morality, ethics, or values - Unable to discard worn-out or worthless objects
- Reluctant to delegate tasks
- A miserly spending style
- Rigidity and stubbornness
25
Explanations of the criteria
1. **Preoccupation with details, rules, schedules, organization** - they make lists, think beforehand what to do so everything is perfect that they don't even start the task in the end or be very late or under stress
2. **Perfectionism that interferes with the task completion** - can be functional but it has lot of down sides since it puts lot of stress on them as it's never perfect as it's unreachable goal and standard
3. **Devotion to work and productivity to the
exclusion of leisure activities and friendships** - can be very productive in sports as well but regardless of what they obsess about leisure activities and holidays can be very difficult for them and hence for the people who participate in these with them
4. **Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values** - when they have this idea or opinion about something that is the only way it can be or counts and therefore they're not open to how someone else might feel or think about something (e.g. in a task, in a group project - all very difficult for them) and they are also prone to correct people if they're not meeting the high standards
5. **Unable to discard worn-out or worthless objects** - they always have a tendency that they think that the objects migth have some use at some point, they have difficulty throwing things out; they are always trying to prepare for the future when things might go wrong so that they have ways to control it
6. **Reluctant to delegate tasks** - ''it's my way or the high way'' because everything has to be perfect and other people don't meet their high standards
7. **A miserly spending style** - they don't like to spend money (on themselves but also others) because they think some catastrophe is gonna happen so they have to save up the money
8. **Rigidity and stubbornness** - they have very rigid plans that they must follow otherwise they might not be productive, responsible or might have to cancel other plans (e.g. once a patient of hers said she can't go on holidays because she had a coffee date planned and she simply must go if it's planned)
26
What would possible challenges be in contact with a person with OCPD in therapy?
- Cancelling a session could be difficult and cause therapeutic rupture
- To some extent lack of insight because they believe that this is how the world should be and everyone should behave this way
- They have a strong urge to control the therapeutic process, come in with lists and overdo their homework
27
Characteristics of OCPD
- Extremely rational - there is no room for emotion because rationality and control is what counts in their eyes
- Workoholics - traits valued by society but that is very tirying to always behave like this and try to be perfect + very difficult in relationships with others
- Relatively few patients seek help for OCPD
- Is the need for control a way of overcompensating for the fact that they're not able to get by in life or do they do that because they surrender to the fact that they always have a need to be in control
28
OCPD etiology
* Lack of emotional expression
* Lack of relaxation, fun, playtime
* Rigid rules, in exchange for love
* Punitive parenting style → Avoiding punishment
* Overprotection
* Emphasis on achievements, rules, production
* Too much responsibility early in life - Parentification (people learn to behave responsibly and be in control as a way to cope with such responsibility in early life)
29
Treatment for cluster C
- Specialised treatment for cluster C (CBT, schema therapy)
- Can be treated individually or in groups (with other cluster C patients; not the case with cluster A and B as for obvious reasons it migth not be beneficial to mix people within these latter clusters)
30
What was the study setup to test the group schema therapy for cluster C?
- Pilot study
- 137 participants with a primary disorder either in AVPD (78.1%), DPD (8%) or OCPD (13.9%)
* Main outcome: General severity PD assessed with clinical interview
* Secondary outcomes: Functional impairment, QoL, Happiness, self-esteem, schema functioning/modes
31
What were the findings from the pilot study?
- Schema therapy takes a very long time
- When you look at the general patterns you see that it's effective overall (picture 4)
- DPD shows larger effect after treatment ended (at 8 months) - during treatment they rely on the therapist but when the treatment ends they have to cope, deal with life on their own and practice skills outside of the support of the therapist which can give them a boost of confidence which they didn't have during treatment because dependency was being triggered
32
What is schema?
* Schema = knowledge representation of the self, others, the world (and relationships)
* It's a construct that is made up of multiple elements: attachment, learning experiences, ideas, cognitions, emotions - representation of how you think the world works
* Explicit and implicit beliefs (unaware)
↪ Explicit beliefs – can be verbalized
↪ Non-verbal knowledge, such as attachment representations and other ideas that are so deeply engrained in ourselves that we're not really aware of them
* Schemas originate in childhood – Early Maladaptive Schemas (EMS)
↪ The world of a child is limited
↪ Childish interpretations - they tend to stick so it's difficult to change them - once they were adaptive (the world was dangerous, grew up in a war zone) but now that the world is not danegrous anymore, the schema is maladaptive
* So, early experiences are the foundation for our general view of ourself, others and the world
33
What are the three levels of cognitions
- Schema is a broad concept that can include certain cognitions
1. **Core beliefs** (I am..., others are) - fundations of other beliefs and they are very closely related to schemas because they're deeply ingraned like schemas
2. **Conditional beliefs** (If x, then y) - linked to the core beliefs
3. **Strategic beliefs** (do A to get B) - If I belief something then in order to deal with the core and conditional beliefs, I have to act in a certain way
34
How do the beliefs relate to PDs?
- Indications that some specific beliefs characterize PDs (but not solely determined by)
- E.g. in AVDP: I am inferior to others, others are critical/judgmental (core belief); if I open up or show my true feelings, others are gonna criticize me (conditional beliefs) because I'm inferior and others are critical; therefore I avoid others and opening up (strategic belief)
- If we believe that PDs are seperate entities that we would hypothesis that there are distinct beliefs in each PD
35
Why are schemas maintained and difficult to change?
- **Assimilation**: Inclusion in already existing schema, sometimes adjusted
↪ Dominant process = When we run into new information we are always more likely to interpret it in such a way that it still fits the original schema that we have
* **Accommodation**: Adjustment of schema according to new information
↪ This is very difficult to do and for some PDs you may never achieve this in full extent (but at keast a little bit or form new schemas)
36
How do schemas influence information processing?
- They determine our behaviour, how we feel, think and process information as it's very diffcult to change them since they're so rigid
- You can explain PDs through these schemas as they influence how we respond to the world
- Schemas influence information processing by:
1) Attention and selection of information
2) Interpretation of information
3) Memory
37
What is the cognitive model of PDs?
## Footnote
Picture 5
- Starts with some type of info, e.g. The lecturer has very low self-esteem and feeling of inferiority but is giving us the lecture
- The schema of inferiority is trigger in this situation and is directly linked to how I process the information
1. **Attentional bias** to which info to select - she focuses on faces that have a slight frown because that confirms the idea she sucks → the attention is focused on what the person fears the most (observed in other disorders as well, e.g. phobia)
2. **Interpretation** - she will interpret it in a way that is consistent with the schema of inferiority so ''this person is frowning because they think I suck and not because they are focused on the lecture and they're frowning becasue it's difficult topic to understand''
3. **Evaluation** - She evaluates it in such a way that ''I suck as a lecturer, I will never give a lecture again, this means that I will loose my job''
4. **Response** - Due to all of the above the response will show as anxiety, nervousness, and the quality of the lecture will decrease because she is so stressed
5. **Memory encoding** - so far it was active information processing before it's stored in memory - so what she is gonna remember from that lecture is that information that confirms the schema that she sucks and is inferior
6. **Autobiographical memory** - so this memory is also stored in the autobiographical memory
7. **Retrieval** - because it's stored in biographical memory, it will be retrieved the next time she gives a lecture
38
What are the implications of this model on studies and specific PDs?
- This process is activated the whole time a cerain schema is activated - it's very difficult to step out of this because it's often unconsious
- Very general model so we would expect that we would see belief specific to different PDs
- To study this is very difficult as we're difficult as this is implicit and it involves biases (difficult to research)
- However, there are studies that focus specifically on one of the biases etc - she talks about one that focuses on interpretation bias
39
Study on interpretation bias
- Participants: 5 groups: Cluster C patients - combined AVPD and DPD; BPD; OCPD; general control group and control with syndrome disorders (Axis I)
Procedure:
- They had 10 scenarios written down (e.g. “You experienced something unpleasant yesterday, making you sad. You cannot let go of the thoughts about what has happened.”)
- Then, at first, they saw three responses (forced responses) and they had to choose which one is most fitting to how they would feel in that situation:
1) There is nobody to comfort me (BPD)
2) I need help, I cannot solve this on my own (DEP)
3) I need to control my thoughts and feelings, otherwise it will go wrong (OCP)
↪ each was always consistent with one PD
↪ They left out a neutral answer to control for desirability bias to choose the more functional/healthy answer to not look crazy etc
- Then they had to give an open response to questions like what would you feel, what would you think, what would you do? (good way to allow for subjectivity)
- Then they had to rate how believable/credible these answers were (both forced and open)
40
Findings from this study
Forced choices (picture 6):
- BPD and AVDE choices were chosen by the corresponding group of PD patients but for OCPD option it was chosen by multiple groups
- possible explanation: social desirability or it might be a relatively healthy and functional response (that's why OCPD is a odd-one-out as a PD because to what extent is it really dysfunctional) - it's more normal and observed in people who have no diagnoses
Open responses:
- similar pattern
- BPD: rated their responses to be more believable
- AVDE: also rated their responses to be more believable but it's not significant so it's not as clear cut
- OCPD-consistent beliefs: more believable by OCPD people or control group participants - so what schemas are we really talking about when we talk about OCPD?
41
Conclusions cognitive models
- PDs are characterized by:
↪ Specific sets of ‘beliefs’
↪ Specific cognitive biases (also implicit)
* Schemas cause cognitive processes and maintain personality disorders
↪ No direct causal evidence yet
* Cognitive model useful for experimental research and translation to practice and treatment!
↪ if this model is true then you should focus on changing or deactivating these schemas in treatment
