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Flashcards in Personality Disorders Deck (48)
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1

Personality:

Personality is the consistent pattern of an individual’s thinking, feeling and behaving that is pervasive across time and contexts (Hulbert et al., 2011).

2

The Five Factor Model (Costa & Widigier, 2002; McCrae & Costa, 1985) identifies 5 essential personality traits:

 

genetic basis

environmental

  • Neuroticism (N)
  • Extroversion (E)
  • Openness to Experience (O)
  • Conscientiousness (C)
  • Agreeableness (A)

 

  • These core personality traits have a 40-60% genetic basis (Livesley, 2008).
  • Environment:
    • Modulates trait expression
    • Shapes behaviours for trait expression

3

  • Personality Disorders
  • what is considered a "personality disorder"

  • Personality Disorders: a persistent pattern of emotions, cognitions and behaviour that results in enduring emotional distress for the person affected and/or for others and may cause difficulties with work and relationships
    • When personality characteristics interfere with relationships with others, cause the person distress, or in general disrupt activities of daily living, we consider these to be “personality disorders”

4

  • DSM-5 definition of Personality Disorders:
  • Core Features:

  • DSM-5 definition of Personality Disorders:
    • “An enduring pattern of inner experience and behaviour that deviates markedly from the expectations 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”
    • PDs show low to moderate stability?
  • Core Features:
    • Functional inflexibility
    • Self-defeating behaviour patterns
    • Tenuous stability under stress

Therapists especially need to guard against letting their personal feelings interfere with treatment when working with people who have personality disorders (countertransference, Freud)

5

General Personality Disorder diagnostic criteria

  • A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two or more of the following areas:
    • Cognition (i.e., ways of perceiving and interpreting self, other people, and events)
    • Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
    • Interpersonal functioning
    • Impulse control
  • B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations
  • C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning
  • D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood
  • E. The enduring pattern is not better explained as a manifestation or consequences of another mental disorder
  • F. The enduring pattern is not attributable to the physiological effects of a substance or another medical condition

6

How PDs complicate treatment

  • Not untreatable, but among most difficult disorders to treat -> involve pervasive and entrenched behaviour patterns that have been present throughout most of a person’s life
  • Traits often experienced as integral to the self
  • May significantly impact treatment of other comorbid disorders
  • May help to explain why some clients fail to respond in treatment as expected

7

General Issues with PD Assessment

  • Question regarding validity/utility of diagnoses
  • Question in regards to whether personality disorders should be measures on dimension rather than category
    • What does it mean when there is disagreement amongst clinicians? Meeting all the criteria but no functional impairment?
  • PDs within each cluster share many characteristics
  • May not be apparent on first meeting
  • Clients may try to hide/minimize/justify symptoms
    • “It’s everyone else’s problem, I’m fine”
  • Countertransference issues

8

3 clusters of personality disorders:

  • Cluster A- Odd or Eccentric Disorders (paranoid, schizoid, schizotypal disorders)
  • Cluster B- Dramatic, Emotional or Erratic Disorders (antisocial, borderline personality, histrionic, narcissistic)
  • Cluster C- Anxious or Fearful Disorders (avoidant, dependent and obsessive-compulsive personality disorder)

9

Difficulties in Research and Diagnosis of PDs

  • Misdiagnosis
    • Criteria not as sharply defined
    • Categories not mutually exclusive
    • Characteristics are dimensional but diagnostic criteria are not (yet)
  • Little known about causal factors
    • High level of comorbidity among personality disorders
    • Little prospective research

10

Main beliefs associated with specific personality disorders

11

Other

  • Personality disorders are sometimes described as chronic because they originate in childhood and continue through adulthood
  • Although gender differences are evident in the research of personality disorders, some differences in the findings may be a result of bias

12

General Causal Factors

  • Biological
  • Psychological

  • Biological factors
    • Inborn temperament
    • Genetic contributions
  • Psychological factors
    • Learning-based habit patterns and maladaptive cognitive styles
    • Parental psychopathology
    • Abuse

13

Paranoid Personality Disorder (cluster A)

  • Prevelance
  • Diagnostic Criteria

  • Prevalence: 2.3% – 4.4%

Diagnostic Criteria

  • A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
    • Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
    • Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
    • Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
    • Reads hidden demeaning or threatening meanings into benign remarks or events
    • Persistently bears grudges (i.e., unforgiving of insults, injuries, slights)
    • Perceives attacks on his/her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
    • Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
  • B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological affects of another medical condition

14

Paranoid PD: Clinical Presentation

  • Generally difficult to get along with and thus have problems in/with close relationships
  • May engage in overt argumentativeness, recurrent complaining, or by quiet, apparently hostile aloofness
  • May act in a guarded, secretive or devious manner
  • Appear to be “cold” and lacking in tender feelings
  • May appear to be objective, rational, and unemotional, more often display a labile (changing) range of affect with hostile, stubborn, and sarcastic expressions dominating
  • Have an excessive need to be self-sufficient and strong sense of autonomy
  • Need a high degree of control of those around them (for whom they are often hostile and critical)
  • May be litigious
  • Tend to develop negative stereotypes of others, particularly those from population groups distinct from their own
  • May experience very brief psychotic episodes in response to stress

Cognitive and cultural factors may interact to produce the suspiciousness observed in some people with paranoid personality disorder

15

Paranoid PD: Treatment

  • Unlikely to seek professional help, even when needed
    • Trust is a major part of therapy
    • Meaningful therapeutic alliance is difficult to establish
  • Cognitive therapy
    • Counter person’s mistaken assumptions about others
    • Focus on changing person’s beliefs that all people are malevolent and most people cannot be trusted

There are no confirmed demonstrations that any form of treatment can significantly improve the lives of people with paranoid personality disorder

16

Schizoid Personality Disorder (cluster A)

  • Prevelance
  • Diagnostic Criteria

  • Prevalence: 3.1% - 4.9% but uncommon in clinical settings

Diagnostic Criteria

  • A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
    • Neither desires nor enjoys close relationships, including being part of a family
    • Almost always chooses solitary activities
    • Has little, if any, interest in having sexual experiences with another person
    • Takes pleasure in few, if any, activities
    • Lacks close friends or confidants other than first-degree relatives
    • Appears indifferent to praise or criticism of others
    • Shows emotional coldness, detachment, or flattened affectivity
  • B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder or autism spectrum disorder and is not attributable to the physiological affects of another medical condition

17

Schizoid PD: Clinical Presentation and Treatment

  • May lack desire for intimacy, seem indifferent to opportunities to develop close relationships, and do not seem to derive much satisfaction from being part of a family or other social group
  • Often appear to be socially isolated or “loners”
  • Reduced experience of pleasure from sensory, bodily, or interpersonal experiences
  • May be oblivious to normal subtleties of social interaction and often do not respond appropriately to social cues
  • React passively to adverse circumstances and have difficulty responding appropriately to important life events
  • Often do not marry
  • Treatment?
    • Point out value in social relationships
    • Empathy and social skills training

18

Schizotypal Personality Disorder

  • Prevalence
  • Diagnostic Criteria

  • Prevalence: 3.9% - 4.6%

Diagnostic Criteria

  • A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behaviour, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
  1. Ideas of reference (excluding delusions of reference)
  2. Odd beliefs or magical thinking that influences behaviour and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense;” in children and adolescents, bizarre fantasies or preoccupations)
  3. Unusual perceptual experiences, including bodily illusions
  4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, over-elaborate, or stereotyped)
  5. Suspiciousness or paranoid ideation
  6. Inappropriate or constricted affect
  7. Behaviour or appearance that is odd, eccentric, or peculiar
  8. Lack of close friends or confidants other than first degree relatives
  9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

19

Schizotypal PD: Clinical Presentation and Treatment

  • Most often seek treatment for associated symptoms of anxiety/depression
    • 30% - 50% also have a concurrent diagnosis of a major depressive disorder when entering clinical setting
  • May experience transient episodes of psychosis during times of stress
  • Is different from schizophrenia by absence of delusions and hallucinations
  • Ideas vs. delusions: defined by strength of conviction
  • May believe that they have magical control over others, which can be implemented directly
  • Often suspicious and paranoid
  • Anxious in social situations—behaviour suggests a decreased desire for intimate contacts
  • Found to be a genetic relationship between schizotypal and schizophrenia (with the former considered to be a precursor to the latter)
  • Schizotypal disorder has been associated with mild to moderate decrements in ability to perform on tests involving memory and learning (suggesting damage to left hemisphere) as well as generalised brain abnormalities (using magnetic resonance imaging)
  • Treatment
    • Early intervention (cognitive therapy and antipsychotics) to reduce chance of full-blown psychosis
    • Treat comorbid diagnoses (e.g., anxiety, depression)

20

Cluster B characterised by traits that are:

  •  
    • Impulsive
    • Dramatic
    • Exciting
    • Emotional
    • Erratic
    • Acting Out
    • Flamboyant
  • Commonly seen at mental health services
  • Often attract other people/partners
  • Have many unsuccessful relationships
  • Need to differentiate from a manic episode

21

Antisocial Personality Disorder

  • Prevalence
  • Diagnostic criteria

  • Prevalence: 0.2% - 3.3%

Diagnostic Criteria

  • A. There is a pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:
  1. Failure to conform to social norms with respect to lawful behaviours, as indicated by repeatedly performing acts that are grounds for arrest
  2. Deceitfulness, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure
  3. Impulsivity or failure to plan ahead
  4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults
  5. Reckless disregard for safety of self or others
  6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations
  7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
  • B. The individual is at least age 18 years
  • C. There is evidence of Conduct Disorder with onset before age 15 years

22

ASPD: Clinical Presentation and Treatment

  • Frequently lack empathy and tend to be callous, cynical, and contemptuous of feelings, rights, and sufferings of others
  • May have an inflated and arrogant self-appraisal, and be excessively opinionated, self-assured, or cocky
  • Irresponsible and exploitative in their sexual relationships
  • May receive dishonorable discharges from armed services, become impoverished or homeless, or may spend many years in penal institutions
  • May experience dysphoria, including complaints of tension, inability to tolerate boredom, and depressed mood
  • May have associated anxiety/depressive disorders, substance use disorders, somatic symptom disorder, gambling disorder, other disorders of impulse control
  • Treatment?
    • Few documented success stories
    • Don’t feel they need treatment, not likely to engage in it honestly
    • Cognitive Behaviour Therapy
    • Parent training

23

ASPD and Psychopathy

  • Considered subtype of Antisocial PD
    • Obsolete terms in the DSM-5 and ICD-10
  • Term still used in clinical practice and in general
  • Psychopathy Characterized by (Clerckley/ Hare Criteria):
    • Lack of empathy
    • Inflated and arrogant self-appraisal
    • Very often glib and superficially charming
    • Deceitful and manipulative
    • Callously use others to achieve their own ends
    • Also included are hostile people who are prone to acting out impulses in remorseless and often senseless violence
  • Problems in 3 basic categories
    • Inadequate conscience development
    • Irresponsible and impulsive behavior
    • Ability to impress and exploit others

24

       Inadequate Conscience Development Psychopathy

  • Appear unable to understand and accept ethical values except on a verbal level
  • May glibly claim to adhere to high moral standards that have no apparent connection with their behavior
  • Behave as though social regulations and laws do not apply to them
  • Intellectual development typically normal

25

       Ability to Impress and Exploit Others Psychopathy

  • Are often charming and likeable
  • Disarming manner that easily wins new friends
  • Typically have a good sense of humor and an optimistic outlook
  • Frequent liars who usually seem sincerely sorry if caught in a lie and promise to make amends, but will not do so
  • Seem to have good insight into other people’s needs and weaknesses and are adept at exploiting them
  • Seldom able to keep close friends -> cannot understand love in others or give it in return
  • Manipulative and exploitative in sexual relationships -> irresponsible and unfaithful mates

26

       Physiological Evidence? ASPD and Psychopathy

  • Diminished aversive emotional arousal and conditioning
    • Fearlessness hypothesis: Less prone to experience fear and anxiety in stressful situations and less prone to normal conscience development and socialization
    • Underarousal hypothesis: psychopaths have abnormally low levels of cortical arousal and therefore seek more stimulus
    • Show deficient conditioning responses when anticipating an unpleasant or painful event, slow to stop responding in order to avoid punishment
      • It is these negative experiences that help to develop our conscience -> if we don’t have them, we don’t learn to avoid bad things (deficient behavioural inhibition system)

27

Borderline Personality Disorder (BPD) diagnostic criteria

  • A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
  1. Frantic efforts to avoid real or imagined abandonment
  2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealization and devaluation
  3. Identity disturbance: markedly and persistently unstable self-image and sense of self
  4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)
  5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
  6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
  7. Chronic feelings of emptiness
  8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms

28

BPD characteristics

  • Prevalence rate of 1.6% - 5.9%
  • 6% in primary care settings, 10% amongst individuals seen in outpatient mental health clinics, 20% amongst psychiatric inpatients
  • 75% diagnosed are females (ratio F, 3:M, 1)
  • Suicide rate: 10%
  • Deliberate self-harm/parasuicidal behaviour
  • Onset is late childhood/adolescence
  • Chronic but can decline with age
  • 88% achieve remission after 10 years of treatment

29

BPD: Clinical Presentation

  • Pattern of undermining themselves at the moment a goal is about to be realized
  • Psychotic-like symptoms during periods of stress
  • May feel more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships
  • Recurrent job losses, interrupted education, and separation or divorce are common
  • Physical and sexual abuse, neglect, hostile conflict, and early parental loss are common in childhood histories

30

Causes/Aetiology of BPD

  • Biological vulnerability (impulsivity and affective instability)
  • High emotionality and invalidating environment
  • Childhood trauma, particularly sexual abuse
  • Multidimensional theory (awaits validation and future research)
    • Diathesis (hereditary or constitutional predisposition) to develop borderline PD, combined with presence of certain psychological risk factors such as trauma, loss, and parental failure
    • When one or more of these risk factors occur in someone who is affectively unstable, he or she may become dysphoric and labile, and if he or she is also impulsive, may engage in impulsive acting out to cope with the dysphoria
    • Children who are impulsive and unstable tend to be difficult/troublesome children -> may be at an increased risk for being rejected and/or abused
    • Parental psychopathology and personality disorders