Chapter 16: Personality Disorders

Obsessive-Compulsive Personality Disorder TREATMENT FOR OBSESSIVE-COMPULSIVE PERSONALTIY DISORDER

People with obsessive-compulsive personality disorder do not usually believe there is anything wrong with them. They are unlikely to seek treatment unless they also are suffering from another disorder (anxiety or depression). Psychodynamic: accept underlying feelings/insecurities and personal limitations. Cognitive: change dichotomous thinking - perfectionism, indecisiveness, procrastination, chronic worrying. Drug Therapy: a number of clinicians report success with SSRIs. Not fully studied.

Personality disorder

lasting pattern of behavioral and inner experience that markedly deviates from a person's culture and indicates problems such as inappropriate emotions and cognition, lack of impulse control, chronic deficiencies in interpersonal functioning. (American Psychiatric Association, 2013).

Categorical approach to personality disorders.

-Problematic personality traits are present/absent. -Symptoms displayed/not displayed. Why do some theorists challenge use of the DSM-5 categorical approach to personality disorders?

Big Five theory of personality and personality disorders

A large body of research conducted with diverse populations consistently suggests that the basic structure of personality may consist of five supertraits or factors: Neuroticism Extroversion Openness to experience Agreeableness Conscientiousness

Dependent Personality Disorder

A pervasive and excessive need to be taken care of leading to submissive and clinging behavior and fears of separation (APA, 2013). Difficulty making everyday decisions without excessive amount of advice and reassurance from others. Needs others to assume responsibility for most major areas of life. Difficulty expressing disagreement with others. Excessive need to obtain nurturance/support. Feels uncomfortable or helpless when alone. Preoccupation with fear of being left alone to care for self. Affects fewer than 1% adults. Equal male to female ratio.

Paranoid Personality Disorder

A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent (APA, 2013). -Suspects without sufficient basis that others are exploiting, harming, or deceiving him/her. -Preoccupied with unjustified doubts about loyalty or trustworthiness of friends or associates. -Reads threatening meaning to benign remarks/event. -Persistently bears grudges. -Perceives attacks on his/her character or reputation; likely to react with anger or counterattack. Must have 4 or 5 of these symptoms, cause distress, and manifest in more than one situation to be diagnosed -Unjustified suspicion about fidelity of spouse/partner. -Limited close relationships. -Critical of weakness/fault in others; extremely sensitive to criticism. -Excessive jealousy. -4.4% of U.S. adults affected. -More common in men.

Schizoid Personality Disorder

A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings (APA, 2013). Does not desire/enjoy close relationships, including family. Pleasure in few if any activities; almost always chooses solitary activities. Little interest in sexual activity with another person. Indifferent to praise or criticism of others. Split off from normal social relations: a "loner". Emotional coldness, detachment, or flattened affect: Seen as flat, humorless, dull. Present in 3.1% U.S. adults. Slightly more common in men.

Narcissistic Personality Disorder

A pervasive pattern of grandiosity (fantasy or behavior), need for admiration, and lack of empathy (APA, 2013). Grandiose sense of self-importance. Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love. Belief self is "special" and unique. Requires excessive admiration. Sense of entitlement. Interpersonal exploitation. Lack of empathy. Exaggeration of achievements and talents, often arrogance. Selective about friends; often favorable first impressions. Common among normal teenagers; does not usually lead to adult narcissism. Found in 6.2% of U.S. adults. Affects up to 75% of men.

Borderline Personality Disorder

A pervasive pattern of instability in interpersonal relationships, self-image, affect; and marked impulsivity in variety of contexts (APA, 2013). Begin early adulthood -Frantic efforts to avoid real or imagined abandonment. -Pattern of unstable/intense interpersonal relationships. -Suicidal and or self-mutilation behavior, gestures, threats. -Intense anger (may be physical aggression; violence). -Transient stress-related paranoid ideation or severe dissociative symptoms. 75% ATTEMPT SUICIDE/ 10% COMPLETE Affective instability. Chronic feelings of emptiness. Transient stress-related paranoid ideation or severe dissociative symptoms. Found in 5.9 of U.S. adults. 75% are women.

Obsessive-Compulsive Personality Disorder

A pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control, at the expense of flexibility, openness, and efficiency (APA, 2013). Preoccupation with detail, rules, lists, order, organization, or schedules to the extent that major point of activity lost. Perfectionism that interferes with task completion. Excessive devotion to work/productivity to exclusion of leisure activities and friendships. Difficulty expressing affection; relationships are often stiff and superficial. Overly conscientious, scrupulous, inflexible about matters of morality, ethics, values. Inability to discard worn-out or worthless objects. Reluctant to delegate tasks or work with others. Rigidity and stubbornness. Unreasonably high standards for self and others; fear of making mistakes/decisions. As many as 7.9% of adult population affected. Men are twice as likely as women to display disorder.

Schizotypal Personality Disorder

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 ad eccentricities (APA, 2013). -Ideas of reference. -Unusual perceptual experiences (bodily illusions). -Odd, eccentric, or peculiar behavior. -Odd speech (digressive and vague conversation, even sprinkled with loose associations). Affects 3.9% of adults; slightly more males than females. -Odd beliefs or magical thinking not consistent with cultural norms (extreme superstition; unusual beliefs in magic or the supernatural). -Suspicious and paranoid ideation. -Lack close friends other than first- degree relatives. -Social anxiety; chronic feelings of not "fitting in".

Avoidant Personality Disorder

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation (APA, 2013). Avoids occupational activities that involve interpersonal contact due to fear of criticism, disapproval, or rejection. Unwilling to get involved with people unless certain of being liked. Consistent discomfort and restraint in social situations. Preoccupation with being criticized or rejected. Self-view: socially inept, personally unappealing, inferior. Unusual reluctance to take personal risks or engage in new activities. Want intimate relationships but few or no close friends. Similar to Social Anxiety Disorder. At least 2.4% of adults; men as frequently as women. Treatments for this cluster appear to be modestly to moderately helpful, which is considerably better than the outcomes with other personality disorders.

Criteria: General Personality Disorder (APA, 2013)

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas: 1. Cognition (ways of perceiving/interpreting self, others, events). 2. Affectivity (range, intensity, lability (mood swings), and appropriateness of emotional response). 3. Interpersonal functioning. 4. 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. -can distress the impaired person as well as those around them D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. -not diagnosed til 18 years old

Multicultural Factors: Research Neglect

According to DSM-5, a pattern diagnosed as a personality disorder must "deviate markedly from the expectations of a person's culture". Lack of multicultural research is of special concern regarding borderline personality disorder (gender and other cultural factors). 75% women. Genetic predisposition or diagnostic bias? Reactions to marginalization, powerlessness, social inequality. Clinical theorists have suspicions, but no compelling evidence, that cultural differences exist.

Personality disorder—trait specified

According to the proposal, five groups of problematic traits would be eligible for a diagnosis of PDTS: Negative affectivity Detachment Antagonism Disinhibition Psychoticism This dimensional approach to personality disorders may improve DSM-5's current categorical approach.

Whom Do You Distrust?

Although distrust and suspiciousness are the hallmarks of paranoid personality disorder, even people without this disorder are often untrusting. In various surveys, the majority of respondents have said they distrust Internet information, the mass media (newspapers, TV, and radio), and members of Congress.

Selfies: Narcissistic or Not?

As the selfie phenomenon has grown, opinions about selfies have intensified (Diefenbach & Christoforakos, 2017). Turkle suggests that people who post an endless stream of selfies are often seeking external validation of their self-worth, even if that pursuit may not rise to a level of clinical narcissism. Other psychologists believe that, for the most part, selfies are an inevitable by-product of "technology-enabled self-expression" What do you think???

Borderline Personality Disorder INTEGRATIVE EXPLANATIONS

Biosocial: combination of internal and external forces. -Children have intrinsic difficulty identifying/controlling emotions; parents teach them to ignore their feelings. Developmental psychopathology: childhood traumas and dysfunctional parental attachments🡪 flawed capacity for healthy relationships; positive factors can counter. Mentalization deficits: The capacity to understand one's own mental state in relation to others Dysfunctional attachment relationships.

Personality disorder - trait specified: DSM-5's proposed dimensional approach (APA, 2013).

Categorical approach assumes: Problematic personality traits are either present or absent. Personality disorder is either displayed or not displayed. A person who suffers from a personality disorder is not markedly troubled by personality traits outside of that disorder.

Cluster C - "Anxious" Personality Disorders

Cluster of "anxiety" personality disorders includes: Avoidant personality disorder Dependent personality disorder Obsessive-compulsive disorder People with these disorders typically display anxious and fearful behavior. As with most of the personality disorders, research is limited.

Cluster B: "Dramatic" Personality Disorders

Cluster of "dramatic" personality disorders includes: Antisocial personality disorder Borderline personality disorder Histrionic personality disorder Narcissistic personality disorder Dramatic, emotional, or erratic problems make it almost impossible to establish relationships. Disorder causes are not well understood; treatments are ineffective to moderately effective.

Schizotypal Personality Disorder TREATMENTS FOR SCHIZOTYPAL PERSONALITY DISORDER

Cognitive-Behavioral: Behavioral: speech lessons; social skills raining; appropriate dress and manners. Cognitive: help client recognize unusual thoughts and magical predictions. Drug Therapy: low-dose antipsychotic drugs beneficial for some patients.

Clusters

DSM-5 (APA, 2013) identifies 10 Personality Disorders, which are organized into three categories (clusters): Cluster A: odd and eccentric patterns of thinking (schizoid, schizotypal, and paranoid personality disorders). Cluster B: dramatic, emotional, impulsive, or erratic social behavior (histrionic, narcissistic, antisocial and borderline personality disorders). Cluster C: highly anxious emotional and interpersonal styles (dependent, avoidant, and obsessive-compulsive personality disorders).

Personality disorder - trait specified

DSM-5 framers designed an alternative dimensional approach for possible use in a future revision. People whose traits significantly impair their functioning should receive a diagnosis of personality disorder - trait specified (PDTS). When assigning this diagnosis, clinicians would also identify and list the problematic traits and rate the severity of impairment caused by them.

Antisocial Personality Disorder TREATMENTS FOR ANTISOCIAL PERSONALITY DISORDER

Education, therapeutic community, psychotropic medication. Typically ineffective due to lack of conscience and lack of desire to change. Most forced into treatment through employment, school, or the law. May see reduction in antisocial behaviors by fourth decade of life.

Dimensional approach: proposed alternative.

Each specific trait seen as varying along continuum from non-problematic to extremely problematic. Personality disorders: extreme degrees.

Phrenology

Early "Personality Assessment" -Phrenology: distinct human faculties identified and located in precisely defined areas of the brain. Phrenologists assessed personality by feeling bumps and indentations on a person's head. "Pseudoscience".

Mass Murders: Where Does Such Violence Come From?

Most clinicians believe that mass killers typically suffer from a mental disorder, but there is little agreement about which disorders. Antisocial, borderline, paranoid, or schizotypal personality disorder may be a factor in persons who exhibit this type of behavior. Other severe thought, mood, and/or conduct disorder; may be in combination with personality disorder.

Narcissistic Personality Disorder TREATMENT FOR NARCISSISTIC PERSONALITY DISORDER

One of the most difficult personality patterns to treat. Therapy for related disorder. Client may try to manipulate therapist to support sense of superiority. Psychodynamic (Object Relations): recognize and work through basic insecurities and defenses. Cognitive-Behavioral: self-centered thinking/redirection. No major treatment approaches have had much success.

Cluster A: "odd" personality disorders includes:

Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder. (closest to schizophrenia) People with these disorders display behaviors similar to, but not as extensive as, schizophrenia. Few people with these disorders seek treatment; treatment success is limited. *people with personality disorders are ego-syntonic: that is just who they are and they accept that -only treatment if causing anxiety

Personality

Personality: a set of uniquely expressed characteristics that influence our behaviors, emotions, thoughts, and Interactions (Comer & Comer, 2017). Early attempts to assess personality: Franz Joseph Gall (1758-1828): brain consists of distinct portions. Mind composed of a number of "faculties": intellectual and affective. Each faculty lies in specific area of cortex for everyone. Strength of faculties in skull shape = Doctrine of the Skull

Antisocial Personality Disorder (psychopaths, sociopaths)

Pervasive pattern of disregard for and violation of the rights of others with evidence of conduct disorder prior to age 15. Failure to conform to social norms of lawful behavior. Deceitfulness; repeated lying. Irritability and aggressiveness; repeated physical fights/assaults. ****Lack of remorse: indifferent to or rationalizing having hurt, mistreated, stolen from another.****KNOW Aside from substance-related disorders, this is the disorder most linked to adult criminal behavior. Most people with an antisocial personality disorder displayed some patterns of misbehavior before they were 15 years old. Consistent irresponsibility regarding work and financial obligations). Higher rates of substance use disorders. Person be at least 18 years of age (DSM-5). Found in 3.6% of U.S. adults. Four times more common in men than in women. ex./ Financier Bernard Madoff sentenced 150 years after defrauding thousands of investors of billions of dollars.

Histrionic Personality Disorder

Pervasive pattern of excessive emotionality and attention seeking in varying contexts (APA, 2013) -Continually seek to be center of attention. -Inappropriate sexually seductive or provocative behavior. -Rapid shifting, shallow expression of emotions. -Uses physical appearance to draw attention to self. -Dramatic, theatrical, always "on stage"; extreme emotionality. Cannot delay gratification long. Seek approval and praise. Vain, self-centered, demanding. Some make suicide attempts, often to manipulate others. Found in 1.8% of U.S. adults. Male to female ratio = equal.

TREATMENTS FOR PARANOID PERSONALITY DISORDER

Psychodynamic: Object Relations Self Therapy Cognitive-Behavioral Therapy: Behavioral: reducing anxiety; improving interpersonal problem solving skills. Cognitive: developing more realistic interpretations of words and actions of others. Drug Therapy: seems to have limited success.

Henry Lavery's "psychograph"

Phrenology brief revival early 1930's.

Obsessive-Compulsive Personality Disorder THEORETICAL EXPLANATION

Psychodynamic (Freudian): overly harsh toilet training during anal stage; anal retentive and fixated. Cognitive-Behavioral: illogical thinking processes. Dichotomous thinking🡪 rigidity and perfectionism. Exaggeration of potential outcome of mistakes/errors.

Schizoid Personality Disorder THEORETICAL EXPLANATIONS

Psychodynamic (Object Relations; Self Therapy): roots in unsatisfied need for human contact. Cognitive-Behavioral Therapy: Focus on cognitive deficiencies (vague, empty thoughts without much meaning). Difficulty scanning environment; picking up emotional cues from others. Cannot respond to emotions.

Histrionic Personality Disorder TREATMENT FOR HISTRIONIC PERSONALITY DISORDER

Psychodynamic and group therapies: help client recognize excess dependence; find inner satisfaction; increase self reliance. Cognitive-Behavioral: help clients change belief that they re helpless. Develop better and more deliberate ways of thinking, problem-solving. Drug Therapy: less successful except for depression symptom relief.

Borderline Personality Disorder THEORETICAL EXPLANATIONS

Psychodynamic: Early parental relationships. Object Relations: lack of early acceptance by parents🡪 loss self-esteem, increased dependence, inability to cope with separation. Biological: genetic predisposition; lower brain serotonin activity; abnormal brain activity (especially impulsivity with suicidal attempts or aggression toward others). Hyperactive amygdala; underactive hippocampus and prefrontal cortex. Sociocultural: impact of rapidly changing cultures🡪 identity problems, sense of emptiness; anxiety, fear abandonment.

Histrionic Personality Disorder THEORETICAL EXPLANATION

Psychodynamic: Unhealthy relationships with cold, controlling parents in childhood; feelings of being unloved and fear of abandonment; dramatic crisis invented for protection. Cognitive-Behavioral: lack of substance and extreme suggestibility tied to self-focused and emotional behavior; search for others to meet needs related to sense of helplessness. Sociocultural/multicultural: partially influenced by cultural norms and expectations.

Antisocial Personality Disorder THEORETICAL EXPLANATIONS

Psychodynamic: absence of parental love leads to lack of basic trust; research links to childhood stress. Cognitive Behavioral: Behavioral: antisocial symptoms learned through operant conditioning, modeling, imitation. Cognitive: difficulty recognizing others' viewpoints or feelings. Biological: biological predisposition; lower serotonin activity; dysfunctional brain circuits.

Narcissistic Personality Disorder THEORETICAL EXPLANATION

Psychodynamic: childhood with cold, rejecting parents. Object relations: focus on grandiose self-presentation; self-sufficiency replaces warm relationships. Cognitive-Behavioral: disorder may develop when children treated too positively rather than too negatively in early life; overvalue self-worth. Sociocultural: link between narcissistic personality disorder and eras of narcissism in society.

Avoidant Personality Disorder THEORETICAL EXPLANATION

Psychodynamic: focus on shame and insecurity traced to childhood experiences. Development of negative self-image🡪 unlovable in adulthood. Cognitive-Behavioral: harsh criticism and rejection in early childhood🡪 expected rejection; discount of positive feedback; general fear of social involvements. Failure to develop effective social skills.

Paranoid Personality Disorder THEORETICAL EXPLANATIONS

Psychodynamic: linked to patterns of early interactions with demanding parents. -more specifically distant fathers and overbearing and controlling mothers: no love, always on the alert Cognitive-Behavioral: tied to broad maladaptive assumptions. Biological: genetic causes. Little systematic research. -higher rate with first degree relatives *no real way to explain and treat personality disorders

Dependent Personality Disorder TREATMENTS FOR DEPENDENT PERSONALITY DISORDER

Psychodynamic: transference of dependency needs. Like treatment for depression. Cognitive-Behavioral: help clients take control of their lives. Behavioral: assertiveness training to express own wishes. Cognitive: Challenge and change incompetence and helplessness assumptions. Group therapy can be helpful. Drug Therapy: antidepressants when disorder is comorbid with depression.

Dependent Personality Disorder THEORETICAL EXPLANATIONS

Psychodynamic: unresolved conflicts during oral stage. Object Relations: early parental loss or rejection prevents normal attachment and separation. Other psychodynamic: over-involvement or overprotection. Cognitive-Behavioral: Behavioral: unintentional clinging and loyal behavior rewarded by dependent parents. Cognitive: maladaptive attitudes; dichotomous thinking. Inadequate and helpless to deal with world. Need to find person to provide protection.

Borderline Personality Disorder TREATMENTS FOR BORDERLINE PERSONALITY DISORDER

Psychotherapy can eventually lead to some improvement, but difficult building therapeutic alliance. Contemporary Psychodynamic: Relational psychoanalytic therapy. (more supportive). New Wave Cognitive-Behavioral: treatment of choice Dialectical Behavior Therapy (DBT) (Marsha Linehan). Individual and group sessions: skill building; goal setting, psychoeducation; reinforce positive behavior; mindfulness. Drug Therapy: antidepressant, antibipolar, antianxiety, or antipsycotic. Usually adjunct to psychotherapy.

Are There Better Ways to Classify Personality Disorders?

Significant problems posed by DSM-5's current categorical approach. Perhaps personality disorders should be described and classified by dimensional approach (key personality traits). "Big Five" theory of personality (each seen on continuum). Personality disorder: those who display extreme degrees of several key traits not common in general population. DSM-5 model: Personality disorder—trait specified.

Schizotypal Personality Disorder THEORETICAL EXPLANATIONS

Similar factors are at work in schizotypal personality disorder as in schizophrenia and related disorders. Symptoms are often linked to family conflicts and to psychological disorders in parents. Schizotypal personality disorder is linked to some of the same biological factors found in schizophrenia, such as high dopamine activity. Links to mood disorders, especially depression, have been found. -prevalent with 1st degree relatives that have schizophrenia

TREATMENTS FOR SCHIZOID PERSONALITY DISORDER

Unlikely to seek therapy unless some other disorder makes treatment necessary. Cognitive-Behavioral Therapy: Behavioral: social skills training; role-play; exposure techniques; homework assignments. Group therapy. Cognitive: help clients connect with emotions; keep log of pleasurable experiences. Drug Therapy: seems to have limited success.

Personality traits

particular characteristics that lead us to react in fairly predictable yet flexible ways.