ch. 15: personality disorders

antisocial personality vs psychopathy

all psychopaths have antisocial but not all antisocial are psychopaths

checklist

individual displays a long term, rigid, wide ranging pattern of inner exp and behav that leads to dysfunction in at least two of : cog, emotion, social interaction, or impulsivity - symptoms last for years among most difficult psych disorders to treat - affect around 11 % of population - comorbidity is common

1. antisocial

- "psychopaths" or "sociopaths," persistently disregard and violate others' rights (APA, 2013). Aside from substance use disorders, this is the disorder most closely linked to adult criminal behavior. DSM-5 stipulates that a person must be at least 18 years of age to receive this - The disorder is as much as four times more common among men than women. - people with antisocial personality disorder have higher rates of alcoholism and other substance use disorders than do the rest of the population - the personality disorder is manifested by 23 percent of all people with gambling disorder

Multicultural Factors: Research Neglect

- ACCORDING TO THE current criteria of DSM-5, a pattern diagnosed as a personality disorder must "deviate markedly from the expectations of the individual's culture"

How Do Theorists Explain Paranoid Personality Disorder?

- According to one psychodynamic view, some people come to view their environment as hostile as a result of their parents' persistently unreasonable demands. They must always be on the alert because they cannot trust others, and they are likely to develop feelings of extreme anger. They also project these feelings onto others and, as a result, feel increasingly persecuted. - Similarly, some cognitive- behavioral theorists suggest that people with paranoid personality disorder generally hold broad maladaptive assumptions, such as "People are evil" and "People will attack you if given the chance" - biological genetic causes:

How Do Theorists Explain Schizotypal Personality Disorder? ​

- Because the symptoms of schizotypal personality disorder so often resemble those of schizophrenia, researchers have hypothesized that similar factors may be at work in both disorders. - often linked to family conflicts and to psychological disor- ders in parents. - They have also learned that defects in attention and short-​term memory may contribute to schizotypal personality disorder, just as they apparently do to schizophrenia - second. Finally, researchers have linked schizotypal personality disorder to some of the same biological factors found in schizophrenia, such as high activity of the neurotransmitter dopamine, enlarged brain ventricles, smaller temporal lobes, and loss of gray matter

Treatments for Schizoid Personality Disorder

- Cognitive- behavioral therapists have sometimes been able to help people with this disorder experience more positive emotions and more satisfying social interactions - On the cognitive end, their techniques include presenting clients with lists of emotions to think about or having them write down and remember pleasurable experiences. On the behavioral end, therapists have sometimes had success teaching social skills to such clients, using role- playing, exposure techniques, and homework assignments as tools. Group therapy is apparently useful when it offers a safe setting for social contact, although people with schizoid personality disorder may resist pressure to take part

How Do Theorists Explain Dependent Personality Disorder?

- Freudian theorists argue, for example, that unresolved conflicts during the oral stage of development can give rise to a lifelong need for nurturance, thus heighten- ing the likelihood of a dependent personality disorder. Similarly, object relations theorists say that early parental loss or rejection may prevent normal experiences of attachment and sep- aration, leaving some children with fears of abandonment that persist throughout their lives. Still other psychodynamic theorists suggest that, to the contrary, many parents of people with this disorder were overcon- trolling and overprotective, thus increasing their children's dependency, insecurity, and separation anxiety - Cognitive- behavioral theorists point to both behavioral and cognitive factors in their explanation of dependent personality disorder. In the behavioral realm, they propose that parents of people with dependent personality disorder unintentionally rewarded their children's clinging and "loyal" behavior, while at the same time punishing acts of independence, perhaps through the withdrawal of love. the cognitive realm, the theorists identify maladaptive attitudes as further helping to produce and maintain this disorder, such as "I am inadequate and helpless to deal with the world,"

How Do Theorists Explain Obsessive- Compulsive Personality Disorder?

- Freudian theorists suggest that people with obsessive- compulsive personality dis- order are anal retentive. That is, because of overly harsh toilet training during the anal stage, they become filled with anger, and they remain fixated at this stage. collectors. Other psychodynamic theorists suggest that any early struggles with parents over control and independence may ignite the aggressive impulses at the root of this personality disorder - cog behav : that illogical thinking processes help keep it going... dichotomous thinking

narcissistic personality disorder

- are generally grandiose, need much admiration, and feel no empathy with others (APA, 2013 ). Convinced of their own great success, power, or beauty, they expect constant attention and admiration from those around them. - more men than women - Narcissistic-​type behaviors and thoughts are common and normal among teenagers and do not usually lead to adult narcissism (see MindTech).

Treatments for Narcissistic Personality Disorder ​

- one of the most difficult personality patterns to treat because the clients are unable to acknowledge weaknesses, to appreciate the effect of their behavior on others, or to incorporate feedback from others. - Psychodynamic therapists seek to help people with this disorder recognize and work through their underlying insecurities and defenses. Cognitive- behavioral therapists, focusing on the self- centered thinking of such individuals, try to redirect the clients' focus onto the opinions of others, teach them to interpret criticism more rationally, increase their ability to empathize, and change their all-or-nothing notions

categorical approach

- Like a light switch that is either on or off, this kind of approach assumes that (1) problematic personality traits are either present or absent in people, (2) a personality disor- der is either displayed or not displayed by a person, and (3) a person who suffers from a personality disorder is not markedly troubled by personality traits outside of that disorder. - but fact, the symptoms of the personality disorders listed in DSM-5 overlap so much that clinicians often find it difficult to distinguish one disorder from another, resulting in frequent disagreements about which diagnosis is correct for a person with a personality disorder.

How Do Theorists Explain Histrionic Personality Dis- order?

- Most psychodynamic theorists believe that as children, people with this disorder had cold and controlling parents who left them feeling unloved and afraid of abandonment. To defend against deep- seated fears of loss, the children learned to behave dramatically, inventing crises that would require other people to act preventingly. - Cognitive-​ behavioral theorists see these individuals as becoming less and less interested in knowing about the world at large because they are so self- focused and emotional. With no detailed memories of what they never learned, they must rely on hunches or on other people to provide them with direction in life. Some such theorists also believe that people with this disorder hold a general assumption that they are helpless to care for themselves, and so they constantly seek out others who will meet their needs - Sociocultural, particularly multicultural, theorists believe that histrionic personality disorder is produced in part by cultural norms and expectations The vain, dramatic, and selfish behavior of the histrionic personality may actually be an exaggeration of femininity as our culture once defined it.

Treatments for Paranoid Personality Disorder

- Object relations therapists — ​the psychodynamic therapists who give center stage to relationships — ​try to see past the patient's anger and work on what they view as the individual's deep wish for a satisfying relationship - Cognitive- behavioral therapy has also been used to treat people with paranoid personality disorder - On the behavioral side, therapists help clients to master anxiety- reduction techniques and to improve their skills at solving interpersonal problems. - On the cognitive side, therapists guide the cli- ents to develop more realistic interpretations of other people's words and actions and to become more aware of other people's points of view. Antipsychotic drug therapy seems to be of limited help

demential instead of categorical classification of personality disorders: the dark triad

- Over the past 15 years, researchers have studied the Dark Triad, a trio of "malicious" traits that work together to produce socially offensive behaviors. People with these traits—narcissism, psychopathy, and Machiavellianism—tend to undermine others, perhaps secretly, to achieve their own ends. a triangle with each corner: 1. Narcissism: Self-admiring Self-absorbed Admiration-seeking Special treatment-seeking Overly entitled Gratification-seeking 2. Psychopathy Callous Insensitive Antisocial Unempathetic Remorseless Disinhibited 3. Machiavellians : Manipulative Self-interested Duplicitous Cynical Amoral Focused on personal gain ***page 483 more info

Treatments for Avoidant Personality Disorder

- They may distrust the therapist's sincerity and start to fear the clinician's rejection. Thus, as with several of the other personality disorders, a key task of the therapist is to gain the person's trust - Beyond building trust, therapists tend to treat people with avoidant personality disorder much as they treat people with social anxiety disorder and other anxiety disorders.

Treatments for Borderline Personality Disorder

- Traditional psychoanalytic therapy has not been effective for people with borderline personality disorder - However, contemporary psychodynamic approaches, particularly relational psychoanalytic therapy (see page 60) and a related treatment called transference- focused psychotherapy — approaches in which therapists take a more supportive posture and focus largely on issues that occur within the therapist- patient relationship — ​have had some success. In these treatments, therapists work to provide an empathic setting within which borderline clients can explore their unconscious conflicts and pay attention to their central relationship disturbance, poor sense of self, and perva- sive loneliness and emptiness. Research has found that contemporary psychodynamic approaches of this kind may help reduce suicide attempts, self-​harm behaviors, and the number of hospitalizations, and bring at least some improvement to those with the disorder - dialectical behavior therapy (DBT), of weekly individual therapy and group skill- building sessions that last for approximately one year. While targeting all of the features of borderline personality disorder, DBT places special emphasis on clients' efforts at self-​harm and/ or suicide. include many of the same behavioral and cognitive techniques DBT clients also participate in social skill-building groups. - Antidepressant, mood- stabilizing, antianxiety, and antipsychotic drugs have helped calm the emotional and aggressive storms of some people with borderline personality disorder. How- ever, given the numerous suicide attempts by people with this disorder, some clinicians believe that the use of drugs on an outpatient basis is unwise. Most professionals believe that psychotropic drug treatment for this disorder should be used largely as an adjunct to psychotherapy approaches, and indeed many clients seem to benefit from a combination of psychotherapy and drug therapy

histrionic personality disorder

- are extremely emotional — they are typically described as "emotionally charged" — and continually seek to be the center of attention - chameleons, they keep changing themselves to attract and impress an audience, and in their pursuit they change not only their surface characteristics — according to the latest fads — ​but also their opinions and beliefs. In fact, their speech is actually scanty in detail and substance, and they seem to lack a sense of who they really are. - Surveys suggest that around 2 percent of adults have this personality disorder, with women receiving the diagnosis more often than men

3. obsessive-compulsive personality disorder

- are so preoccupied with order, perfection, and control that they lose all flexibility, openness, and efficiency - They also tend to be rigid and stubborn, particularly in their morals, ethics, and values. They live by a strict personal code and use it as a yardstick for measuring others. They may have trouble expressing much affection, and their relationships are some- times stiff and superficial. In addition, they are often stingy with their time or money. Some cannot even throw away objects that are worn out or useless - Men are twice as likely as women to display the disorder. - people with the personality disorder are more likely to suffer from either major depressive disorder, an anxiety disorder, or a substance use disorder than from obsessive- compulsive disorder

1. avoidant personality disorder

- are very uncomfortable and inhibited in social situations, overwhelmed by feelings of inadequacy, and extremely sensitive to negative evaluation (APA, 2013 ). They are so fearful of being rejected that they give no one an opportunity to reject them — or to accept them either: - contact. At the center of this withdrawal lies not so much poor social skills as a dread of criticism, disapproval, or rejection. - similar to social anxiety disorder... but people with social anxiety disorder primarily fear social circumstances, while people with the personality disorder tend to fear close social relationships.

Treatments for Schizotypal Personality Disorder

- behavioral: Most therapists agree on the need to help these clients "reconnect" with the world and recognize the limits of their thinking and their powers. begin. Other therapy goals are to increase positive social contacts, ease loneliness, reduce overstimulation, and help the individuals become more aware of their personal feelings - Cognitive- behavioral therapists further try to teach clients to evaluate their unusual thoughts or perceptions objectively and to ignore the inappropriate ones

Treatments for Dependent Personality Disorder

- clinician. Thus a key task of therapy is to help patients accept responsibility for themselves (Skodol & Bender, 2019). Because the domineering behaviors of a spouse or parent may help foster a patient's symptoms, some clinicians suggest couple or family therapy as well, or even separate therapy for the partner or parent. - On the behavioral end, the therapists often provide assertiveness training to help the individuals better express their own wishes in relationships. On the cognitive end, the therapists also try to help the clients challenge and change their assumptions of incompetence and helplessness

1. paranoid personality disorder

- deeply distrust other people and are suspicious of others' motives - People with this disorder are critical of weakness and fault in others, particularly at work (Skodol, 2019b). They are unable to recognize their own mistakes, though, and are extremely sensitive to criticism.

schizotypal personality disorder

- display a range of interpersonal problems marked by extreme discomfort in close relationships, very odd patterns of thinking and perceiving, and behavioral eccentricities (APA, 2013 ). Anxious around others, they seek isolation and have few close friends. - These symptoms may include ideas of reference — ​ beliefs that unrelated events pertain to them in some important way — ​and bodily illusions, such as sensing an external "force" or presence.

personality disorder

- display an enduring, rigid pattern of inner experience and outward behavior that impairs their sense of self, emotional experiences, goals, capacity for empathy, and/or capacity for intimacy (APA, 2013 ) (see Table 15-1). Put another way, they have personality traits that are much more extreme and dysfunctional than those of most other people in their culture, leading to significant problems and psychological pain for themselves or others.

2. borderline personality disorder

- display great instability, including major shifts in mood, an unstable self-image, and impulsivity - interpersonal relationships unstable - swing in and out of very depressive, anxious, and irritable states that last anywhere from a few hours to a few days or more - Many try to hurt themselves as a way of dealing with their chronic feelings of emptiness, boredom, and identity confusion. - typically have dramatic identity shifts. Because of this unstable sense of self, their goals, aspirations, friends, and even sexual orientation may shift rapidly. - prone to bouts of anger that sometime results in physical aggression and violence,

Treatments for Obsessive-Compulsive Per- sonality Disorder

- don't usually think there is anything wrong with them, so Because of this, therapists often feel as though they must "win over" and engage the clients in the therapy process.

Treatments for Antisocial Personality Disorder

- education, therapeutic community, psychotropic medication - ineffective and Major obstacles to treatment include the individual's lacking a conscience, a desire to change, or respect for therapy. - Cognitive- behavioral therapists may try to guide clients with antisocial personality disorder to think about moral issues and about the needs of other people.

2. dependent personality disorder

- have a pervasive, excessive need to be taken care of (APA, 2013 ). As a result, they are clinging and obedient, fearing separation from their parent, spouse, or other person with whom they are in a close relationship. They rely on others so much that they cannot make the smallest decision for themselves. - Because they so fear rejection, they are overly sensitive to disapproval and keep trying to meet other people's wishes and expectations, even if it means volunteering for unpleasant or demeaning tasks. - Many people with dependent personality disorder feel dis- tressed, lonely, and sad; often they dislike themselves. Thus they are at risk for depressive, anxiety, and eating disorders

The "Big Five" Theory of Personality and Personality Disorders

- of five "supertraits," or factors — ​ neuroticism, extroversion, openness to experiences, agreeableness, and conscientious- ness - Each of these factors, which are frequently referred to as the "Big Five," consists of a number of subfactors. Anxiety and hostility, for example, are subfactors of the neuroticism factor, while optimism and friendliness are subfactors of the extroversion factor. Theoretically, everyone's personality can be summarized by a combination of these supertraits.

schizoid personality disorder

- persistently avoid and are removed from social relationships and demonstrate little in the way of emotion... they genuinely prefer to be alone. - People with schizoid personality disorder focus mainly on themselves and are generally unaffected by praise or criticism. They rarely show any feelings, expressing neither joy nor anger. They seem to have no need for attention or acceptance; are typ- ically viewed as cold, humorless, or dull; and generally succeed in being ignored. - slightly more common in men than in women

personality

- personality — a set of uniquely expressed characteristics that influence our behaviors, emotions, thoughts, and interactions. Our particular characteristics, often called personality traits, lead us to react in fairly predict- able ways as we move through life.

How Do Theorists Explain Borderline Personality Disorder? ​

- psychodynamic: early parent relationships: Object relations theorists, for example, propose that an early lack of acceptance by parents may lead to a loss of self- esteem, increased dependence, and an inability to cope with separation - predisposition - Borderline personality disorder also has been tied to low serotonin and abnormal activity in certain brain structures, including the amygdala (hyperactive), hippocampus (underactive), prefrontal cortex (underactive), and other structures in the frontal lobes — structures that collectively help people plan well, form accurate judgments, make good decisions, exercise self- control, and express emotions properly - some sociocultural theorists suggest that cases of borderline personality dis- order are particularly likely to emerge in cultures that change rapidly. As a culture loses its stability, they argue, it inevitably leaves many of its members with problems of identity, a sense of emptiness, high anxiety, and fears of abandonment. - developmental: interested in all such factors — ​from genetic to environmental — ​they also believe that early parent-child relationships are particularly influential in the development of borderline personality disorder... disorder. Consistent with the psychodynamic model's object relations theorists, developmental psychopathologists contend that children who experience early trauma and abuse and whose parents are markedly inattentive, uncaring, confusing, threatening, and dismissive are likely to enter adulthood with a disorganized attachment style — ​a severely flawed capacity for healthy relationships... developmental psychopathology theorists have also come to believe that a central psychological deficit in borderline personality disorder is the person's inability to mentalize. "Mentalization" refers to people's capacity to understand their own mental states and those of other people — ​that is, to recognize needs, desires, feelings, beliefs, and goals. that persons who emerge from childhood with a disorganized attachment style have a weakened ability to mentalize and, correspondingly, a poor ability to control their own emotions, attention, thinking, and behavior, and their relationships. As one theorist has stated, a mind that repeatedly misinterprets itself is going to misinterpret others as well

How Do Theorists Explain Narcissistic Personality Disorder? ​

- psychodynamic: focus on psycho; cold, rejecting parents - cognitive- behavioral theorists propose that narcissistic personality dis- order may develop when people are treated too positively rather than too negatively in early life. - sociocultural theorists: see a link between personality disorder and eras of narcassism.

How Do Theorists Explain Schizoid Personality Disorder?

- psychodynamic: unsatisfied need for human contact. The parents of people with this disorder, like those of people with paranoid personality disorder, are believed to have been un- accepting or even abusive of their children. - Cognitive- behavioral theorists propose, not surprisingly, that people with schizoid personality disorder suffer from deficien- cies in their thinking.

How Do Theorists Explain Avoidant Personality Disorder?

- same causes as anxiety disorders — ​such as early traumas, conditioned fears, upsetting beliefs, or biochemical abnormalities. - Psychodynamic theorists focus mainly on the general feelings of shame and insecurity that people with avoidant personality disorder have. Some trace the shame to childhood experiences such as early bowel and bladder accidents. - cognitive-behavioral theorists believe that harsh criticism and rejection in early childhood may lead certain people to assume that others in their environment will always judge them negatively... and fail to develop effective social skills, a failure that helps maintain the dis- order.

Treatments for Histrionic Personality Disorder

- ​People with histrionic personality disorder are more likely than those with most other personality disorders to seek out treatment on their own. Working with clients with histrionic personality disorder can be very difficult because of the demands, tantrums, and seductiveness they may deploy - In all of these approaches, therapists ultimately aim to help the clients recognize their excessive dependency, find inner satisfaction, cope better, and become more self- reliant

ABCS of psych functioning:

A-affect: range , intensity, and changeability of emotions and emotional responsiveness B-behavior: ability to control impulses and interactions with others C-cognition- perception and interpretations of events, other people, and oneself

dimensional approach

They believe that personality disorders differ more in degree than in type of dysfunction and should instead be classified by the severity of personality traits rather than by the presence or absence of specific traits — ​a pro- cedure called a dimensional approach - each trait is seen as varying along a continuum extending from nonproblematic to extremely problematic. - After much debate, they decided to retain a classic 10-disorder categorical approach in the current DSM. At the same time, however, the framers acknowledged the likely future direction of personality disorder classifications by also describing an alternative dimensional approach.

How Do Theorists Explain Antisocial Personality Disorder?

a. disorders, psychodynamic theorists propose that this one begins with an absence of parental love during infancy, leading to a lack of basic trust. In this view, some children — ​the ones who develop antisocial personality disorder — respond to the early inadequacies by becoming emotionally distant, and they bond with others through the use of power and destructiveness. In support of the psycho- dynamic explanation, researchers have found that people with this disorder are more likely than others to have had significant stress in their childhoods, particularly in such forms as family poverty, family violence, child abuse, and parental conflict or divorce. b. cog behav : - On the behavioral side, they suggest that antisocial symptoms may be learned through principles of conditioning, particularly modeling, or imitation. - operant conditioning to help explain this disorder. They suggest that some parents unintentionally teach antisocial behavior by regularly rewarding a child's aggressive behavior. - cognitive side, cognitive-behavioral theorists say that people with antisocial personality disorder often hold attitudes that trivialize the importance of other people's needs . people with this disorder have genuine difficulty recognizing points of view or feelings other than their own9 c. biological: - predisposition - particularly those who are highly impulsive and aggressive, have lower activity of the neurotransmitter serotonin than other people - studies indicate that individuals with this disorder display deficient functioning in their prefrontal cortex, anterior cingulate cortex, amygdala, hippocampus, and temporal cortex — ​brain structures that, collectively, help people follow rules; plan and execute realistic strategies; and display sympathy, judgment, and empathy - poor functioning by a brain circuit consisting of the structures mentioned above. Poor communication (that is, poor interconnectivity) between those structures in the circuit may produce chronic low reactions to stress by the two brain-body stress routes — the sympathetic nervous system and the hypothalamic- pituitary- adrenal axis — leading, in turn, to a state of low arousal, weak stress reactions, poor empathy for the pain of others, and other features of antisocial personality disorder

"Personality Disorder — Trait Specified": DSM-5's Proposed Dimensional Approach

approach. It begins with the notion that people whose traits significantly impair their functioning should receive a diagnosis called personality disorder — ​trait specified (PDTS) (APA, 2013). When assigning this diagnosis, clinicians would also identify and list the problematic traits and rate the severity of impairment caused by them. According to the proposal, five groups of problematic traits would be eligible for a diagnosis of PDTS: negative affectivity, de- tachment, antagonism, disinhibition, and psychoticism: a. Negative Affectivity People who display negative affectivity experience negative emotions frequently and intensely. b. Detachment People who manifest detachment tend to withdraw from other people and social interactions. c. Antagonism People who display antagonism behave in ways that put them at odds with other people. They may exhibit any of the following traits: manipulativeness, deceitfulness, grandiosity, attention seeking, callousness, and hostility. d.Disinhibition People who manifest disinhibition behave impulsively, without reflecting on potential future consequences. They may exhibit any of the following traits: irresponsibility, impulsivity, distractibility, risk taking, and imperfection/ disorganization. e. Psychoticism People who display psychoticism have unusual and bizarre experiences. They may exhibit any of the following traits: unusual beliefs and experiences, eccentricity, and cognitive and perceptual dysregulation (odd thought processes and sensory experiences). - If a person is impaired significantly by any of the five trait groups, or even by just 1 of the 25 traits that make up those groups, the individual would qualify for a diagnosis of personality disorder — ​trait specified. - According to this dimensional approach, when clinicians assign a diagnosis of per- sonality disorder — trait specified, they also must rate the degree of dysfunction caused by each of the person's traits, using a five-point scale ranging from "little or no impair- ment" (Rating = 0) to "extreme impairment" (Rating = 4).

ANXIOUS PERSONALITY DISORDERS

avoidant, dependent, and obsessive- compulsive personality disorders.

"Odd" Personality Disorders (Cluster A)

paranoid, schizoid, schizotypal - People with these disorders typically have odd or ec- centric behaviors that are similar to but not as extensive as those seen in schizophrenia, including extreme suspiciousness, social withdrawal, and peculiar ways of thinking and perceiving things.