Personality Disorders

Personality Disorders (Axis II): Are long-standing, pervasive, & inflexible patterns of behavior. Are long-standing, pervasive, & inflexible patterns of behavior. Usually impair social & occupational functioning. Usually impair social & occupational functioning. Are often comorbid with Axis I disorders. Are often comorbid with Axis I disorders. Make treating an Axis I disorder more difficult. Make treating an Axis I disorder more difficult.

Personality disorder clusters in the DSM-IV Cluster A (paranoid, schizoid, & schizotypal): odd/eccentric Cluster A (paranoid, schizoid, & schizotypal): odd/eccentric Cluster B (antisocial, borderline, histrionic, & narcissistic): dramatic/erratic Cluster B (antisocial, borderline, histrionic, & narcissistic): dramatic/erratic Cluster C (avoidant, dependent, & obsessive-compulsive): anxious/fearful Cluster C (avoidant, dependent, & obsessive-compulsive): anxious/fearful

I. Odd/Eccentric Cluster: 1. Paranoid Personality Disorder: PPD 1. Paranoid Personality Disorder: PPD Suspiciousness of others is hallmark of personality. --secretiveness; hostility & anger --secretiveness; hostility & anger --assume others are out to harm them --assume others are out to harm them --reluctant to confide in others; --reluctant to confide in others; --blame others when they are at fault --blame others when they are at fault --jealous & accusatory --jealous & accusatory -read hidden messages in others actions -read hidden messages in others actions Prevalence (1%): occurs mostly in men Prevalence (1%): occurs mostly in men

How does PPD differ from paranoid schizophrenia? Hallucinations & other symptoms (negative) aren’t present in PPD. Hallucinations & other symptoms (negative) aren’t present in PPD. Impairment in functioning is less than in schizophrenia. Impairment in functioning is less than in schizophrenia. **Also differs from delusional disorder because delusions are not full-blown. **Also differs from delusional disorder because delusions are not full-blown.

2. Schizoid personality disorder People with this: appear dull, bland, aloof appear dull, bland, aloof -don’t show warmth for or interest in others -don’t show warmth for or interest in others -report little enjoyment in life -report little enjoyment in life -are indifferent to praise, criticism; -are indifferent to praise, criticism; -show flat affect; are loners -show flat affect; are loners Prevalence (less than 1%); occurs more in men Prevalence (less than 1%); occurs more in men

3. Schizotypal personality disorder: Have interpersonal problems of people with schizoid PD & excessive social anxiety that does not diminish. Have interpersonal problems of people with schizoid PD & excessive social anxiety that does not diminish. These people: -are superstitious (magical thinking) -are superstitious (magical thinking) -think they’re clairvoyant & telepathic -think they’re clairvoyant & telepathic -behavior & dress oddly -behavior & dress oddly -may show paranoid ideation -may show paranoid ideation -may show flat affect -may show flat affect Is like a mild version of schizophrenia; prevalence- 3%; mostly in males Is like a mild version of schizophrenia; prevalence- 3%; mostly in males

Etiology of Odd/Eccentric cluster May be genetically linked. Relatives of schizophrenics & patients with major depression are at increased risk for schizotypal personality disorder. Family studies of PPD find higher rates of disorder in relatives of schizophrenics. No clear pattern has emerged for schizoid personality disorder. Is higher among relatives with schizotypal personality disorder. No clear pattern has emerged for schizoid personality disorder. Is higher among relatives with schizotypal personality disorder.

II. Dramatic/erratic cluster: 1. Borderline personality disorder (BPD): 1. Borderline personality disorder (BPD): Core features are impulsivity & instability in relationships, mood, & self-image. Core features are impulsivity & instability in relationships, mood, & self-image. -attitudes, thoughts, & emotions are erratic -attitudes, thoughts, & emotions are erratic -emotions shift abruptly from idealization to contemptuous anger (angel to devil) -emotions shift abruptly from idealization to contemptuous anger (angel to devil) -argumentative, irritable, sarcastic, defensive -argumentative, irritable, sarcastic, defensive -indulge in self destructive behaviors (drugs, sex) -indulge in self destructive behaviors (drugs, sex) -lack of coherent sense of self -lack of coherent sense of self -self mutilation (cutting with razor/knife) -self mutilation (cutting with razor/knife) -suicide attempts -suicide attempts -intense fear of abandonment -intense fear of abandonment

Borderline PD: Facts Prevalence is 1 to 2 %; more common in women than in men. Prevalence is 1 to 2 %; more common in women than in men. Treatment prognosis is very poor; extremely difficult to treat. Treatment prognosis is very poor; extremely difficult to treat. In a 7 year follow-up study, 50% of patients still had disorder. In a 7 year follow-up study, 50% of patients still had disorder. Comorbidity with Axis I mood disorder, substance abuse, PTSD, and eating disorders Comorbidity with Axis I mood disorder, substance abuse, PTSD, and eating disorders

Kellerman’s account: “The borderline patient is a therapist’s nightmare...because borderlines never really get better. The best you can do is help them coast, without getting sucked into their pathology...They’re chronically depressed, the determinedly addictive, the compulsively divorced, living from one emotional disaster to the next. Bed hoppers, stomach pumpers, freeway jumpers, and sad-eyed bench-sitters with arms stitched up like footballs and psychic wounds that can never be sutured. Their egos are as fragile as spun sugar, their psyches irretrievably fragmented, like a jigsaw puzzle with crucial pieces missing. They play roles with alacrity, excel at being anyone but themselves, crave intimacy but repel it when they find it. Some of them gravitate toward stage or screen; others do their acting in more subtle ways. “The borderline patient is a therapist’s nightmare...because borderlines never really get better. The best you can do is help them coast, without getting sucked into their pathology...They’re chronically depressed, the determinedly addictive, the compulsively divorced, living from one emotional disaster to the next. Bed hoppers, stomach pumpers, freeway jumpers, and sad-eyed bench-sitters with arms stitched up like footballs and psychic wounds that can never be sutured. Their egos are as fragile as spun sugar, their psyches irretrievably fragmented, like a jigsaw puzzle with crucial pieces missing. They play roles with alacrity, excel at being anyone but themselves, crave intimacy but repel it when they find it. Some of them gravitate toward stage or screen; others do their acting in more subtle ways. Borderlines go from therapist to therapist, hoping to find a magic bullet for the crushing feelings of emptiness. They turn to chemical bullets, gobble tranquilizers and antidepressants, alcohol and cocaine. Embrace gurus and heaven-hucksters, any charismatic creep promising a quick fix for the pain. And they end up taking temporary vacations in psychiatric wards and prison cells, emerge looking good, raising everyone’s hopes. Until the next letdown, real or imagined, the next excursion into self-damage. What they don’t do is change.” Borderlines go from therapist to therapist, hoping to find a magic bullet for the crushing feelings of emptiness. They turn to chemical bullets, gobble tranquilizers and antidepressants, alcohol and cocaine. Embrace gurus and heaven-hucksters, any charismatic creep promising a quick fix for the pain. And they end up taking temporary vacations in psychiatric wards and prison cells, emerge looking good, raising everyone’s hopes. Until the next letdown, real or imagined, the next excursion into self-damage. What they don’t do is change.”

Causes of BPD 1. Object-Relations Theory 1. Object-Relations Theory Adverse childhood experiences (receiving praise, but not warmth) cause children to develop insecure egos. Adverse childhood experiences (receiving praise, but not warmth) cause children to develop insecure egos. Patients engage in splitting– where they lump objects into all good or all bad categories (black-n-white thinking). Patients engage in splitting– where they lump objects into all good or all bad categories (black-n-white thinking). Evidence: Evidence: *BPD patients report low level of maternal care *BPD patients report low level of maternal care *families are emotionally unexpressive, high in conflict. *families are emotionally unexpressive, high in conflict. *childhood sexual & physical abuse common *childhood sexual & physical abuse common

Linehan’s Diathesis-Stress theory BPD occurs when people with a biological diathesis (possibly genetic) of emotion dysregulation are raised in a family environment that is invalidating. BPD occurs when people with a biological diathesis (possibly genetic) of emotion dysregulation are raised in a family environment that is invalidating. An invalidating environment-the persons wants and feelings are discounted and disrespected. An invalidating environment-the persons wants and feelings are discounted and disrespected. (child abuse) (child abuse) dysregulation & invalidation interact in a dynamic system. dysregulation & invalidation interact in a dynamic system.

2. Histrionic personality disorder (HPD) 2. Histrionic personality disorder (HPD) Applies to people who are overly dramatic & attention seeking. Applies to people who are overly dramatic & attention seeking. Symptoms: Symptoms: -attention to physical appearance -attention to physical appearance -may act inappropriately sexual -may act inappropriately sexual -needs to be center of attention -needs to be center of attention -displays of emotion are extravagant & shallow -displays of emotion are extravagant & shallow Prevalence (2-3 %), occurs more in women than men. Prevalence (2-3 %), occurs more in women than men.

3. Narcissistic personality disorder (NPD) Core feature: they are the “center of the universe” Core feature: they are the “center of the universe” -grandiose view of one’s own importance -grandiose view of one’s own importance -great fantasies of success -great fantasies of success -extremely self-centered -extremely self-centered -require constant attention & admiration -require constant attention & admiration -lack empathy for others; expect special considerations -lack empathy for others; expect special considerations -malignant arrogance -malignant arrogance Prevalence (less than 1%)

Causes of NPD: Parents did not provide unconditional love & empathy they needed. Parents did not provide unconditional love & empathy they needed. Rather, parents placed their own needs above the needs of the child. Rather, parents placed their own needs above the needs of the child. People with NPD spend lives trying to bolster low sense of self, through endless quests for love & attention. People with NPD spend lives trying to bolster low sense of self, through endless quests for love & attention.

4. Antisocial Personality Disorder (APD): DSM diagnosis: DSM diagnosis: 1. The presence of a conduct disorder before the age of The presence of a conduct disorder before the age of 15 Truancy; running away from home Truancy; running away from home Theft; compulsive lying Theft; compulsive lying Arson; vandalism Arson; vandalism 2. The continuation of this pattern of behavior into adulthood. 2. The continuation of this pattern of behavior into adulthood.

APD features: Irresponsible & antisocial behavior Irresponsible & antisocial behavior Criminality (breaking laws)**core feature Criminality (breaking laws)**core feature Irritability Irritability Physically aggressive Physically aggressive Default on debts Default on debts Impulsivity Impulsivity Pathological lying Pathological lying Lack of remorse ***Not necessary for diagnosis*** Lack of remorse ***Not necessary for diagnosis*** Prevalence: 3% of males; 1% of females Prevalence: 3% of males; 1% of females

Psychopaths Core features- Psychopaths lack remorse Psychopaths lack remorse Poverty of emotions (positive & negative) Poverty of emotions (positive & negative) Psychopaths are: Superficially charming Pathological liars & cheaters Impulsive; sensations seekers Manipulative, will change story to fit facts Less responsive to fear/anxiety Immoral Prevalence greater among men

Psychopaths identified by Hare checklist Two clusters: Two clusters: 1. Emotional detachment cluster (a selfish remorseless individual with inflated self- esteem who exploits others.) 1. Emotional detachment cluster (a selfish remorseless individual with inflated self- esteem who exploits others.) 2. Antisocial lifestyle cluster- marked by impulsivity & irresponsibility. 2. Antisocial lifestyle cluster- marked by impulsivity & irresponsibility.

Problems with diagnosis of APD: 1. You can’t trust reports made by antisocial personalities (they are chronic liars). 1. You can’t trust reports made by antisocial personalities (they are chronic liars). 2. Many researchers believe psychopathology should not be synonymous with criminality. 2. Many researchers believe psychopathology should not be synonymous with criminality. 3. “Lack of remorse,” a core symptom of psychopathy is not required for diagnosis of APD. 3. “Lack of remorse,” a core symptom of psychopathy is not required for diagnosis of APD.

Causes of APD & Psychopathy Family Family Lack of affection & severe parental rejection may cause psychopathic behavior (McCord & McCord, 1964) Lack of affection & severe parental rejection may cause psychopathic behavior (McCord & McCord, 1964) Fathers of psychopaths likely to be antisocial themselves. Fathers of psychopaths likely to be antisocial themselves.

Genetic factors: APD 1. Higher concordance rate for MZ twins than for DZ twins. 1. Higher concordance rate for MZ twins than for DZ twins. 2. Higher rate of antisocial behavior in adopted children of biological parents with APD. 2. Higher rate of antisocial behavior in adopted children of biological parents with APD.

Emotions & Psychopathy Psychopaths feel emotions less intensely than normal individuals. Psychopaths feel emotions less intensely than normal individuals. Psychopaths not under-aroused compared to normal Ss, but are better at tuning out unpleasant stimuli. Psychopaths not under-aroused compared to normal Ss, but are better at tuning out unpleasant stimuli. They lack empathy They lack empathy

III. Anxious/Fearful Cluster: 1. Dependent Personality Disorder: 1. Dependent Personality Disorder: Core feature: lack of self-confidence & autonomy Core feature: lack of self-confidence & autonomy --need to be taken care of --need to be taken care of --uncomfortable with self --uncomfortable with self --intense fear of abandonment --intense fear of abandonment --need to be in relationships --need to be in relationships

2. Obsessive-compulsive Personality disorder: Core feature—perfectionist person preoccupied with details, schedules, & rules. Core feature—perfectionist person preoccupied with details, schedules, & rules. --work oriented --work oriented --difficulty making decisions --difficulty making decisions --poor interpersonal relationships --poor interpersonal relationships --stubborness; need to control events --stubborness; need to control events --rigid thinking—overly moralistic --rigid thinking—overly moralistic Does not include obsessions & compulsions Does not include obsessions & compulsions