1. Personality Disorders

2. Hallmarks of Personality Disorders Stable or persistent maladaptive patterns Problems in at least two areas: –Cognition –Affectivity –Interpersonal functioning –Impulse control

3. Prevalence of Personality Disorders 1 in 10 adults has a personality disorder

4. Cluster A Odd and Eccentric Paranoid –Vigilance, overwhelming fear, hostility –High neuroticism, low agreeableness –2-4% prevalence rates Schizoid –Disinterested, detached (links with asperger syndrome, autism and pdd) –1-3%, higher rates in homeless populations Schizotypal –Odd pecular beliefs or behaviors –Suspicious and apprehensive –Some links with schizophrenic spectrum disorder

5. Cluster B Dramatic, Emotional, Erratic Antisocial –Control or manipulation of others without remorse –Aggressive, controlling, manipulative –1-4 % prevalence rates Borderline –Instability in affect and identity accompanied by rejection fears –Impulsive, self damaging, emptiness, anger and reactive to real/perceived abandonment –2% prevalence rates –10% complete suicide (primarily with comorbid madd, antisocial pd and family histories of substance abuse).

6. Cluster B Histrionic –High levels of emotinality and attention seeking; view relationships as more intimate than they really are –Prevalence rates of ~2% in the general population Narcissitic –Use of grandiosity, entitlement or exploitation to maintain self esteem –Arrogance and superiority, anger, shame and envy, lack of empathy –There is a vulnerable conceptualization of NPD in which the indivdual lacks that gradiose features –~1% in general populations

7. Cluster C Anxious and Fearful Avoidant PD –Shy and guarded, feelings of inadequacy, reticent but longing social inhibition, sensitive to negative evaluation, difficulty with relationship due to fears –2-5% in general population Dependent PD Defers excessively and inappropriately, weak and ineffectual, relationships provide protection and support, needs to be taken care of.5-1.5 % prevalence in general population

8. Cluster C Anxious and Fearful Obsessive compulsive PD –Stubbornly pefectionistic, self-critical, inflexible –Focus on orderliness, perfectionism, mental and interpersonal control –~1% in general population

9. Clark Personality Disorders are Dimensional FFM Neruoticism –Extramversion –Agreeableness –Conscientiousness –Culture/Openness to Experience Domains of normal and abnormal personalities are overlapping Used 30 facets of the Revised NEOPI-R for each PD diagnosis Concerned that the diagnoses themselves do not represent an adequate gold standard Personality Disorders have both current and longlasting effections on functioning though some of these effects may be associated with the comorbid axis I disorders Collateral sources assist with providing reliable/valid information

10. Clark Comorbidity with Axis I disorders: 50% or greater More common with earlier age of onset More severe conditions More challenging to treat More resistant to remission Lower functioning Greater medical utilization More suicide attempts and completion Greater risk of psychopathology in children

11. Clark Comorbidity Pervasive comorbidity of PDs with mood and anxiety disorders (particularly avoidant and dependent PD) Both pd and axis I disorders predict onset of one anothern and share genetic variance with each other and with trait neuroticsm/negative affect In terms of subtypes of comorbidity BPD, OCPD,, avoidant/depent were more common in unipolar Narcisstic PD was more commin in bipolar though BPD features were characteristic of bipolar disorder (BPD also linked to PTSD)

12. Clark Comorbidity Substance abuse comorbidity is particularly strong in cluster b PDs Severity of substance disorder moderates comorbidity e.g., antisocial PD increases about twofold (~30-60%) from mild to severe drug abuse/dependence Comorbidity is associated with pooer outcome Comorbid presentations have earlier substance use and more legal family problems, greater rates of relapse in the presence of cravings, and greater interpersonal conflict Broad underlying factor of externalizing characertized by impulsivity may axis I and II disorders.

13. Clark Comorbidity Avoidant PD was associated with all types of eating disorders (AN restricting, AN bingeing, BN, BED ANR and BED had highest comorbidity with OCPD Severe ED with bingeing associated with BPD BN overlapped with antisocial and narcissistic PD Traits include perfectionism and related OC State effects of starvation may influence the presentation of the pd

14. Clark Stability Dimensional pds are more stable than diagnostic Mean level trait change is moderate through adolescence and well into early adulthood with increasingly levels of positive traits (A and C) and decreasingly levels of negative traits (N/NA) Personality structure is stable as early as adolescence where as individual profile stability is moderate with more change in level and spread than shape (i.e., more quantitative change than qualitative) Personality is set like ‘plaster’ after the age of 50

15. Clark Stability Criteria that are more changeable are odd behvior and constricted affect (schizotypal PD), self injury and abandonment avoidance behaviors (BPD), avoiding inerpersonal jobs and potentially embarrassing situations (avoidant pd), miserly and strict moreal behaviors (OCPD) More stable criteria paranoid ideation (schizotypal), affective instability and anger (BPD), feeling inadequate and socially inept (avoidant PD), and rigidity and difficulty delegating (OCPD).

16. Reconceptualization Integration of Axis I and Axis II Move toward a single hierarchical integrated framework linking temperament with personality and psychopathology (impulsivity/aggression, sleep disturbance, negative affect and serotonin dysfunction) Focus on diagnosing a pd on axis I and describing the traits on axis II