Personality Disorders

Prevalence of Personality Disorders in the U.S

10-15% of ppl in the U.S

-More common in men, young, uneducated, unemployed

Personality Disorder Criteria (3)

A.

pattern of inner experience and behavior that is widely different from expectations of culture

Manifested in 2 or more of the following areas:

1. Cognition – perceiving and interpreting self, others, events

2. Affectivity – range, intensity, lability, appropriateness

3. Interpersonal functioning

4 .Impulse control

B.

Pattern pervasive and inflexible across broad personal & social situations

C.

Pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning

- Pattern stable and of long duration (traced back to at least adolescence or early adulthood)

- Not better accounted for by other mental disorder, physiological effect of substance or medical disease

At what age is a personality disorder diagnosed?

Diagnosis 18 or older

- Children are not usually dx bc personality is not completely developed and symptomatic traits may not persist into adulthood

(if child is dx the traits have to last longer than 1 year)

Causes of personality disorders (4)

Multi-factorial etiologies: biologic, developmental, genetic

1. Frequent psychiatric history... Higher risk for Axis I psych disorders

2. Temperament (genetics) plus character (environment)

3. Developmental abnormalities due to abuse or incest

4. Maladaptive patterns may result from dysfunctional early environments that prevent evolution of adaptive patterns of perception, response and defense

What situation may reveal an unrecognized disorder?

- Stressful situations

Personality disorders increase risks of what? (5)

1. Physical injury from fights

2. Accidents due to impulsive and reckless behavior

3. Unplanned pregnancy, high-risk sexual behavior

4. Suicidal/homicidal ideation and/or attempts

5. Comorbid anxiety, mood disorders (MDD), substance abuse

Cluster A personality disorders (3)

-Odd and eccentric

-Less severe/intense in middle age and late life

-Increase incidence in homeless population

Includes:

1. Paranoid

2.Schizoid

3. Schizotypal

Paranoid Personality disorder (definition and prevalence)

-Extensive distrust or suspiciousness of others such that their motives are interpreted as malicious

-More common in males

* Possible genetic link to Schizophrenia

Paranoid personality disorder Criteria (7)

4 or more of the following:

1. Suspects others are exploiting, harming, or deceiving them

2. Preoccupied with unjustified doubts about loyalty or trustworthiness of friends or associates

3. Reluctant to confide in others (my be used against them)

4. Hidden demeaning/threatening meanings in benign remarks

5. Persistently bears grudges (unforgiving insults, injuries)

6 .Perceives attacks on character or reputation not apparent to others; is quick to react in anger or counterattack

7. Recurrent suspicions regarding fidelity of spouse or partner

Main defense mechanism used in paranoid personality disorder

Projection

Ppl with Paranoid personality disorder are at increased risk of what? (5)

1. Substance abuse

2. MDD

3. OCD

4. Homicidal ideation

5. Agoraphobia

Some character traits of ppl with paranoid personality disorder (7)

1. Hostile, aggressive

2. Secretive

3. Stubborn (can't take criticism)

5. Avoids intimacy

6. Strong sense of autonomy

7. Hypervigilant and hypersensitive

Dysphoric self consciousness

-Exacerbating situations that lead to hyper vigilance, rumination, and paranoid behavior in ppl with paranoid personality disorder

-May be first seen in childhood/adolescence

-Ex: feeling different for the rest of the group

Schizoid personality disorder (definition, prevalence, and onset)

-Extensive detachment from social relationships and a restricted range of expression of emotions in interpersonal settings

- More common in Males

- Onset in early childhood (solitary child)

Schizoid personality disorder criteria (7)

4 or more of the following:

1. Neither desires nor enjoys close relationships, including family

2. Almost always chooses solitary activities

3. Has little, if any, interest in sexual experiences with another person; intimacy avoidance (normal libido, masturbation)

4. Takes pleasure in few, if any, activities

5. Lacks close friends/confidants other than 1st degree relatives

6. Appears indifferent to the praise or criticism

7. Shows emotional coldness, detachment or flattened affect

Character traits of ppl with Schizoid personality disorder (4)

1. Works best alone

2. Direct attention toward inner life and away from external world.

3. Rare experiences strong emotions

4. Can be in relationships with few emotional/intimate demands

Most common stressor in schizoid personality disorder

- Close interpersonal relationships

Possible causes of schizoid personality disorder (5)

1. Poor peer relationships, underachiever in school - subject to teasing

2. Perceived inadequate mothering, "emotional void" belief that they cannot expect to receive nurture in any situation

3. Parental indifference to emotional issues (i.e., reserved, formal, cold)

4. Family behavior patterns: orderly home, overprotection of child, no parental attempts to socialize the child

5. Genetic ties with schizophrenia and schizotypal PD

Schizotypal personality disorder (definition and prevalence)

- Extensive pattern of social and interpersonal deficits marked by acute discomfort with a decreased capacity for close relationships; cognitive or perceptual distortions, eccentricities of behavior

-Most common in males

-Most common in 1st degree relatives of schizophrenic ("genetic spectrum)

Schizotypal personalty disorder criteria (9)

5 or more of the following:

1. Ideas of reference (excluding delusions of reference)

2. Odd beliefs or magical thinking influences behavior and is inconsistent with cultural norms (i.e. superstition, belief in clairvoyance, paranormal, telepathy, “sixth sense“, bizarre fantasies)

3. Unusual perceptual experiences (including bodily illusions, depersonalization, derealization)

4. Odd thinking and speech without gross incoherence

5. Suspiciousness or paranoid ideation

Inappropriate or constricted affect (i.e., cold, aloof, stiff)

6. Behavior or appearance that is odd, eccentric, or peculiar

8. Lack of close friends/confidants other than 1st degree relative

9. Excessive social anxiety - does not diminish with familiarity (paranoid fear

Character traits of ppl with schizotypal personality disorder (4)

1. Avoid eye contact

2. Wear clothes that are ink-stained and ill-fitting

3. Unable to join in the give-and-take banter of coworkers (react oddly in conversations)

4. Difficulty interpreting social cues

Causes of Schizotypal personality disorder (3)

1. Parenting styles (distant, formal, confusing communication - reenacted; regularly humiliated by parents, siblings and peers = mistrust; low self-esteem, self-deprecating behavior

2. Early separation

3. Trauma/maltreatment (especially early childhood neglect)

Schizoid personality are at increased risk of what disorder?

Major Depressive Disorder (30-50%)

Cluster B personality disorders (4)

- Dramatic, emotional. erratic

-Less severe/intense in middle age and late life

Contains:

1. Narcissistic

2.Borderline

3. Antisocial

4. Histrionic

*Character trait found in all cluster B:

Craves excitement to ward off boredom and emptiness

Narcissistic personality disorder (definition and prevalence)

-Extensive pattern of grandiosity, need for admiration, lack empathy

-More common in males

Narcissistic personality disorder Criteria (9)

5 or more of the following:

1. Grandiose sense of self-importance

2. Preoccupied with fantasies: success, intelligence, power, beauty, love

3. Believe they are "special"/unique and can only be understood by, or should associate with other special or high-status

4. Requires excessive admiration

5. Has a sense of entitlement

6. Interpersonally exploitative

7. Lacks empathy (unwilling to needs of others)

8. Envious of others; or believes others are envious of them

9. Shows arrogant, haughty behavior or attitude

Character traits of ppl with narcissistic personality disorder (5)

1. Pretentious

2. Displays dominance and seeks power

3. Center of attention

4. Devalues contributions of other

5. Reacts to criticism with rage, shame or humiliation

6. Appears to have strong self esteem and confidence

Causes of Narcissistic Personality Disorder (4)

1. Dysfunctional interactions with parents (attention or lack of)

2. Childhood emotional abuse

3. Excessive admiration never balanced with realistic feedback

4. Overindulgence, overadmiration, excessive praise

Narcissistic personality disorder increases the risk of? (3)

1. MDD

2. Eating disorder (anorexia)

3. Substance abuse

Borderline personality disorder (definition and prevalence)

- Extensive pattern of instability of interpersonal relationships, self-image and affect, marked impulsivity

-More common in females (75%)

Borderline personality disorder criteria (9)

5 or more of the following

1. Frantic efforts to avoid real or imagined abandonment

2. Intense/unstable interpersonal relationships alternating between extremes of idealization vs. devaluation

3. Identity disturbance: unstable self image or sense of self

4. Impulsive behavior (in >2 areas that are potentially self-damaging)

5. Recurrent suicidal behavior, gesture, threat or self-mutilation

6. Affective instability – marked reactivity in mood

7. Chronic feelings of emptiness

8. Inappropriate, intense anger or difficulty controlling anger

9. Transient, stress-related paranoid ideation/dissociation

Character traits of borderline personality disorder (6)

1. Extreme reactions to rejection, criticism, abandonment followed by shame/guilt

2. Conflict between desperate need for connection with others and fear, mistrust, anger

3. Failure to develop capacity to self-soothe

4. Pattern of undermining goals (i.e., dropping out of school just before graduation, regressing severely after “good therapy step”)

5. Self-injury – occurs in 50-80%; MC cutting… immediate relief

6. Manipulation to obtain nurturance

Most common defense mechanism in borderline personality disorder

Splitting

Four categories of dysphoria

1. Extreme emotions

2. Destructiveness or self-destructiveness

3. Feeling fragmented or lacking identity

4 .Feelings of victimization

Borderline personality disorder increases the risk of (4)

1. Anxiety disorders (75%)

2. Substance abuse (73%)

3. Eating disorders (bulimia)

4. PTSD (40%)

Symptom of Borderline Personality Disorder

-Dissociation

-Often happens in response to experiencing a painful event

-Provides temporary relief

Antisocial Personality Disorder (definition and prevalence, onset and dx age)

-Extensive pattern of disregard for and violation of the rights of others, occurring since the age of 15

- Must be diagnosed at 18 years or older

-More common in females (3%)

Antisocial personality disorder criteria (7)

3 or more of the following:

1. Failure to conform to social norms and morals with respect to lawful behaviors

2. Deceitfulness

3. Impulsivity or failure to plan ahead

4. Irritability, Aggressiveness

5. Reckless disregard for safety of self or others

6. Consistent irresponsibility

7. Lack of remorse

Character traits of antisocial personality disorder (8)

1. Unable to maintain enduring relationships

2. Irresponsible as parent

3. Parasitic lifestyle

4. Subjective dysphoria/depression

5. Superficial charm

6. Pathological lying

7.Juvenile delinquency

8. Manipulation

Causes of antisocial personality disorder

1. Grow up in fractured families

2. Parental conflict or harsh parenting

3. Childcare may be interrupted (foster)

4. Leads to truancy, delinquent associates, substance abuse, poor and unstable housing, inconsistent adult relationships

Antisocial personality disorder are at increased risk of (4)

1. Homicide

2. Anxiety disorder

3. Substance abuse

4. Impulse disorders

Psychopath

- Origin of the illness is likely innate

-Less likely to be educated and have a good job

-Controlled behavior

-Manipulative

-Unable to form personal attachments

-Crime are calculated

Sociopath

-Origin of the illness is environmental

-Likely uneducated and no stable job

-Erratic behavior (rage and anger)

-May be able to form attachment to person or group

-Crimes usually spontaneous

What test is used to help dx antisocial personality disorder?

-Conduct disorder

-Looks at :

1. Aggression to ppl and animals

2. Destruction of property (setting fires)

3. Deceitfulness or theft

4. Serious violation of rules

Histrionic personality disorder (definiton and prevalence)

-Extensive pattern of excessive emotionality and attention-seeking

-4 times more common in females

Histrionic personality disorder criteria (8)

5 or more of the following:

1. Uncomfortable in situations if not center of attention

2. Interactions inappropriately sexually seductive/provocative

3. Displays rapidly shifting and shallow expression of emotion

4. Uses physical appearance to draw attention to self

5. Style of speech – excessively impressionistic, lacking in detail

6. Self-dramatizing, theatrical, exaggerate expression of emotion

7. Is suggestible, easily influenced by others; current fad, gullible

8. Considers relationships more intimate than they are

Character traits Histrionic personality disorder (6)

1. Often acts out role of victim/princess (unaware)

2. Highly social

3. Lively, dramatic, color

4. Egocentric

5. Impaired same sex relationship (seen as threat)

6. La belle indifference (describing something impactful very indifferently)

Histrionic personality disorder are at increased risk for (7)

1. Somatization disorder

2. Conversation disorder

3. MDD

4. Anxiety

5. Social phobia

6. Suicide (recurrent interpersonal conflict)

7. Exhibitionists

Causes of Histrionic Personality Disorder (4)

1. Lack of maternal nurturing

2. Parental focus on attractiveness or entertainment value

3. Authoritarian, seductive or distant attitudes by parents

4. Childhood events such as death, illness in immediate family or divorce of parents

Cluster C personality disorders (3)

-Anxious, fearful, inhibited

-More severe/intense in middle ages and late life

Contains:

1. Avoidant

2. Obsessive-compulsive

3. Dependent

Avoidant personality disorder (definition and prevalence)

-Extensive pattern of social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation

- Equal gender preference

Avoidant personality disorder criteria (7)

4 or more of the following:

1. Avoids occupational activities that involve significant interpersonal contact – fears criticism, ridicule, disapproval, rejection

2. Unwilling to get involved with people unless certain of being liked

3. Restraint in intimate relations – fear of shame, ridicule

4. Preoccupied with being criticized or rejected in social situations

5. Inhibited in new interpersonal situations - feelings of inadequacy

6. Views self as socially inept, personally unappealing, inferior

7. Reluctant to take personal risks or engage in new activities as they may prove embarrassing

Character traits of avoidant personality disorder (6)

1. Self imposed isolation (but desires close relationships)

2. Severe low self esteem, self loathing

3. May give up job promotion

4. Extreme sensitive to negative evaluation

5. See ppl as critical and disapproving

6. Uses fantasy as form of escape

Causes of avoidant personality disorder

1. Peer group or family rejection/ childhood emotional neglect

2. Shame-based social experiences (long-term)

3. Family/social behavior patterns: relentless parental control, parental need for child to cultivate “good social image”

4. Mockery due to imperfection

Avoidant personality disorder increases the risk for (5)

1. Anxiety disorder (20-40%)

2. Social phobia

3. Agoraphobia

4. MDD

5. OCD

Obsessive-compulsive personality disorder (definition and prevalence)

-Preoccupation with orderliness, perfectionism and mental and interpersonal control, at expense of flexibility, openness and efficiency

- 2 times more common in men

Obsessive-compulsive personality disorder criteria (8)

4 or more of the following:

1. Preoccupied with details, rules, lists, order, organization, schedules to extent that major point of activity is lost

2. Perfectionism that interferes with task completion

3. Excessively devoted to work to exclusion of leisure and friendship

4. Overconscientious, scrupulous, inflexible about morality, ethics, values

5. Unable to discard non-sentimental worn-out, worthless objects

6. Reluctant to delegate tasks or work with others unless their way

7. Miserly spending toward self/others ($ hoarded for future catastrophe)

8. Rigidity and stubbornness

Character traits of Obsessive-compulsive personality disorder (6)

1. Dislikes unpredictable events

2. Excessive compliance with rules

3. Pessimism

4. Difficulty expressing tender feelings/affection

5. Actions are right or wrong no gray area

6. Thrives on hierarchy

Causes of Obsessive-Compulsive Personality Disorder

1. Genetics/heritability

2. Control manifests as defense against shame/powerlessness

3. History child abuse/harsh punishment – coping strategy in effort to be “perfect” and obedient; parents unavailable, overly controlling/protective

*23-32% of people with OCD have OCPD

obsessive-compulsive disorder are at increased risk for (6)

1. MI (type A)

2. Anxiety disorder

3. MDD

4. OCD

5. Eating disorder (anorexia)

6. Asperger's syndrome (40%)

Dependent personality disorder (definition and prevalence)

-Extensive and excessive need to be taken care of that leads to submissive and clinging behavior and fear of separation

-Freud's oral stage fixation

- Most common in females or equal distribution

Dependent personality disorder criteria (8)

5 or more of the following:

1. Difficulty making everyday decisions

2. Needs others to assume responsibility for most major aspects of life

3. Difficulty expressing disagreement – fear of loss of support/approval

4. Difficulty initiating projects or doing things on own (lack confidence)

5. Goes to excessive lengths to obtain nurturance and support from others –

6. Uncomfortable or helpless when alone

7. Urgently seeks another relationship when close one ends

8. Unrealistically preoccupied with fears of being left to take care of self

Character traits of dependent personality disorder (4)

1. Feels in adequate, powerless, helpless

2. Dependents on parent, spouses, or children

3. Judgement of other is distorted (idealization)

4. Submit to abuse and intimidation

Causes of dependent personality disorder (4)

1. Insecure form of attachment to others; clinging parental behavior

2. Chronic physical illness in childhood, severe separation anxiety

3. History of neglect or abusive upbringing

4. Overprotective or authoritarian parents

Dependent personality disorder are at increased risk for (3)

1. Anxiety disorder

2. MDD

3. Adjustment disorder

Personality disorder treatment (3)

1. Dialectical and cognitive behavior therapy

2. Advise that patterns of perception and response result from some combination of inheritance and personal history and that recovery is therefore likely to be a prolonged process, requiring effort and attention

3. With PT's permission, education can be provided to family to alert them to the possibilities of disruptive and destructive behavior and can provide guidelines for limit setting and safety

Most commonly treated personality disorder?

1. Borderline personality disorder

- Quit rate is 70%

Paraphillias (definition and prevalence, time criteria)

-Psychosexual disorders

-Persistent, recurrent intense sexual interest other than sexual interest in genital stimulation with physically mature consenting human partner

-Most common in males

* must cause significant distress or harm for other for 6 or more months

Paraphilia Criteria (2)

Criteria A. Specifies qualitative nature of paraphilia (i.e., erotic focus on child, exposing genitals)

Criteria B. Specifies negative consequence of paraphilia (i.e., distress, impairment, harm to others)

Fetishistic disorder

-Use of non living or highly specific focus on non genital body parts (ex: underwear, leather, shoes, feet)

Transvestic fetishism

-When the fetish involves cross dressing

-in DSM-4 only in heterosexual male dropped in DSM-5

Voyeuristic disorder (definition, prevalence, dx age)

- Observing or spying an unsuspecting person in private activities

- Most common potentially law breaking sexual behavior, more common in men

- Must 18 yrs old for dx

* Fear of being caught adds to arousal

Exhibotionistic Disorder

- Exposure of genitals to an unsuspecting person

- 2-4% in men (unknown for women)

- Often married with satisfactory sexual relationships with adults

** specifier if child

Frotteurism Disorder

-Unexpected, secret touching or rubbing against non consenting person

- More common in men

Sexual Sadism Disorder

-Acts of physical or psychological suffering of another person

- More common in men

Sexual Masochism Disorder

-Act of being humiliated, beaten, bound, or made to suffer

-Extensive used of S&M pornography

-Specifier: +/- asphyxiophillia (chocking)

(risk of accidental death)

Pedophilic Disorder

-Sexual activity with prepubescent child of children younger than 13

-Adults must be at least 16 and at least 5 years older than the child (does not involve late adolescents involved with 12 or 13 yrs olds )

-Most common in males

-1/3 admits to childhood hx of abuse

Specifiers of pedophilic disorder

-Exclusive or non exclusive type (only children or not)

-attracted to girl and boys or both

-limited to incest

Diagnostic indicator of pedophilic disorder

-Extensive used of pornography showing prepubescent children

Notorious paraphilia (2)

1. Necrophilia

2. Zoophilia