psyc 337 - personality disorders

personality

traits and behaviors that characterize a person. big 5 OCEAN

when were personality disorders introduced

1980 in DSM III

intro of personality disorders

means of distinguishing longstanding maladaptive ways of relating to the world from phasic clinical syndromes. largely ignored by researchers until 1980. DSM-III devoted Axis II

dsm 5 definition

a personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individuals culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress and impairment

what can distress and suffering be

egosyntonic - consistent with their core beliefs (like yes I should punch something), ego dystonic - makes no sense but still doing it (like ocd), much more distressing

cluster a personality disorders

odd/eccentric

cluster b personality disorders

dramatic/emotional/erratic

cluster c personality disorders

anxious/fearful

personality disorders prevalence

varies hugely, depending on study and population, 4-15 percent in the general population. much higher in inpatient settings

personality disorders comorbidity

extremely high rates. with the other ads, with major disorders (mood, anxiety, substance use etc

since the dsm-III...

more research done but many still poorly researched

personality disorders controversies

is there a difference between axis I and II conditions? are personality disorders a difference of degree or a difference or kind? what does it mean to be diagnosed with 2 plus personality disorders

problems with assessment of personality disorders

insight - who reports? informants? who nominates the informants. current mood states can exacerbate PD symptoms. different assessment instruments often deliver different symptoms

interrater reliability for categorical diagnoses

reasonable: .86 to .97

test retest reliability

agreement in diagnosis over time. weak .11 to .57. these estimates have been improving somewhat in recent years

categorical vs continuous

many argue better viewed as a constellations of traits. each a long a continuum. proposed as revision for DSM-5. hybrid dimesonial - categorical model

Proposed Revision to DSM-5

winnow list of PDS from 10 to 6. Keep antisocial/psychopathic, avoidant, borderline, narcissistic, obsessive-compulsive, schizotypal. eliminate dependent, histrionic, schizoid, paranoid

DSM-5 alternative model for personality disorders

in the alternative model, the essential criteria to define any personality disorder are: A) moderate to greater impairment in personality functioning B) the presence of of pathological personality traits

personality functioning (DSM alternative)

the degree to which there is an intact sense of self (involving a clear, coherent identity and effective self directness). interpersonal functioning (reflecting a good capacity for empathy and for mature, mutually rewarding intimacy with others). a level of functioning scale provided: moderate impairment the threshold to indicate the presence of a personality disorder

the presence of pathological personality traits (DSM alternative)

organized into five trait domains (negative affectivity, detachment, antagonism, disinhibition, psychotics - correlates well with the five factors).

gender and cultural issues

potential for misdiagnosis based on perspective of clinician. few clear behavioral indicators, no discrete time period (like 3 or more drinks in 3 hours on 3 or more occasions. much more leeway to the clinician.

what are clinicians more reluctant to diagnose

women with APD, men with histrionic PD. aggression in APD may take different forms in men and women, depending on culture. histrionic explicitly gendered

Warner 1978

175 mental health professionals diagnose case history. 1/2 cases described as a man, 1/2 described as a man. 76% of female cases dx had vs 49% male cases

how many individuals identified as BPD are women

80 percent

can men have bpd

yes, may manifest differently in men and women. nssi more common females aggression more common in males

diagnosis of male federal inmates

15 to 25 percent of male federal inmates dx of psychopathy, very few federal inmates. does not seem to represent true prevalence if look at responses on a checklist

comorbidity and diagnostic overlap

both problems with PDs. of people diagnosed with BPD, 47% met criteria for APD and 57% for histrionic. APD has overlapping symptoms with both schizoid and NPD. huge conceptual overlap within clusters

comorbidity with axis I disorders

highly comorbid. avoidant, dependent highly comorbid with anxiety and depression. BPD comorbid with unipolar, bipolar, PTSD. substance use disorder comorbid with ASPD, BPD, NPD. avoidant comorbid with all eating disorders. highest comorbidity for AN-R and BED is OCPD

BPD diagnostic criterion

5 or more of the following - diagnostic heterogeneity. frantic efforts to avoid real or imagined abandonment. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. identity disturbance:markely and persistently unstable self image or sense of self. impulsivity in at least two areas that are potentially self damaging. recurrent suicidal behavior, gestures, threats or self inuring behavior. affective instability due to a marked reactivity of mood. chronic feelings of emptiness. inapproproiaye anger or difficulty controlling anger. transient, stress related paranoid ideation, delusions, or severe dissociative symptoms, or seeing or hearing things that are not really there (hallucinations).

clinically completing notion of personality disorders

clinically, difficult patients present with problems that primarily appear to arise from problems in interpersonal relationships (intrapersonal vs interpersonal). they may have anxiety, depression, etc - but these appear to be secondary to problematic ways of interacting with the world. complicates treatment

which is the least studied cluster of PDs

cluster a - odd and eccentric

paranoid personality disorder

A. pervasive suspiciousness, tendency to see self as blameless, on guard for perceived attacks by others. occurs more commonly in the families of people with schizophrenia (viewed as a related disorder, a cousin). primary difference is the severity, often a very fine line between the two. significant diagnostic overlap with avoidant and BPD

schizoid personality disorder

A. near total lack of interest in intimate involvement with others. limited emotional responsiveness. loners - perceived as cold, indifferent. diagnostic criteria overlap with schizotypal personality disorder. recent data suggests it may be more related to asocial disorders (autism), one of those proposed for exclusion

schizotypal personality disorders

A. cognitive and perceptual distortions. eccentricity of thought or behavior. odd beliefs, odd speech. magical thinking. telepathy, clairvoyance. ideas of reference. contact with reality maintained. great deal of overlap with schizophrenia. severity and quality of symptoms (eccentric and odd but not delusional). some argue a mild or proximal schizophrenia, familial co-aggregation, found in both schizophrenia spectrum disorders and personality disorders in DSM

histrionic PD

B. highly dramatic, lively, extraverted. high excitement seeking, low self consciousness, preoccupation with physical appearance, irritability and temper outbursts if attention seeking is frustrated. about 2-3 prevalence. sex differences. proposed for removal

narcissistic PD

B. grandiosity, preoccupation with receiving attention, self-promoting, lack empathy, easily offended, highly variable clinical presentation. complicates treatment - increased likelihood of dropout, slow symptom change. hypercritical and retaliatory if they are not validated. male students with high narcissistic tendencies.

etiology of narcissistic PD

grandiose associated with parental overvaluation. vulnerable associated with emotional, physical, sexual abuse/intrusive, controlling, cold parenting styles

Avoidant Personality Disorder

C. avoiding interpersonal contact. extreme sensitivity to criticism and disapproval, avoid intimacy though they desire it. extreme loneliness, low self esteem, excessive self-consciousness. differential dx with generalized social phobia very difficult. can find SP without avoid, very rare to find avoidant without SP. shared genetic vulnerability. fear of evaluation is also heritable. distinct diagnoses may not be warranted. chopping block

dependent personality disorder

C. inability to function independently. adopt a submissive role in relationship[s. allow other people to assume responsibility for multiple important aspects of their lives (jobs, classes, clothes, hair styles). some data to suggest more likely to be involved in abusive relationships (limited). relatives of male DPD - increased depression. relatives of female DPD - increased panic. very culture specific - more prevalent in individualistic cultures. much less prevalent in collectivist cultures

OCPD

inflexibility and a desire for perfection. preoccupation with rules and order. often moralistic and judgmental. viewed by others as rigid, stubborn, cold. most stable features: rigidity, stubbornness, perfectionism, reluctance to delegate most common and stable features. very limited research since 1980. no true obsessions or compulsive rituals, not always associated with anxiety and or extreme distress, can be egosyntoic. perfectionism, preoccupation with details, hoarding

how many OCPD pts comorbid with OCD

20%

how many OCPD pts comorbid with Panic Disorder

20%

what is OCD more likely to be comorbid with

avoidant or dependent pd