PTSD, dissociative disorders, and personality disorders

Trauma and stressors related disorders

characterized by exposure to traumatic or stressful event with subsequent psychological distress

symptoms of trauma and stressors related disorders may involve hypervigilance, severe anxiety, flashbacks, to traumatic or stressful experiences, insomniac, emotional detachment, and hostility

Posttraumatic stress disorder (PTSD)

disorder in which a person experiences fear and related symptoms for >1 month after a traumatic event

continual avoidance of trauma linked stimuli, negative changes in trauma linked cognition and moods, noticeable changes in arousal and reactivity

common triggers: combat, disasters, abuse, terrorism, victimization

Dissociative disorder

characterized by dissociative from consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior

includes dissociative amnesia, dissociative fugue, Dissociative identity disorder (DID)

dissociative amnesia

inability to recall important autobiographical information, usually of a traumatic or stressful nature

Types of dissociative amnesia:

Failure to recall events during a certain time period. Most common type.

Person can recall some, but not all, of the events during a certain time period. Second most common type.

Sudden, complete loss of memory for one’s life history. Rare, but more common in combat veterans and sexual assault victims.

dissociative fugue

dissociative amnesia + travel to a new location

Dissociative identity disorder DID

Diagnostic criteria:

Disruption of identity by ≥2 distinct personality states called subpersonalities or alternate personalities. The disruption in identity involves marked discontinuity in the sense of self, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning.

Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting

Etiology of DID and Diagnosis

Main etiology of DID is believed to be severe and prolonged trauma experienced during childhood, including emotional, physical or sexual abuse.

>90% of the cases of DID involve a history of childhood abuse and neglect

Women are more likely to be diagnosed

Men are more likely to deny symptoms and trauma histories

Lack of supportive or comforting people to counteract abusive relative(s)

Dissociation is thought to be a coping or defense mechanism. The person dissociates from a situation or experience that's too violent, traumatic or painful.

core personality

person’s usual personality

alternate personality or alters (DID)

may have their own name, species, gender, sexual orientation, age, nationality, personal history, self image, musical or foreign language abilities. Usually emerge ≈ age 6.

switching: transition from one subpersonality to another. Switching can take seconds to minutes to days. Often triggered by a stressful event but can also occur through hypnotic suggestion.

interaction between sub personalities (DID)

mutually amnesic relationship, mutually cognizant patterns, one way amnesic relationship

50% of DID patients have fewer than 11 identities, though there have been cases in which 100 distinct alters were reported. Average # of subpersonalities is 15 for women and 8 for men. Some judges have required each alter to be sworn in separately prior to testifying.

mutually amnesic relationship

subpersonalities have no awareness of one another

mutually cognizant patterns

subpersonalities are aware of the rest

one way amnesic relationship

some personalities are aware of each of other, but the awareness is not mutual

most common

Personality

a person’s consistent and enduring patterns of thinking, feeling, and behaving

personality disorder

characterized by enduring patterns of internal experience and behavior that is deviant from one’s culture is pervasive and inflexible, begins in adolescence or early adulthood, is stable over time, leads to personal distress or impairment

Personality disorder Cluster A

odd or eccentric cluster

paranoid personality disorder, schizoid personality disorder, schizoptypal personality disorder

personality disorder Cluster B

dramatic, emotional or erratic cluster

Antisocial personality disorder, borderline personality disorder, histrionic personality disorder, narcissistic personality disorder

personality disorder cluster c

anxious or fearful cluster

avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder

paranoid personality disorder

pervasive distrust and suspiciousness of others such that their motives are interpreted as hostile, and indicated by more than four of the following:

• unjustifiably suspects that others are exploiting, harming, or deceiving them

• Constantly doubts the loyalty or trustworthiness of friends and associates

• Avoids sharing personal information out of fear it might be used against them

• Interprets harmless remarks as hidden insults or threats

• Holds grudges 

• Sees attacks on their character that others don’t notice and reacts angrily

  • Frequently suspects their partner of cheating without any evidence 

Schizoid personality disorder

pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal relationships as indicated by more than 4 of the following:

• Limited or no enjoyment of close relationships

  Nearly always chooses solitary activities

  Minimal interest in sexual experiences

  Finds pleasure in a few activities

  Lacks close friends or confidants other than first-degree relatives [parent, sibling or child]

  Appears indifferent to praise or criticism

  Shows emotional coldness, detachment, or flattened affectivity [emotional expression]

Schizotypal personality disorder

pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, as indicated by more than 5 of the following:

• Ideas of reference (excluding delusions of reference)

• Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”)

• Unusual perceptual experiences, including bodily illusions

• Odd thinking and speech (e.g., vague, circumstantial, metaphorical)

• Suspiciousness or paranoid ideation

• Inappropriate or constricted affect

• Behavior or appearance that is odd, eccentric, or peculiar

• Lack of close friends or confidants other than first-degree relatives

• Excessive social anxiety that doesn’t diminish with familiarity and tends to be associated with paranoid fears rather than negative self judgements

Antisocial personality disorder

characterized by pervasive pattern of disregarding the rights of others

Individuals are sometimes called psychopaths or sociopaths

Must be at least 18 years old to receive this diagnosis

Show no conscience or guilt for causing pain, damage or loss to others – even their children

Lie, deceive and manipulate others for personal gain

Borderline personality disorder

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, and displays more than 5 of the following:

• Frantic efforts to avoid real or imagined abandonment

• A pattern of unstable and intense interpersonal relationships

• Markedly and persistently unstable self-image or sense of self

• Impulsivity in ≥2 areas that are potentially self-damaging

• Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior

• Affective instability due to a marked reactivity of mood

• Chronic feelings of emptiness

• Inappropriate, intense anger or difficulty controlling anger

• Transient, stress-related paranoid ideation or severe dissociative symptoms

Histronic personality disorder

A pervasive pattern of excessive emotionality and attention seeking, and indicated by more than 5 of the following: 

• Is uncomfortable in situations in which they are not the center of attention 

• Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior 

• Displays rapidly shifting and shallow expressions of emotions 

• Consistently uses physical appearance to draw attention to self 

• Has a style of speech that is excessively impressionistic and lacking in detail 

• Shows self-dramatization, theatricality, and exaggerated expressions of emotion 

• Is suggestible (i.e., easily influenced by others or circumstances) 

• Considers relationships to be more intimate than they actually are 

Narcissistic personality disorder

A pattern of grandiosity, need for admiration, and lack of empathy, and indicated by more than 5 of the following:

• Has a grandiose sense of self-importance

• Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

• Believes they are “special” and unique and can only be understood by, or should associate with, other high-status people

• Requires excessive admiration

• Has a sense of entitlement

• Is interpersonally exploitative

• Lacks empathy

• Is often envious of others or believes that others are envious of them

• Shows arrogant, haughty behaviors or attitudes

Avoidant personality disorder

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, as indicated by more than 4 of the following:

• Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection

• Is unwilling to get involved with people unless certain of being liked

• shows restraint with intimate relationships because of the fear of being shamed or ridiculed

• Is preoccupied with being criticized or rejected in social situations

• is inhibited in new interpersonal relationships because of feelings in inadequacy

• Views self as socially inept, personally unappealing, or inferior to others

  • Is unusually reluctant to take personal risks or to engage in any new activities because they may prove to be embarrassing

Dependent personality disorder

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, as indicated by more than 5 of the following:

• Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others

• Needs others to assume responsibility for most major areas of his/her life

• Has difficulty expressing disagreement with others because of fear of loss of support or approval

• Has difficulty initiating projects or doing things on his/her own

• Goes to excessive lengths to obtain nurturance and support from others

• Feels helpless when alone because of exaggerated fears of being unable to care for himself/herself

• Urgently seeks another relationship as a source of care and support when a close relationship ends

  • Is unrealistically preoccupied with fears of being left to take care of himself/herself

Obsessive-compulsive personality disorder

A pervasive pattern of preoccupation with orderliness, perfection, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, as indicated by more than 4 of the following:

• Is preoccupied with details, rules, lists, order, organization, or schedules to the extent where the major point of the activity is lost

• Shows perfectionism that interferes with task completion

• Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships

• Is overconscientious, scrupulous, and inflexible in matters of morality, ethics, or values

• Is unable to discard worn-out or worthless objects even when they have no sentimental value

• Is reluctant to delegate tasks or to work with others unless they submit to exactly his/her way of doing things

• Adopts a miserly spending style; money is viewed as something to be hoarded for future catastrophes

• Shows rigidity and stubbornness