Psychopathology & Mental Health Exam #4

what are personality disorders?

personality refers to traits that are fairly stable over time. often expressed (and measured) in terms of interpersonal relationships (social motivation, emotional expression, views of self and others).

five factors model of personality (big 5)

OCEAN: neuroticism (expression of negative emotion), extraversion (interest in interacting with others), openness (willingness to consider other perspectives), agreeableness, conscientiousness.

personality disorders

enduring patterns of perceiving, relating to, and thinking about the environment and oneself that cause impairment/distress, presumably evident by adolescence and stable over the adult lifespan, vary from a lot of other disorders in the sense that they often don't cause personal distress or impairment, but rather cause other people distress, lso vary in the sense that other disorders are ego-dystonic.

ego-dystonic

dissonant with person's self image, personal distress, discomfort with one's symptoms

ego-syntonic

consistent with person's self image, they do not generally bother the person. ex: someone with narcissism isn't going to be upset by the fact that they think they're better than everyone else, but they might be upset by the fact that they don't have many friends (not the symptom, but the consequence)

why care about personality disorders?

significant impairment in one’s life, risk factor for other mental disorders, treatment implications.

history of personality disorders

in previous versions of the DSM, personality disorders were Axis II and separate from other disorders (Axis I). that said, they weren’t always separable, which led to diagnostic confusion. some axis I disorders are very stable and some personality disorders are treatable.

assessment and treatment of personality disorders

difficult to assess and treat, tremendous overlap among categories, not clear that they are culturally universal, little research.

classification of personality disorders

DSM-5 uses a categorical model (you either have a PD or you don’t, criteria for 9 disorders).

advantages of PD categorical classification

familiar and convenient, ease in communication, consistent with clinical diagnoses.

disadvantages of PD categorical classification

low inter-rater reliability, very high comorbidity, high overlap among symptom criteria, some not based on a theoretical model, ambiguity occurs regarding presence vs. absence of symptoms, most commonly diagnosed personality disorder is PD-NOS (not otherwise specified).

dimensional model of personality traits

not currently used, but people think it will be in the future. looks at a continuum of normal to abnormal personality. various dimensional models exist.

advantages of dimensional classification of PD

theoretical basis, retention of information, flexible (different cutoffs for different needs, but not arbitrary), resolution of a variety of classification dilemmas.

disadvantages of dimensional classification of PD

less familiar, lacks clinical application

clusters of personality disorders

cluster A: all of these share similarities with schizophrenia and can proceed the onset of psychosis.

cluster B: erratic, dramatic, emotional behavior

cluster C: anxious, fearful, avoidant

cluster A PDs

paranoid PD, schizoid PD, schizotypal PD

cluster A PD prevalence and course

.5-4.9%, gender difference (males more likely than females)

paranoid PD

distrust or suspicious of others and self-blameless. pervasive, extreme mistrust, often hostile, perceives others’ motives as malevolent.

paranoid PD criteria

• 4 or more of symptoms:

  • suspects others are exploiting, harming, or deceiving him or her

  • doubts the loyalty or trustworthiness of friends or associates

  • reluctant to confide in others

  • reads hidden demeaning or threatening meanings

  • persistently bears grudges

  • perceives attacks and is quick to react angrily or to counterattack

  • recurrently suspects sexual partner of cheating

paranoid PD associated features

• usually difficult to get along with

• suspicious and hostility

• hyper vigilant for potential threats

• excessive need for self-sufficiency

• often controlling, rigid, and critical

• involved in legal disputes

paranoid PD treatment

unlikely to be sought, but usually involves a trusting environment

schizoid PD

impaired social relationships, inability and lack of desire. little expression of emotion. aloof, cold. detached from social relationships. restricted range of emotions. not distressed by lack of social contact.

schizoid PD criteria

• 4 or more symptoms:

  • neither desires nor enjoys close relationships

  • almost always chooses solitary activities

  • has little interest in having sexual experiences with another person

  • takes pleasure in a few activities

  • lacks close friends or confidants

  • appears indifferent to others' praise or criticism

  • shows emotional coldness, detachment, or flattened affectivity

schizoid PD treatment

unlikely to seek treatment, long-term prognosis is not very optimistic.

schizotypal PD

discomfort with close relationships, peculiar thought patterns, odd perception and speech, peculiar behavior, socially isolated, cognitive or perceptual distortions, but not hallucinations

schizotypal PD criteria

• 5 or more symptoms:

  • ideas of reference (think that something is out to get them that isn't, but not delusions or held in firm conviction)

  • odd beliefs or magical thinking that influence behavior and are inconsistent with cultural norms

  • Unusual perceptual experiences (hearing your name being murmured, feeling presence of a dead relative, different from hallucinations)

  • Odd thinking and speech (idiosyncratic speech, incoherent, vague, apply concepts in unusual ways

  • Suspiciousness or paranoid ideation

  • Inappropriate or constructed affect

  • Behavior or appearance that is odd, eccentric, or peculiar (not washing hair, wearing mismatchy clothes)

  • Lack of close friends of confidants

  • Excessive social anxiety that does not diminish with familiarity

schizotypal PD treatment

most do not seek treatment, medication (antipsychotics, SSRIs)

therapy: supportive, psychoeducational treatment. Insight oriented therapy does not appear to be effective

dimensional model of cluster A PDs

cluster B PDs

erratic, dramatic, emotional behavior.

narcissistic PD, antisocial PD, histrionic PD, borderline PD

narcissistic PD

pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy. preoccupation with own achievements.

narcissistic PD criteria

• Five or more of the following:

  • Grandiose sense of self-importance

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

  • Believes that he or she is "special" and unique

  • Requires excessive admiration

  • Sense of entitlement

  • Interpersonally exploitative

  • Lacks empathy-- unwilling to recognize or identify with the feelings and needs of others

  • Often envious of other or believes others are envious of them

  • Shows arrogant, haughty behaviors or attitudes (annoyed with incompetence)

narcissistic PD associated features

vulnerable self-esteem, care deeply about their own self-perception, relationship impairments

narcissistic PD comorbidities

bipolar disorder, substance use disorder, major depressive disorder. other cluster B PDs.

narcissistic PD prevalence and etiology

up to 6.2%, linked to poor parenting, more common in men, difficulties adjusting to onset of limitations inherent to aging

narcissistic PD treatment

talk therapy (psychotherapy).

antisocial PD

a pervasive pattern of disregard for and violation of the rights of others.

antisocial PD criteria

• Repeatedly breaks the law

• Deceitfulness

• Impulsivity/failure to plan ahead

• Irritability or aggressiveness

• Reckless disregard for the safety of self or others

• Consistent irresponsibility

• Lack of remorse

• At least 18

• Evidence of conduct disorder before age 15

conduct disorder

• Pattern of violating basic rights of others and/or major societal norms

  • Aggressive to people and animals,

  • Destruction of property

  • Deceitfulness or theft

  • Serious rule violation

psychopathy and ASPD

a related diagnostic category: deceitful, lacks empathy, and incapable of learning from experience

• Not in the DSM-5, captures a subset of people with ASPD, strong emphasis on emotional and interpersonal traits, better predictor of recidivism

• ASPD blurs criminality. How is antisocial pd different than criminality?

antisocial PD prevalence and course

3% men, 1% women, higher in samples that are economically disadvantaged. may burnout after age 40; life course persistent, person's options become narrowed, limited range of behavioral skills, ensnared by consequences of earlier behaviors

histrionic PD

Pervasive pattern of excessive emotionality and attention seeking behavior (self-centered, vain)

histrionic PD criteria

• Five or more of the following:

  • Is uncomfortable if not the center of attention

  • Often inappropriately sexually seductive or provocative

  • Rapidly shifting and shallow expressions of emotions

  • Consistently uses physical appearance to draw attention

  • Speech is excessively impressionistic and lacking is detail

  • Self-dramatization, theatricality, and exaggerated emotion

  • Is suggestible

  • Considers relationships to be more intimate than they are

histrionic PD associated features

 may have difficulty with emotional intimacy, act out roles, alienate others, crave novelty, stimulation and excitement

histrionic PD comorbidity

suicidality

histrionic PD prevalence

2-3%, more common in women.

borderline PD

Pervasive pattern of instability in personal relationships, self-image, and affects, and marked impulsivity.

borderline PD criteria

Five or more of the following

• Frantic efforts to avoid abandonment (threatens suicide if you break up with them)

• Pattern of unstable and intense personal relationships

• Identity disturbance

• Self-damaging impulsivity

• Recurrent suicidal behavior, gestures, threats

  • Reccurent suicidal behavior, gestures, threats of self-mutilating behaviors

    • 4-9% commit suicide

    • Self harm is not the same as a desire to die

    • Reasons for self-harm: make someone feel something

• Affective instability

• Chronic feelings of emptiness

• Inappropriate, intense anger, or difficulty controlling anger

• Transient, stress-related paranoid ideation or severe dissociation

borderline PD associated features

 pattern of undermining themselves, may feel more secure with transient object

borderline PD etiology

childhood maltreatment (elevated of sexual assault for girls).

borderline PD prevalence and comorbidities

2%, comorbid with mood disorders (depression, bulimia, substance use disorders), gender distribution: slightly higher in women

borderline PD treatment

difficult, medicinal (antipsychotics, antidepressants, anticonvulsants, lithium), DBT has the strongest support for being effective in the treatment of BP (reorganizes BPD as a disorder of dysregulation).

cluster C PDs

anxious, fearful, or avoidant.

avoidant PD, dependent PD, obsessive-compulsive PD

avoidant PD

Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation occurring in a range of situations

avoidant PD criteria

four or more of the following:

• avoids work 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 within intimate relationships because of the fear of being shamed or ridiculed

• preoccupied with social criticism or rejection

• is inhibited in new interpersonal situations because of feelings of 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 embarrassing

avoidant PD associated features

shy, timid, lonely, hyper vigilant, often target of ridicule, low self-esteem and hypersensitivity to rejection, may fantasize about idealized relationships,

avoidant PD prevalence and course

1.2%-4%, equally common in men and women, related to generalized social phobia, same condition, more severe? often starts in infancy or childhood, some evidence for remission over life

dependent PD

A pervasive and excessive need to be taken care of that leads to submissive and often clinging behavior and fears of separation

dependent PD criteria

• Five or more of the following:

  • Needs an excessive amount of advice and reassurance from others to make everyday decisions

  • Needs others to assume responsibility for most major areas of their life

  • has difficulty expressing disagreement with others

  • has difficulty initiating projects

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

  • feels uncomfortable or helpless when alone because of exaggerated fear of being unable to care for themself

  • urgently seeks another relationship

  • is unrealistically preoccupied with fears of being left to take care of themself

dependent PD associated features

pessimism and self-doubt, may avoid positions of responsibility

dependent PD prevalence and etiology

.3-2%, equal gender distribution, may be linked to neglect and disruptions in attachment patterns.

obsessive-compulsive PD

preoccupation with orderliness, perfectionism, and mental and interpersonal control.

obsessive-compulsive PD criteria

four or more of the following:

• is preoccupied with details and organization to the extent that 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 over conscientious, scrupulous, and inflexible about values

• is unable to discard worn out or worthless objects

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

• adopts a miserly spending style toward both self and others

• shows rigidity and stubbornness

obsessive-compulsive PD

 may be preoccupied with logic, difficulty prioritizing tasks, prone to be upset if they cant control a situation, relationships may have formal quality

obsessive-compulsive PD comorbidities

anxiety disorders

obsessive-compulsive PD prevalence

2-8%

Autistic disorder (classic autism) central symptoms

impaired social interaction, impaired communication, restrictive and repetitive behaviors, interests or actions.

Autistic disorder (classic autism) and social interaction

• marked impairment in nonverbal behaviors

• absence of developmentally appropriate peer relations

• lack of spontaneous seeking of enjoyment, interests activities

• lack of social or emotional reciprocity

Autistic disorder (classic autism) and impaired communication

• delay or total lack of spoken language

• impairment in conversation

• stereotyped or repetitive language

• lack of make-believe or social imitative play

Autistic disorder (classic autism) and restrictive and repetitive behaviors, interests, or actions

• preoccupations with patterns of interest

• inflexible adherence to routine

• stereotyped or repetitive motor mannerisms

• preoccupation with parts of objects (ex. wheels of a toy car)

Autistic disorder (classic autism) associated features

reduced eye contact — in study where they asked kids with ASD to look at fans and faces, they better-encoded fans

self-injury: one of the most dangerous difficulties of autism, should not be misinterpreted as suicidal behavior

savant performance: an exceptional ability in a highly specialized area of functioning. no adequate theory for savant performance. note: not common —> 70% of kids with autism have intellectual disabilities according to DSM-5 (IQ lower than 70)

DSM-IV criteria for Autistic disorder

6+ symptoms: impairment in social interaction (at least 2), impairment in communication (at least 1), restricted and repetitive behaviors, interests, and activities (at least 1).

delays or abnormal functioning in one before age 3: social interaction, language used in social communication, symbolic/imaginative play.

autistic disorder (classic autism) assessment

autism diagnostic observation schedule (DOS). standardized behavioral observation and coding

autistic disorder (classic autism) DMS-4 course/prognosis

early signs are subtle. some symptoms have early onset in school-aged kids, developmental gains common.

prognosis is generally poor for classic autism, 1/3 achieve partial independence as adults.

autistic disorder (classic autism) prevalence

large increases in diagnoses (criteria broadened). 3-4 more common among boys than girls, occurs in all demographics

autistic disorder (classic autism) etiology

initially people thought that parents of kids with autism were smarter than average (what really was happening was that parents who were more aware of signs initially were seeking treatment, and happened to be more educated) —> not related to education levels

vaccines don't cause autism!

is asperger’s disorder in the DSM-5?

NO

asperger’s disorder central symptoms

impaired social interaction, restrictive, repetitive, behaviors, interests, or activities.

DSM-4 criteria for asperger’s

no significant delays in language, cognitive development, self-help skills, adaptive behaviors (other than social interaction), curiosity about environment.

DSM-5 ASD central symptoms

impairment in social interaction, restricted and repetitive behaviors, interests, or actions

ASD and impaired social interaction

marked impairment in nonverbal behaviors, absence of developmentally appropriate peer relations, lack of social or emotional reciprocity.

ASD and restrictive and repetitive interests, behaviors, and actions

highly restricted fixated interests, inflexible adherence to routine, stereotyped or repetitive motor mannerisms, hyper or hyporeactivity to sensory input.

additional criteria for ASD

symptoms must be present in early developmental period, symptoms cause impairment.

asperger’s and ASD specifiers

with or without accompanying intellectual impairment, With or without accompanying language impairment, associated with known medical or genetic condition or environmental factor

asperger’s and ASD risk factors

 advanced parental age (older father especially), low birth weight, exposure to certain meds in utero. 37-90% heritability estimates

asperger’s and ASD treatment

medications not effective for core symptoms. Interventions focus on enhancing daily living, communication, and social skills, and reducing undesirable behaviors. applied behavior analysis

ASD prevalence

1% of the population, increased diagnoses, 4x more common in boys, some concern about girls being undiagnosed.

applied behavior analysis

Intensive behavior modification using operant conditioning techniques, therapists focus on treating the specific symptoms of autism. 1st goal is to identify very specific target behaviors, 2nd goal is to gain control over these behaviors using reinforcement and punishment

developmental approach to childhood psychopathology

definitions of “normal” depend on age. classification of many childhood disorders rests on our knowledge of normal childhood behavior.

externalizing disorders

children who have problems in conforming to expected norms. kids with externalizing disorders are more likely to receive treatment.

key features of externalizing disorders

norms violated at a younger age than is typical, importance of age of onset. rule violations, negativity, impulsivity, hyperactivity, attention deficits

early childhood irritability

clinically significant levels, role of dysregulated tantrums, moderately stable, has clinical and predictive validity.

callous behaviors

reliably assessed, coherent developmental patterns, predictive utility

types of conduct problems

ADHD

attention deficit hyperactivity disorder. persistent pattern of inattention and/or hyperactivity.

inattention: careless mistakes, easily distracted, forgetful, difficulty organizing tasks.

hyperactivity and impulsivity: fidgets, unable to stay in seat, talks excessively, interrupts other.

DSM-5 criteria: for at least 6 months, need greater than or equal to 6 symptoms of inattention or hyperactivity and impulsivity. several symptoms must be present before the age of 12 in at least two settings. must cause impairment.

social problems in kids with ADHD

impairments in relationships with peers, teachers, and parents.

ODD

oppositional defiance disorder. a pattern of angry/irritable mood, argumentative/defiant behavior or vindictiveness. need greater than or equal to 5 symptoms over 6+ months (with at least one person who isn’t a sibling). associated with distress for self or others OR causes significant impairment. cannot occur exclusively during psychotic, substance use, or mood disorder.

conduct disorder

a repetitive pattern of violating basic rights of others and/or major societal norms of: aggression to people and animals, destruction of property, deceitfulness or theft, serious rule violation. over 12 months need greater than or equal to 3 symptoms across 4 categories. must cause impairment. for those over 18 yrs of age, criteria for ASPD are not met.

prevalence and course of externalizing disorders

19% lifetime prevalence rate for adolescents. boys have 2-10x higher rates, prevalence declines with age.

ADHD epidemiology

most diagnosed ages 7-9. more common among boys than girls. lifetime prevalence: 3-10% of American children, 1-5% European children.