chapter 12- personality disorders and impulse control disorders

personality disorders

overly rigid and maladaptive patterns of behavior and ways of relating to others that reflect extreme variations on underlying personality traits

personality disorders features

• these problem traits become evident by adolescence or early adulthood

• estimated 9% of general population is believed to be affected by personality disorders

• people with personality disorders often fail to see how their own behaviors are seriously disrupting their live

• people with personality disorders tend to perceive their traits as ego syntonic— natural parts of themselves

• people with anxiety disorders and mood disorders tend to view their behaviors as ego dystonic — do not see their behaviors as parts of their self-identities

personality

set of distinctive psychological traits and behavioral characteristics that make each of us unique and help account for the consistency of our behavior

dsm and personality disorders

classifies personality disorders in three categories called clusters:

• cluster A: people who are perceived as odd or eccentric; includes paranoid, schizoid, and schizotypal personality disorders

• cluster B: people whose behavior is overly dramatic, emotional, or erratic; consists of antisocial, borderline, histrionic, and narcissistic personality disorders

• cluster C: people who often appear anxious or fearful; includes avoidant, dependent, and obsessive-compulsive personality disorders

cluster A personality disorders

• paranoid personality disorder

• schizoid personality disorder

• schizotypal personality disorder

paranoid personality disorder

tendency to interpret other people’s behavior as deliberately threatening or demeaning

paranoid personality disorder features

• overly sensitive to criticism

• question sincerity and trustworthiness of friends and associates

• difficulty forming relationships

• do not have outright paranoid delusions

• prevalence: 2.3 - 4.4% of American

schizoid personality disorder

social isolation; described as loner or eccentric; lacks interest in social relationships

schizoid personality disorder features

• emotions appear blunted; rarely experience anger, joy, or sadness

• faces show no emotional expression

• prevalence unknown

• some cases, they harbor deep sensitivity about people and animals they cannot express

schizotypal personality disorder

difficulty forming close relationships; display behaviors, mannerisms and thought patterns viewed as odd; not disturbed enough to merit a diagnosis of schizophrenia

schizotypal personality disorder features

• lack coherent sense of self

• lack capacity for empathy

• difficulty forming relationships

• social anxiety linked to paranoid thinking

• may experience unusual perceptions or illusions, but not enough for it to be psychotic

schizotypal personality disorder features cont

may develop:

• ideas of reference: believing others are talking behind their backs

• magical thinking: possessing 6th sense

• attach unusual meanings to words, speech may be vague but not incoherent to be considered schizophrenia

• prefrontal cortex is not affected like schizophrenia

cluster B disorders

• antisocial personality disorder

• borderline personality disorder

• histrionic personality disorder

• narcissistic personality disorder

antisocial personality disorder

disorder characterized by antisocial or irresponsible behavior and lack of remorse for misdeeds

antisocial personality disorder features

• tend to be impulsive and fail to live up to commitments to others

• show superficial charm and at least average intelligence

• little anxiety and lack feelings of guilt or remorse

• psychopath and sociopaths are considered to have antisocial personalities

• antisocial and criminal behavior decline with age

• sociocultural factors and antisocial personality disorders

  • most common among people in lower socioeconomic groups

antisocial personality disorder prevelence

• 6% men

• 2% women

• limited to ages 18 or older

• pattern of behavior for younger children are diagnosed as conduct disorder

early forms of antisocial behavior we see in childhood and adolescence include:

• truancy

• running away

• initiating fights

• use of weapons

• forcing someone into sexual activities

• physically cruel to people or animals

• deliberate destruction of property

• fire setting, lying, stealing, robbery, and assaulting others

antisocial behavior and criminality

• associated, but not all criminals have antisocial personalities

• most are law abiding citizens

antisocial personality is composed of two dimensions

• personality dimension

• behvaioral dimension

• most antisocial ind show both

personality dimension

consists of traits such as superficial charm, selfishness, lack of empathy, callous and remorseless use of others, and disregard for others’ feelings and welfare → this type applies to people who don’t become law breakers

behavioral dimension

characterized by adoption of generally unstable and antisocial lifestyle; including frequent problems with law, poor employment history, and unstable relationships

psychopathic traits can be grouped into four basic factors

interpersonal factor: characterized by superficiality, grandiosity, and deceitfulness

affective factor: characterized by lack of remorse, empathy, failure to accept responsibility for misbehavior

lifestyle factor: characterized by impulsivity and lack of goals

antisocial factor: characterized by poor behavioral control and antisocial behavior

borderline personality disorder

characterized by features such as deep sense of emptiness, an unstable self-image, a history of turbulent and unstable relationships, dramatic mood changes, impulsivity, difficulty regulating negative emotions, self-injurious behavior, and recurrent suicidal behaviors

borderline personality disorder features

• uncertain about their personal identities

• cannot tolerate being alone

• fear of abandonment leads to clinginess, demanding in their personal relationships

• clinginess pushes people away

• rejection— real or imagined— may enrage them

• feelings towards others is intense and shifting

• most common among latino americans

• men with BPD show more violent or aggressive behavior and self harm than women

• borderline personality disorder was originally used to refer to individuals whose behavior appeared to be on the border between neuroses and psychoses

• usually maintain better contact with reality than people with psychoses, but may show signs during times of stress

core feature of BPD is difficulty regulating emotions

• troubled by intense emotional pain and chronic feelings of anger

• feelings of emptiness and shame are common

• lack ability to thoughtfully plan their actions in advance, and will act impulsively without considering the consequences

BPD prevelence

• 1 in 10 commit suicide, 3 out of 4 attempt suicide

• women show more inwardly directed aggression, such as cutting or other forms of self mutilation

• men show more outward expressions of aggression

• diagnosed in early adulthood

• impulsive behavior might include:

  • spending sprees

  • gambling

  • drug abuse

splitting in BPD

inability to reconcile the positive and negative aspects of one’s experience of oneself and others

histrionic personality disorder

characterized by excessive emotionality and an overwhelming need to be the center of attention

histrionic personality disorder features

• tend to be dramatic and emotional but emotions seem shallow and exaggerated

• previously called hysterical personality

• tend to be flirtatious but too wrapped up with themselves to develop intimate relationships

• use their physical appearance to draw attention to themselves grow restless quickly with routine, and crave stimulation

narcissistic personality disorder

characterized by an inflated self image or grandiose sense of themselves and an extreme need for admiration

narcissistic personality disorder features

• share features with histrionic personalities, but have more inflated view of themselves and less melodramatic than people with HPD

• most people diagnosed are men

• preoccupied with fantasies of success and power, ideal love, or recognition for brilliance or beauty

• extremely sensitive to rejection

• interpersonal relationships are strained

  • usually one sided, seek people who will serve their interests and nourish their sense of self importance

cluster C disorders

• avoidant personality disorder

• dependant personality disorder

• obsessive compulsive personality disorder

avoidant personality disorder

terrified of rejection and criticism that they may be unwilling to develop relationships with others without ardent reassurances of acceptance

avoidant personality disorder features

• have few relationships with others

• affects 0.5-1% of general population

• features of social withdrawal, but interested and feelings of warmth towards others

• fear public embarassment

• stick to routines and exaggerate the risks or effort involved in trying new things

• often comorbid with social phobia

• heightened amygdala activity in people with APD compared to healthy controls in social situations

dependent personality disorder

people who have an excessive need to be taken care of by others

dependent personality disorder features

• leads them to be overly submissive and clingy in relationships

• extremely fearful of separation

• seek advice in making even the smallest decision

• avoid positions of responsibility

• may agree with outlandish statements about themselves and do degrading things to please others

• must be viewed through cultural lense

dependent personality disorder features cont

• diagnosed more frequently in women

• linked disorder to increased risk of mood disorders and social phobia, as well as suicide and health problems

  • hypertension, cardiovascular disorder, and gastrointestinal disorders

  • link between disorder and smoking, eating disorders, and alcoholism

obsessive compulsive personality disorder

includes excessive orderliness, perfectionism, rigidity, and need for control over one’s environment

obsessive compulsive personality disorder prevelence

• 2.1-7.9% of population

• twice as common in men as in women

obsessive compulsive personality disorder features

• do not experience obsessions or compulsions

• preoccupied with perfection they cannot complete work on time

• stingy with money

• difficulty making decisions in fear of wrong choice

• inflexible and rigid in morality and ethics

• overly formal in relationships and difficulty expressing feelings

categories or dimensions problems with the classification of personality disorders

• problem with categories, too black and white

• where to draw the line?

• personality disorders’ features to some degree show up in all of the population,

• when does it become abnormal

• dimensional model

personality disorders dimensional model

depicts personality disorders as maladaptive and extreme variations of personality traits commonly found within general populaiton rather than discrete categories

• limitation of dimensional model is we lack clear guidelines for setting cutoff scores

five factor model problems with the classification of personality disorders

• neuroticism or emotional instability

• extraversion

• openness to experience

• agreeableness or friendliness

• conscientiousness

problems distinguishing personality disorders from other clinical syndromes

overlap

• comorbidity is quite common

• people receiving diagnosis for a personality disorder usually meet criteria for more than one

• difficulty distinguishing between normal and abnormal behavior

• confusing labels with explanations

psychodynamic perspectives of PD

• traditional freudian theory focuses on problems arising from Oedipus complex

• more recently theories focused on earlier pre-Oedipal period during which infants develop identities separate from their parents

Hans Kohut Psychodynamic perspective on PD

• theory of self psychology

• argues that what matters most is how the self develops

  • whether the person is able to develop self-esteem, values, and a cohesive and realistic sense of self opposed to an inflated narcissistic personality

• believed people with narcissistic personality mount a facade of self importance to cover up feelings of inadequacy

• narcissistic personalities may become enraged by others whom they perceive have failed to protect them from disappointment or have declined to shower them with reassurance, praise, and admiration

• early childhood involves normal stage of healthy narcissism

  • infants feel powerful, empathetic parents reflect their childs perceptions

  • gradually, unrealistic expectations dissolve

  • lack of parental empathy sets stage for pathological narcissism

    • develop damaged self concepts and feel incapable of being loved and admired

    • involves facade of self perfection that cloaks perceived inadequacies

otto kerberg perspective on PD

• views BPD in terms of a failure in early childhood to develop sense of constancy and unity in one’s image of oneself and others

• BPD individuals cannot synthesize positive and negative elements of themselves and others into complete stable wholes

  • they shift back and forth between pure idealization and utter hatred → referred to splitting

margaret mahler psycho persp on PD

• explained BPD in terms of childhood separation from the mother figure

• normally children gradually differentiate their own identities from those of their mothers → process called separation-individuation

  • mother may disrupt normal separation-individuation by refusing to let go of the child or by too quickly pushing child toward independence

limitation of the theory psych persp

largely based on inferences drawn from behavior and retrospective accounts of adults rather than observation

learning theory persp on PD

• focus on maladaptive behaviors rather than disorders of personality

  • interested in identifying the learning histories and environmental factors that give rise to maladaptive behaviors

• childhood experiences shape pattern of maladaptive habits

  • example: children discouraged from speaking their minds may develop dependent behavior pattern

  • excessive discipline may lead to OCPD

• Millon suggests histrionic personality disorder may be rooted in childhood experiences in which social reinforcers are connected to a child’s appearance and willingness to perform for others

social cog theorists on PD

emphasize the role of reinforcement in explaining origins of antisocial behaviors

• Ullman and Krasner propose people with antisocial personalities failed to learn to respond to other people as potential reinforcers

albert bandura on PD

studied observational learning in aggressive behavior

• children most likely imitate violent role models who get their way with others by acting aggressively

• limitation is grounded in theory rather than observations

family perspectives on PD

• evidence links childhood physical or sexual abuse or neglect to development of

  personality disorders (BPD and antisocial personality)

  • splitting may be result of learning to cope with unpredictable and harsh behavior from caregivers

  • childhood loss of parental figures is also common with BPD

• parental overprotection or authoritarianism are implicated in the development of dependent personality traits

• OCPD may develop as result of living in strongly moralistic and rigid family environment

• Parental rejection or neglect are connected to antisocial personality disorder → may not develop warm feelings of attachment

genetic factors of PD

• evidence suggests genetics play roles in antisocial, narcissistic, paranoid, and borderline personality disorders

• parents and siblings of people with personality disorders such as antisocial, schizotypal, and borderline types are more likely to be diagnosed with these disorders themselves

• personality traits are associated with interactions of genetic factors and life experiences

lack of emotional responsiveness biological factor of PD

people with antisocial personalities can maintain composure in stressful situations → lack of anxiety may explain failure of punishment

• most people experience galvanic skin response when anxious, but people with antisocial personalities experienced lower levels

• may be underresponsive to threatening stimuli, explaining lack of anxiety

craving for stiumulation model biolog persp on PD

explanation for antisocial personalities lack of emotional response in terms of levels of stimulation necessary to maintain optimum level of arousal

• people with antisocial personalities tend to crave excitement and stimulation

• may need more stimulation than normal people to maintain interest and function normally

brain abnormalities biolog persp on PD

link BPD and ASPD to dysfunctions in parts of brain involved in regulating emotions, making thoughtful decisions, and restraining impulsive behaviors

• prefrontal cortex and limbic system are responsible for these

neurological basis to lack of empathy and concern seen in antisocial personalities

• differences in brain structure in amygdala and prefrontal cortex may explain consequences of behavior and impulse control issues

sociocultural persp on PD

lower socioeconomic class associated with antisocial personality disorder

• stressors are associated with increased likelihood of child abuse and neglect

• childhood maltreatment may lead to cycle of violence → multigenerational

• children in poverty may be exposed to negative role models such as drug dealers

multifactorial model of antisocial personality disorder

psychodynamic approaches treatment of PD

psychodynamic oriented therapies focus on clients awareness of how their behaviors cause problems in their close relationships

• therapists take more direct, confrontational approach that addresses the client’s defenses than would be the case in traditional psychoanalysis

• with BPD, psychodynamic therapists help clients better understand their own and other people’s emotional responses in the context of their close relationships

cbt approaches for PD

CBT focuses on changing client’s maladaptive behaviors and dysfunctional thought patterns rather than their personality structures

• may use behavioral techniques such as modeling and reinforcement to help clients develop more adaptive behaviors

• show good results in personality disorders characterized by anxiety

• CBT benefits in BPD patents

• antisocial adolescents are usually placed in residential programs and includes behavioral treatment

  • most rely on token economies

Marsha Linehan’s technique called dialectical behavior therapy (DBT) is specifically designed to treat BPD

• DBT combines CBT and buddhist mindfulness meditation to help BPD patients accept and tolerate strong negative emotions and learn more adaptive ways of relating to others

• DBT also helps adolescence with borderline features and high risk of suicide

• DBT helps clients improve relationships with others, develop problem solving skills, and learn more adaptive ways of handling confusing feelings

• therapists offer acceptance and support

biological approaches to PD

drug therapy does not directly treat personality disorders

• some antidepressants and antianxiety drugs can treat depression and anxiety in people with personality disorders

• neurotransmitter activity is implicated in aggressive behavior → SSRIs can help temper feelings of anger and rage

• atypical antipsychotics have helped aggressive and self destructive behavior in people with BPD, but effectiveness is mixed

impulse control disorders

characterized by difficulties in controlling or restraining impulsive behavior

• kleptomania

• IED

• pyromania

kleptomania

characterized by repeated acts of compulsive stealing

kleptomania features

• objects usually have little value or use to the person

• person may give them away, return them secretly, discard them, or keep them hidden

• thefts are unmotivated by anger or vengeance

• fewer than 1% of population have the disorder

• kleptomaniacs experience pleasurable excitement or gratification from stealing

• psychodynamic viewed kleptomania as a defense against unconscious penis envy in women and castration anxiety in men

• little research on treatment, but behavioral approaches have been successful

Intermittent Explosive Disorder

characterized by repeated episodes of impulsive, uncontrollable aggression in which people strike out at others or destroy property

Intermittent Explosive Disorder features

• core feature is impulsive aggression

• even minor provocations or perceived insults can lead to aggressive outbursts

• people with IED experience tension before outburst and relief afterwards

  • they feel remorse

• links between trauma, violent behaviors and development of IED

• links between disorder and serotonin

• functioning of prefrontal cortex may be impaired

• psychological treatment in form of anger management may help

pyromania

characterized by repeated acts of compulsive fire setting in response to irresistible urges

pyromania features

• small percentage of arsonists have pyromania, most set fires out of anger or revenge

• fire setting may also be associated with antisocial personality disorder

• origins are unknown, but morbid fascination with fire from early age is a sign

  • setter may feel excitement by watching firefighting event, or feel feelings of empowerment

• treatment involves CBT