Personality Disorders

Final Exam

Personality

Patterns of thinking, feeling, behaving that define a person across time and situations

• Also the characteristic ways a person relates and reacts to others

• If one’s usual way of behaving and expressing prevents a person from maintaining close relationships, their personality may be their biggest problem/disordered

General definition of personality disorders

An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture

General criteria across the disorders

• These patterns of thinking, behaving, and relating must also be:

  1. Inflexible and pervasive across a broad range of situations

  2. The source of clinically significant distress or impairment in social, occupational, or other areas of functioning

  3. Stable and of long duration, starting in adolescence or early adulthood at the latest

Relevance of social disruption in PDs

• Justifies defining personality characteristics as mental disorders

• They strongly impair one’s ability to relate successfully with one another

Do personality disorders tend to be egosyntonic or egodystonic

Ego-Syntonic

• Because their patterns are intrinsic and common to who they are, often only bothering others, they are acceptable to the client

Lack of insight

Do not view themselves realistically and fully

• Tend not to see and own their problems, believing others are the real problem/at fault

Symptoms of PDs

• Unbalanced primary social motives

  • Communion, agency

  • Contemporary interpersonal theory

• Self & Other (Mis)perception

  • Distorted understanding of self and others

Strong harmful traits

1. INFLEXIBLE (a.k.a. RIGID)

   • Those with PDs often act very much the same across many situations, even if it’s highly inappropriate or harmful to do so.

   • Very little ADAPTATION TO CONTEXT

   • Mental and relational health often means changing your behavior to fit a certain situation.

     • Yet those with PDs often do not adapt to situations welll

2. PERVASIVE

• Harmful ways of acting remain across time, across life.

Social motives

People with PDs have unbalanced social motives

• Communion

• Agency

A person’s interpersonal style can be captured by how much of each of these motivations they have — two dimensions of motivation

Communion

Desire for closeness, intimacy, connection

• AKA affiliaton, love, warmth

Agency

Desire for influence, dominance, prestige

• AKA power, dominance

The interpersonal circumplex/Contemporary interpersonal theory

Y-Axis → Agency

X-Axis → Communion

Social motives are on a dimension

• Cold, hostile, rejecting ←————— Communion ——————> Warm, friendly, seeking harmony

• Submissive, deferent, “Backseat” ←—————- Agency ———————→ Dominant, goal-oriented, in control

Rigid personality style

Inflexible way of thinking and behaving, characterizeeed by diffiiculty adapting, an obsessive need for order, adherence to rules, black and white thinking, and resistance to changing beliefs or perspectives

Self & others misperceptions

• Distorted understanding of SELF — Who am I? How worthy am I?

  • Skewed, unstable, or absent concept of identity, values, esteem

  • May have overly high/low self-esteem, change self-evaluations quickly, depend on others for all self-understanding, or not know self at all

• Distorted understanding of OTHERS — What are their intentions? What is the reason for him or her acting this way?

  • May misperceive others to be trying to be hurtful, abandoning, criticizing, rejecting, uncaring, incredibly amazing, or terribly horrible

  • Defecits in being able to understand other’s emotions

Context & Personality (p. 237)

Differences may not be evident in all situations

• Some important personality featurs may be expressed only under certain challenging circumstances that require or facilitate a particular response

Social circumstances frequently determine whether a specific pattern of behavior will be assigned a positive or negative meaning by other people

Clusters of DSM-5 PDs

Cluster A: Odd or Eccentric Traits — Paranoid, schizoid, schizotypal

Cluster B: Dramatic, Emotional, Erratic traits — Antisocial, borderline, narcissistic, histrionic

Cluster C: Anxious or Fearful traits — Avoidant dependent, obsessive-compulsive

A: Odd or Eccentric Traits

Paranoid PD — Highly mistrustful and suspicious of others without good reason

Schizoid Personality Disorder — Detachment from social relationships and a restricted range of emotional expression

Schiotypal PD — Highly eccentric, odd behavior and cognitive distortions accompanied by social defecits and discomfort with close relationships

Similarities and differences to/from the schizophrenia spectrum disorders

Share core psychotic symptoms but differ primarily in duration, the presence and the persistence of mood symptoms, and overal impact of functioning

B: Dramatic, Emotional, Erratic Traits

Antisocial PD — Persistent disregard for/violation of the rights of others; violation of laws and moral conduct

Borderline PD — Pervase instability in:

• Emotions: Strong “mood swings”; angry outbursts toward others

• Relationships: Strong “hot and cold,” “stormy” relationships

• Identity: Unsure who they are - “identity disturbance.”

Narcissistic PD — Greatly exaggerated sense of own importance and ability

Histrionic PD — Constant attention seeking

C: Anxious or Fearful traits

Avoidant PD — Pervasive pattern of social discomfort, fear of negative evaluation, and shyness

Dependent PD — Defined by an excessive need to be taken care of by others

Obsessive-Compulsive PD — Excessive preoccupation with control, orderliness, and perfectionism

Paranoid PD

Highly mistrustful and suspicious of others without good reason

• Expect that others will harm them and take extraordinary measures to avoid being exploited

  • Rigid belief that the motives of others are to take advantage

• Overreact to preceive indicators that they are being attacked

  • Self-fulfilling prophecy

Self-fulfilling prophecy

Their expectations actually cause the other person to act in the way they fear

Schizoid PD

Detachment from social relationships and a restriced range of emotional expression

• Indifference toward other people — no desire for contact

• Highly isolate (stays away from people)

• Does not enjoy close relationships; has few (if any) friends

• Do not experience strong emotions and have low emotional expression

Schizotypal PD

Highly eccentric, odd behavior and cognitive distortions accompnaied by social defecits and discomfort with close relationships

• Odd beliefs or magical thinking inconsistent w/ cultural norms

  • Beliefs must meaningfully influence their behavior

  • Ex, superstition, psychic powers, amgic, aliens, etc

• Peculiar appearance, bodily motions & speech

• Restricted (”blunted”) or inappropriate affect

Schizophrenic phenotype (textbook)

These maladaptive persnality traits are presumably seen among people who possess the genotype that makes them vulnerable to schizophrenia

Antisocial PD

Persistent disregard for/violation of the rights of others; violation of laws and moral conduct

• Consistent irresponsibility

• Chronic deceitfulness, lying, and conning

  • Repeatedly perform acts that could get client arrested

• Lack of REMORSE and lack of empathy

• Must occur since age 15 and must have evidence of conduct disorder before age 15 (”bad behavior” since very young)

Transient vs Nontransient antisocial behavior (p. 257)

Two primary forms

Considers adolescence-limited antisocial behavior to be a common form of social behavior that is often adaptive and that disappears by the time the person reaches adulthood. This type presumably accounts for most antisocial behavior

• Transient → temporary

• Nontransient → permanent/long-lasting

Borderline PD

Pervase instability in:

• Emotions: Strong “mood swings”; angry outbursts toward others

• Relationships: Strong “hot and cold,” “stormy” relationships

• Identity: Unsure who they are - “identity disturbance.”

• Highly sensitive to perceived signs of abandonment

• Difficulty holding ambivalent (mixed) feelings about self and others

  • Make very strong entirely positive or entirely negative evaluations of others. They switch these extreme evaluations quickly

Narcissistic PD

Greatly exaggerate sese of own importance and ability (→ → →)

• Need for admiration and “recognition” that they are special

• Inability/unwillingness to EMPATHIZE with other people

  • Unable or unwilling to recognize the feelings and needs of others

• Narcissistic Grandiosity:

  • Arrogant, conceited, and domineering attitudes and behaviors

  • Overvalued, entitled self-image and maladaptive self-enhancement strategies:

    • Exploitative, exhibitionistic behaviors

    • Absorption n idealized fantasies

• Narcissistic Vulnerability:

  • Holding a depleted, weak self-image

    • Angry, shameful, and depressed affects

    • Self-criticism and suicidality

    • Hypersensitive interpersonally and social withdrawal

Histrionic PD

Constant attention-seeking

• Always seeking approval from others

• Often inappropriately sexually seductive or provocative (”flirty”)

• Shallow (”faked”) emotions with exaggerated emotional reactions

  • Often appear to be “acting”

Avoidant PD

Pervasive pattern of social discomfort, fear of negative evaluation, and shyness

• Isolate themselves from others due to fear of criticism

• They want connection with others — desire relationship — but are extremely timid and easily hurt

  • This differentiates them from schizoid PD

Dependent PD

Defined by an excessive need to be taken care of by others

• Pattern of needy, clingy, & submissive behaviors

• Related to fears of separation

• Strong difficulty being alone Depend on others for making everyday decisions, getting reassurance, and feeling emotionally secure

Obsessive-compuslive PD

Excessive preoccupation with control, orderliness, and perfectionism

• Leading them to lack flexibility, openness, and efficiency

OCPD Defenses

People rely heavily on control order and organization and planning and time in order to engage in a lot of behavior to stop feelings so much.

• Overly concerened with rules, organization, order, & schedules

• Excessively devoted to work over leisure and relationships

• Very inflexible about morals & ethics

Impulse control disorders (general definition, but not the specific disorders)

Mental health condition marked by a persistent inability to resist powerful urges or impulses leading to repetitive, harmful behaviors, impacting daily life significantly

General causes of PDs (textbook)

Biological, social, and psychological factors are all general reasons behind PDs (Be worried abt BPD)

Social moties also describe the way that a pesron would like things to be done, and explains why people behave in a particular fashion

DSM-5 Diagnosis of BPD/Criteria

• Instability in affect, relationship, & self, indicated by:

  1. Frantic efforts to avoid perceived abandonment

  2. Unstable and intense interpersonal relationships

  3. Intense reactivity of mood

  4. Identity disturbance: persistently unstable self-image or sense of self

  5. Impulsivity in multiple self-damaging arteas (sex, shoppping, binging, etc)

  6. Suicidal gestures, threats, or behavior or self-harm

  7. Chronic feelings of emptiness

  8. Inappropriate, intense anger or difficulty controlling anger

  9. Transient, stress-related dissociation or paranoia

Non-Orientation-Specific Causes of BPD

Genetics

• 35-68% variation in BPD features due to genetic influence (heritability)

  • Most studies suggest about 40-45% (Bornovalova et al., 2009)

• ~22% smaller AMYGDALA columes than controls

  • Pluse HYPER-RESPONSIVE amygdala activation

  • The amygdala is involved in stress response and negative emotion

• Decreased activation of the PREFRONTAL CORTEX (the brain’s control region) during tasks requring inhibition and control of behavior

  • Especially during negative emotiona and stress

Child maltreatment

• Poor bonds with caregivers → dysfunctional attachment

  • Attachment Representation — One’s internal, unconscious concept of being intimately connected to and sufficiently care for by others

  • Strong negative OBJECT RELATIONS (Ex, unloved self, abandoning other)

• Co-existence of anger toward & need for bad parent → splitting

  • Regular use of splitting defenses leads one to lack integration

• Early trauma, such as physical/sexual abuse, may also lead to bad attachment and splitting

Identity Disturbance

Unstable self-image or sense of self, leading to shifting goals, values, self-perception, and a profound sense of emptiness

Differences between BPD and Bipolar

Episodic	Pervasive across life
Must have manic symptoms for 7 days or depressive symtpoms for 2 weeks	Mood switches very quickly, even across a day or moment to moment
Changes in mood due to biology, loss, or success	Changes in mood due to interpersonal events
Can onset at any time in a person’s life	Must onset in early adulthood at the very latest
In mania, can be energized on 3-4 hours of sleep	Requires normal levels of sleep (6-9) to feel energized
	Can’t really use medication for BPD (leads to psychiatrists to make the diagnosis of Bipolar Disorder because it’s easier to do things abt it)

Attachment features of BPD

• Problems in attachment

  • Feel very strong attachment needs (to be close, valued, and prioritized)

  • Once connected, they then strongly fear losing the attachment

  • Due to fear, they easily perceive/distort possible signs of abandonment

    • Once they believe they will lose attachment, they can get intensely angry

Psychodynamic features of BPD

• Those with BPD are unable to tolerate unconscious conflicts

  • Particularly conflict between LOVE and HATE (affection and aggression, liking and disliking) for the same person

    • This include love and hate towards themselves

• To cope, they use defenses that focus soleley on one side of a conflict, as thought the other does not exist

Splitting — View something as entirely good or entirely bad; see one side but not the other

• This late of integration makes them unstable

  • Don’t hold opposing factors together

Splitting

View something as entirely good or entirely bad; see one side but not the other

Integration

Therapeutic goal of merging fragmented self-perceptions and views of others into a more stable, realistic whole, overcoming “splitting
and identity diffusion to build coherent relationships and a stable self-concept

Attachment representation

One’s internal, unconscious concept of being intimately connected to and sufficiently cared for by others

• Strong negative OBJECT RELATIONS

Cognitive-behavioral BPD perspective

Those with BPD have problems with:

• Emotional regulation

  • Changing one’s emotions to be more adaptive and effective

  • Distress tolerance: One’s ability to endure aversive states

• Acceptance

  • Coming to temrs with the way things are, even if frustrating

• Polarized thinking

  • “Black and white,” “all or nothing” cognitive errors are common

Coercive exchanges and their relevance to BPD

1. Person A produces an aversive experience for Persn B

2. Person A only stops when s/he receives a desired positive reinforcer

3. Person A is positively reinforced for creating the aversive experience to get what s/he wants

   • Person B is negatively reinforced for giving in

• Ex, child throwing a tantrum. Kid screams and cries because he wants a snicker, when parent gives into the tantrum, both actions are reinforced

  • Not the same as BPD, but similar

Treatment of BPD info (textbook)

Transference relationship — The way in which the patient behaves towards the therapist is believed to reflect early primary relationships

• Used to increase patients’ ability to experience themselves and other people in a more realistic and integrated way

Persistent alternation between idealization and deacluation leads to frequent rage towards the therapist and can become a significant deterrent t progress in therapy

Dialectical behavior therapy — combines use of broadly based behavioral strategies with the more general principles of supportive psychotherapy

• Emphasis is placed on learning to be more comfortable with strong emotions, such as anger, sadness, and fear, and learning tot hink in a more integrated way that acceppts both good and bad features of the self and other people

• Emphasis on therapist’s acceptance of pateints, including their frequently demanding, manipulative, and contradictory behaviors

Psychotropic medication is used frequenly in the treatment of borderline patients

• No disorder-specific drug has been found

Oxytocin

A drug; Intranasal oxytocin increases trust and cooperation

Oxytocin effects in BPD and possible reasons for Bartz. et al finding

• In healthy adults, intranasal oxytocin increases trust & cooperation

• Yet when those with BPD receive oxytocin before a cooperation task, oxytocin led to LESS Trust & cooperation

  • Ex, those given oxytocin had greater expectations of mistreatment

  • They also chose to punish cooperative partners (more) after ocytocin

• Those with BPD may experience signals and processes of attachment (like oxytocin) differently — negatively — in a fundamental way

  • Or abuse/negative relationships may damage their oxytocin systems

Purposes, methods, finding, and interpretation of Bartz et al., 2011 reading

Purposes

• Investigating the effects of OXT on trust and pro-social behavior in individuals with BPD, who are characterized by interpersonal and affective instability, impulsive aggression, and difficulties sustaining cooperatice, pro-social behavior

• Whether individual differences in attachment anxiety and attachment avoidance moderate the effects of OXT on trust and pro-social behavior

Methods

• 13 healthy and 14 with BPD

• Completed questionaires

• 14 received OXT, other received placebo

• Had them play the assurance game involving salient trust issues. locates the self-interested and interpersonal solution in the same, mutual cooperation cell

Findings

• BPD participants expected their partner to be significantly less cooperative

• OXT resulted in significantly less cooperation in the hypothetical scenario for anxiously attached, rejection-sensitive participants, whereas less anxiously attached participants showed no difference in cooperation in the OXT versus placebo conditions

Interpretations

• BPD participants were guided less by rational game norms and more by an interpersonal desire to punish their partner following OXT

  • OXT promoted actual cooperative behavior for anxiously attached but low avoidant individuals but impeged cooperative behavior for anxiously attached, intimacy-avoidant individuals

• OXT may increase the salience of social cues and therefore may trigger a range of emotions and behaviors involved in regulating social interactions

• OXT may activate approach behaviors and/or a desire to affiliate, but this motivation to affiliate may remind BPD participants of previous experiences when affiliation has gone aqry and set in motion their chronic concerns about trust and closeness

• OXT system may be dysregulated in BPD (neurobiological differences)

• If OXT enhances the salience of social cues and/or activates affiliative motives, it might be an ideal way to facilitate the learning of new relational schemas and interpersonal skills