Personality Disorders

Personality Disorders

•problems in thinking, affect, impulse control and interpersonal functioning

oPersist for years and influence many domains of life

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•DSM-5 provides criteria for personality disorder in general as well as 10 specific personality disorders

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•The 10 personality disorders are classified into 3 clusters:

oOdd/Eccentric (cluster A)

oDramatic/Erratic (cluster B)

oAnxious/Fearful (cluster c)

DSM-5 Criteria:
General Personality Disorder

•An inflexible pattern of inner experience and behaviour that is distinct from cultural expectations, and influences at least two of the following:

oCognition about the self and others

oAffect

oInterpersonal functioning

oImpulse control

•The pattern

oCauses significant distress or impairment

oIs inflexible

oIs pervasive across situations

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•Onset by early adulthood and persistence for a long duration

•Not explained by another mental disorder, by a substance, or by a medical condition

Personality Disorders:
Prevalence

•About 1 out of 10 people meet diagnostic criteria for a personality disorder

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•Important to consider whether patterns of behaviour are unusual for a person’s cultural background

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•Tend to co-occur with psychological disorders

oCommonly encountered in treatment settings

o40% of outpatients meet criteria for a personality disorder

oAssociated with more severe symptoms

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•When using structured interviews, inter-rater reliability is adequate to good for most diagnoses 

Problems with DSM-5 Approach
to Personality Disorders

•Personality disorders are not stable over time

oAbout half of people achieve remission 2 years later

o99% remit when re-assessed after 16 years

oPeople may still have some symptoms after remission

•Many will relapse

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•Personality disorders are highly comorbid

oMore than 50% meet criteria for another personality disorder

oHigh rates of over overlap in symptoms and concerns

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Alternative DSM-5 Model

•Reduced number of personality disorders

oIncludes 6 of the 10 DSM-5 personality disorders, excluding:

•Schizoid, histrionic, dependent, and paranoid

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•Considered if long-term dysfunction is present

oConsiders how personality traits explain difficulties

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•Two types of dimensional personality scores:

o5 personality trait domains

o25 specific personality trait facets

oEvaluated using self-report items

oProfile of extreme scores are used for diagnosis

Strengths of the Alternative Model

•Personality trait ratings are more stable over time than diagnoses

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•Ability to specify which personality traits are of most concern

•Personality traits are related to many psychological disorders

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•Personality traits predict important outcomes

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•Clinicians rate as more descriptive of clinical problems

Common Risk Factors

•Personality disorders tend to co-occur and share genetic vulnerability

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•Environmental factors

oEarly adversity

oChildhood abuse or neglect

Aversive or unaffectionate parental style

Odd/Eccentric Cluster

•Cluster A

oParanoid Personality Disorder

oSchizoid Personality Disorder

oSchizotypal Personality Disorder

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•Different from schizophrenia:

oBizarre thinking and functional impairments are less severe

oHallucinations are not present

Full-blown delusions are not present

Paranoid Personality Disorder

•Suspicious of others

oStrangers, casual acquaintances, family members

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•Expectation for mistreatment or exploitation

oSecretive and continually on the lookout for signs of trickery and abuse

•Hostile and angry in response to perceived insults

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•Seen as difficult and critical

oSocial world filled with conflict, which perpetuates paranoia

DSM-5 Criteria:
Paranoid Personality Disorder

•Presence of 4 or more of the following signs of distrust and suspiciousness from early adulthood across many contexts:

oUnjustified suspiciousness of being harmed, deceived, or exploited

oUnwarranted doubts about the loyalty or trustworthiness of friends or associates

oReluctance to confide in others because of suspiciousness

oThe tendency to read hidden meanings into the benign actions of others

oBears grudges for perceived wrongs

oAngry reactions to perceived attacks on character or reputation

oUnwarranted suspiciousness of the partner’s fidelity

Schizoid Personality Disorder

•Do not desire or enjoy social relationships

oNo close friends

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•Aloof and show no warm, tender feelings when interacting with others

•Rarely experience strong emotions

oNo interest in sex

oEnjoy few activities

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•Indifferent to praise or criticism

DSM-5 Criteria: Schizoid Personality Disorder

•Presence of 4 or more of the following signs of aloofness and flat affect from early adulthood across many contexts:

oLack of desire for or enjoyment of close relationships

oAlmost always prefers solitude to companionship

oLittle interest in sex

oFew or no pleasurable activities

oLack of friends

oIndifference to praise or criticism

Flat affect, emotional detachment, or coldness

•Presence of 5 or more of the following signs of unusual thinking, eccentric behaviour, and interpersonal deficits from early adulthood across many contexts:

oIdeas of reference

oOdd beliefs or magical thinking, e.g., belief in extrasensory perception

oUnusual perceptions

oOdd thought and speech

oSuspiciousness or paranoia

oInappropriate or restricted affect

oOdd or eccentric behaviour or appearance

oLack of close friends

oSocial anxiety and interpersonal fears that do not diminish with familiarity

Schizotypal Personality Disorder

•Eccentric thoughts and behaviour, interpersonal detachment, and suspiciousness

•Some develop more severe psychotic symptoms over time, and a small proportion develop schizophrenia

•Similarities with schizophrenia

oGenetic vulnerability

oDeficits in cognitive and neuropsychological functioning

oEnlarged ventricles

oLess temporal lobe gray matter

oNeurotransmitter dysregulation

Dramatic/Erratic Cluster

•Cluster B

oAntisocial Personality Disorder

oBorderline Personality Disorder

oHistrionic Personality Disorder

oNarcissistic Personality Disorder

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•Characterized by symptoms that range from:

oRule-breaking behaviour

oExaggerated emotional displays

oHighly inconsistent behaviour

oInflated self-esteem

Antisocial Personality Disorder (dramatic/erratic)

•Pervasive disregard for the rights of others

oAggressive, impulsive, and callous traits

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•Pattern of irresponsible behaviours

oWorking inconsistently, breaking laws, being irritable and physically aggressive, defaulting on debts, being reckless and impulsive, neglecting to plan ahead

•Little regard for truth and little remorse for misdeeds

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•5x more common in men

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•75% also meet criteria for another disorder

oSubstance use is very common

Psychopathy

•Focuses on internal thoughts and feelings

oPoverty of emotion

•Negative emotions

oLacks shame, remorse and anxiety; does not learn from mistakes

•Positive emotions

oMerely an act used to manipulate others; superficially charming

oImpulsivity

Behave irresponsibly for thrills

•Psychopathy Checklist – revised (Hare, 2003)

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•Compared to Antisocial Personality Disorder:

oDoes not require symptoms before age 15

oIncludes more affective symptoms (e.g., lack of empathy)

Antisocial Personality Disorder

•Age at least 18

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•Evidence of conduct disorder before age 15

•Pervasive pattern of disregard for the rights of others since the age of 15 as shown by at least three of the following:

oRepeated law breaking

oDeceitfulness, lying

oImpulsivity

Irritability and aggressiveness

oReckless disregard for own safety and that of others

oIrresponsibility as seen in unreliable employment or financial history

oLack of remorse

Etiology of Antisocial Personality Disorder

•Problems with research

oDifferences in diagnosis (APD vs. psychopathy)

oConducted mostly with criminals

o•Interactions of genes and the social environment

oGenetic, behavioural, and family influences are very hard to disentangle

oSocial environment

•Poverty, exposure to violence

oFamily environment interacts with genetics

•Polymorphism of the MAO-A gene predicts psychopathy among males who had experienced childhood physical or sexual abuse or maternal rejection

Etiology of Antisocial Personality Disorder:  Psychological Risk

•Insensitivity to fear and threat

oUnable to learn from experience to avoid trouble

•Weakened classical conditioning

oLack of fear or anxiety

oLower levels and less reactive skin conductance

oBlunted neural responsivity to aversive stimuli

•Poor attention to treat when pursuing rewards/goals

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•Deficits in empathy

oNot in tune with the emotional reactions of others

Borderline Personality Disorder

•Common in clinical settings, very hard to treat, and associated with recurrent periods of suicidality

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•Impulsivity and instability in relationships and mood

oE.g., gambling, reckless spending, indiscriminate sexual activity, and substance abuse

•High levels of stress (e.g., relationship conflicts)

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•Cannot bear to be alone, fears of abandonment, chronic feelings of depression and emptiness

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•Suicidal behaviour is common in BPD

oAlso likely to engage in nonsuicidal self-injury

DSM-5 Criteria:
Borderline Personality Disorder

•Presence of five or more of the following signs of instability in relationships, self-image, and impulsivity from early adulthood across many contexts:

oFrantic efforts to avoid abandonment

oUnstable interpersonal relationships in which others are either idealized or devalued

oUnstable sense of self

Self-damaging, impulsive behaviours in at least two areas, such as spending, sex, substance abuse, reckless driving, and binge eating

oRecurrent suicidal behaviour, gestures, or self-injurious behaviour (e.g., cutting self)

oMarked mood reactivity

oChronic feelings of emptiness

oRecurrent bouts of intense or poorly controlled anger

oDuring stress, a tendency to experience transient paranoid thoughts and dissociative symptoms

Etiology BPD:
Neurobiological Factors

•Diminished connectivity of brain regions involved in emotion experience

oPrefrontal cortex, anterior cingulate cortex, amygdala

Could help explain poor control over emotions and impulsivity when emotions are present

Etiology BPD: Parenting Interacts with Child Vulnerability

•Linehan’s Diathesis-Stress Theory

oDiathesis of emotional dysregulation interacts with a family environment that is invalidating

•Person’s feelings are discounted and disrespected

oEmotional dysregulation and invalidation interact with each other in a dynamic fashion

Etiology BPD:
Genetic Vulnerability and Abuse

•Although abuse is common, it does not appear to be the diathesis for BPD

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•Genetically driven impulsivity, emotionality, or risk-seeking in the parents could increase the risk that both abuse and BPD will occur

Histrionic Personality Disorder

•Overly dramatic and attention-seeking behaviour

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•Often use their physical appearance to draw attention to themselves

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•Self-centered, overly concerned with their physical attractiveness, and uncomfortable when not the center of attention

•Inappropriately sexually provocative and seductive

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•Easily influenced by others

DSM-5 Criteria:
Histrionic Personality Disorder

•Presence of five or more of the following signs of excessive emotionality and attention seeking from early adulthood across many contexts:

oStrong need to be the center of attention

oInappropriate sexually seductive behaviour

oRapidly shifting and shallow expression of emotions

oUse of physical appearance to draw attention to self

oSpeech that is excessively impressionistic and lacking in detail

oExaggerated, theatrical emotional expression

oOverly suggestible

oMisreads relationships as more intimate than they are

Narcissistic Personality Disorder

•Grandiose view of self

oPreoccupied with fantasies of great success

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•Self-centered

oDemands constant attention

oLacks empathy

oFeelings of arrogance, envy, entitlement

oView themselves as superior to others

•Primary goal of interaction with others is to bolster their own self-esteem

oValue being admired more than gaining closeness

oTendency to seek out high status partners

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•Highly likely to be vindictive and aggressive when faced with a competitive threat or a put-down

DSM-5 Criteria:
Narcissistic Personality Disorder

•Presence of five or more of the following signs of grandiosity, need for admiration, and lack of empathy from early adulthood across many contexts:

oGrandiose view of one’s importance

oPreoccupation with one’s success, brilliance, beauty

oBelief that one is special and can be understood only by other high-status people

oExtreme need for admiration

oStrong sense of entitlement

•Presence of five or more of the following signs of grandiosity, need for admiration, and lack of empathy from early adulthood across many contexts (continued):

oTendency to exploit others

oLack of empathy

oEnvious of others

Arrogant behaviour or attitudes

Etiology of Narcissistic
Personality Disorder

•Parenting

oOverly indulgent parents foster children’s belief that they are special

oParental tendencies to see their children as highly superior to others predicts children’s narcissistic traits

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•Fragile Self-Esteem

oInflated self-worth and denigration of others defend against feelings of shame

oSensitivity to negative social interactions

oAssociated with higher levels of neuroticism and depression

Anxious/Fearful Cluster

•Cluster C

oAvoidant Personality Disorder

oDependent Personality Disorder

oObsessive Compulsive Personality Disorder

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•Prone to worry and distress

Avoidant Personality Disorder

•Fearful of criticism, rejection, and disapproval

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•Avoids social situations do to fear of negative feedback

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•Restrained and inhibited in social situations

oFeelings of inadequacy, inferiority

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•Beliefs of incompetence and inferiority

oAvoids taking risks or trying new activities

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•High comorbidity with social anxiety disorder

oSimilar genetic vulnerability

DSM-5 Criteria:
Avoidant Personality Disorder

•A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to criticism as shown by four or more of the following from early adulthood across many contexts:

oAvoidance of occupational activities that involve significant interpersonal contact, because of fears of criticism or disapproval

oUnwilling to get involved with people unless certain of being liked

oRestrained in intimate relationships because of the fear of being shamed or ridiculed

oPreoccupation with being criticized or rejected

oInhibited in new interpersonal situations because of feelings of inadequacy

oViews self as socially inept, unappealing or inferior

oUnusually reluctant to try new activities because they may prove embarrassing

Dependent Personality Disorder

•Excessive reliance on others

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•Intense need to be taken care of

oDiscomfort with being alone

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•Subordinate needs to ensure protective relationships are not threaten

•Urgently seek new relationship when one ends

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•View themselves as weak

oTurn to others for support and decision making

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•Likely to develop depression after interpersonal losses

DSM-5 Criteria:
Dependent Personality Disorder

•An excessive need to be taken care of, as shown by the presence of at least five of the following from early adulthood across many contexts:

oDifficulty making decisions without excessive advice and reassurance from others

oNeed for others to take responsibility for most major areas of life

oDifficulty disagreeing with others for fear of losing their support

oDifficulty doing things on own or starting projects because of lack of self-confidence

oDoing unpleasant things as a way to obtain the approval and support of others

oFeelings of helplessness when alone because of fears of being unable to care for self

oUrgently seeking new relationship when one ends

oPreoccupation with fears of having to take care of self

Obsessive-Compulsive Personality Disorder

•A perfectionist

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•Preoccupied with rules, details, schedules, and organization

oOften to the extreme of being unable to finish projects

oSerious, rigid, formal, and inflexible

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•Overly focused on work

oLittle time for leisure, family, and friends

•Reluctant to make decisions or delegate

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•Compared to OCD:

oDoes not have the obsessions/compulsions of OCD

oSymptoms often co-occur and share genetic vulnerability

DSM-5 Criteria: Obsessive-Compulsive Personality Disorder

•Intense need for order, perfection, and control, as shown by the presence of at least four of the following from early adulthood across many contexts:

oPreoccupation with rules, details, and organization to the extent that the point of an activity is lost

oExtreme perfectionism interferes with task completion

oExcessive devotion to work to the exclusion of leisure and friendships

oInflexibility about morals and values

oDifficulty discarding worthless items

oReluctance to delegate unless others conform to one’s standards

oMiserliness

oRigidity and stubbornness

Treatment of Personality Disorders

•Often enter treatment for a condition other than PD

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•Presence of PD predicts slower improvement in psychotherapy

•Psychotherapy is the treatment of choice

oEvidence that personality traits do change

oOften supplemented with medications

oPsychodynamic theory

•Childhood problems are at the root of PD

oCognitive theory

•Negative cognitive beliefs are at the root of PD

•Help person become more aware of beliefs and challenge maladaptive cognitions

Treatment of Schizotypal PD
and Avoidant PD

•Schizotypal PD

oAntipsychotic and antidepressant medications

•Helpful for reducing unusual thinking

•Avoidant PD

oSame treatments as social anxiety disorder

oAntidepressant medications

oCBT

•Challenge negative beliefs

•Social skills training

•Exposure to feared situations

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Treatment of Borderline PD

•Difficult to treat

oInterpersonal problems play out in therapy

oTherapists often endorse feeling overwhelmed, inadequate, and at the same time, overly involved

oSuicide is always a serious risk

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•Goals of treatment: Reduce symptoms, suicidality, and risk of self-harm

•Psychodynamic therapy

oTransference based therapy

•Helps client consider parallels between response to therapist and experiences in other relationships

oMentalization therapy

•Helps client to be more reflective about feelings, and those of other people, so as to not automatically act without thinking when emotions or interpersonal stressors occur

Treatment of Borderline PD:
Dialectical Behaviour Therapy

•Combines client-centered empathy and acceptance with cognitive behavioural problem solving, emotion-regulation techniques, and social skills training

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•Dialectics

oConstant tension between any phenomenon and its opposite, which is resolved by creating a new phenomenon

•Group and individual therapy sessions

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•Four stages:

oAddressing dangerously impulsive behaviours (e.g., suicidal actions)

oModulating extreme emotionality and coaching the client to tolerate emotional distress

oImproving relationships and self-esteem

oPromoting connectedness and happiness