Psychopathology and Mental Health Exam #4

Personality

Traits that are fairly stable over time, often expressed in terms of interpersonal relationships: social motivation, emotional expression, views of self and others

Five factor model of personality

openness, conscientiousness, extraversion, agreeableness, and neuroticism.

Personality disorders

Enduring patterns of perceiving, relating to and thinking about the environment that cause impairment and/or distress

Distress and personality disorders?

May not have distress

Ego-dystonic vs ego-syntonic

ego dystonic: dissonant with person’s self-image, personal distress, discomfort ego-syntonic: consistent with person’s self-image, do not bother the person

General Personality Disorder diagnosis criteria

1. Pattern in two of the following areas

   1. cognition

   2. affectivity (appropriateness of emotional response

   3. interpersonal functioning

   4. impulse control

2. The enduring pattern is inflexible and pervasive

3. The enduring pattern leads to distress or impairment

4. Can be traced back to adolescence

Why care about PDs?

Significant impairment, risk factors, treatment implications

Why did DSM-4 separate PDs from other disorders?

Believed they had different etiology and were more resistant to treatment (which is not true)

Problems with PDs

Difficult to diagnose, overlap among categories, little research

Categorical classification in DSM5

Its familiar, easy to use, consistent in diagnoses, however it has low inter-rater reliability, very high comorbidity, high overlap among symptoms criteria, ambiguity on presence vs absence, most common pd diagnosed is PD NOS

Dimensional approach of personality

theoretical basis, retention of information (complexity), flexible, resolution of a variety of classification dilemmas, however it is less familiar, lacks clinical application, may be too complex

Cluster A

(Odd and eccentric) Paranoid, Schizoid, Schizotypal

Cluster B

(Particularly hard time to maintain relationships) Narcissistic, Antisocial, Histrionic, Borderline

Cluster C

(Anxious, fearful, and avoidant) Avoidant, Dependent, OCD

Cluster A prevalence

0.5-4.9%, higher in men

Why is treating PDs hard?

Therapists do not understand, PDs play out in a therapeutic relationship, therapists do not want to treat

Paranoid PD

4 or more of the following (not during schizophrenia, bp or mdd):

1. Suspects others

2. Doubts loyalty

3. Reluctant to confide

4. Reads hidden demeaning or threatening meanings

5. Bears grudges

6. Perceives attacks and is quick to react angrily

7. Recurrently suspects partner of cheating

Associated features with Paranoid PD

Difficult to get along with, suspiciousness and hostility, hyper vigilant for potential threats, self-sufficient, controlling, rigid, critical, legal disputes

Treatment for PD

Unlikely to seek treatment, treatment includes cbt and safe environment, most do not want to treat parnoid

Schizoid PD

4 or more:

1. Neither desires nor enjoy close relationships

2. Chooses solitary activities

3. Little interest in having sexual experiences

4. Takes pleasure in few activities

5. Lacks close friends

6. Appears indifferent to others praise or criticism

7. Shows emotional coldness, detachment, or flattened affectivity

Associated features with Schizoid PD

Aloof, cold, detached from social relationships, restricted range of emotion, not distressed by lack of social contact

Treatment for Schizoid

Unlikely to seek treatment, not very optimistic

Schizotypal PD

5 or more:

1. Ideas of reference

2. Odd beliefs or magical thinking (for example: telepathy or sixth sense)

3. Unusual perceptual experiences

4. Odd thinking and speech

5. Suspiciousness

6. Inappropriate affect

7. Behavior that is odd

8. Lack of close friends

9. Excessive social anxiety

Treatment for Schizotypal

Most do not seek treatment, medication: antipsychotics and SSRIs, therapy: supportive, psychoeducational treatment, insight support is NOT helpful

Paranoid (OCEAN)

O: Low

C: Low

A: Low

Schizoid and Schizotypal (OCEAN)

E: Low

N: High

HIstrionic PD

5 or more of the following:

1. Is uncomfortable if not the center of attention

2. Often inappropriately sexual

3. Rapidly shifting and shallow expressions of emotions

4. Consistently uses physical appearance to draw attention

5. Speech is excessively impressionistic

6. Self-dramatization

7. Is suggestible

8. Considers relationships to be more intimate than they really are

Histrionic associated features

May have difficulty with emotional intimacy, act out roles, alienate others, crave novelty, comorbid with MDD and increased risk for suicidality

Prevalence of Histrionic

2-3%, higher in females but not significant

Narcissistic PD

5 or more of the following:

1. Grandiose sense of self importance

2. Preoccupied with fantasies of unlimited success

3. Believes that he or she is special

4. Requires excessive admiration

5. Sense of entitlement

6. Interpersonally exploitive

7. Lacks empathy

8. Often envious of others

9. Shows arrogant, haughty behaviors

Associated features of Narcissistic

Vulnerable self esteem, care deeply about their own self-perception, relationship impairments, comorbid with anorexia and anxiety disorders

Prevalence of Narcisstic

6.2%, linked to poor parenting (over sensitive or over valuing), more common in men than women,

Borderline PD

5 or more of the following:

1. Frantic efforts to avoid abandonment

2. Pattern of unstable and intense personal relationships

3. Identity disturbance

4. Self-damaging impulsivity

5. Recurrent suicidal behavior

6. Affective instability

7. Chronic feelings of emptiness

8. Inappropriate, intense anger

9. Transient, stress-related paranoid ideation

Suicide and BP

Up to 80% of people with BPD have suicidal behaviors, 4-9% commit suicide

Reasons for self harm

Feel something, punish themselves

Borderline PD etiology

Childhood maltreatment

Borderline Prevalence

2%, more common in women, comorbid with MDD

BPD Treatment

Difficult to treat, medication is a frequent choice: antipsychotics, antidepressants, dialectical behavioral therapy

DBT goals

Main treatment goal is to address emotional dysregulation: emotional behavioral cognitive sense of self interpersonal

DBT components of treatment

Individual therapy, group therapy, telephone consultation, consultation theme

Antisocial PD

3 or more of the following:

1. repeatedly breaks the law

2. deceitfulness

3. impulsivity

4. irrtability

5. reckless disregard for safety

6. consistent irresponsibility

7. lack of remorse

Additional criteria for antisocial

must be over 18, evidence of conduct disorder before age 15: aggression to people and animals, destruction of property, deceitfulness or theft, serious rule violation

Psychopathy: related to antisocial

Deceitful, lacks empathy, and incapable of learning from experience. Not in DSM5, captures a subset of people with ASPD, strong emphasis on emotional and interpersonal traits, better predictor of recidivism

Antisocial prevalence

3% in men, 1% in women. Higher in samples that are economically disadvantaged, comorbid with substance abuse, burns out by age 40 although limited behavioral skills may persist

Avoidant PD

4 or more of the following:

1. Avoids work activities that require sig. interpersonal contact

2. Unwilling to get involved with people unless certain of being liked

3. Shows restraint within intimate relationships, because of fear of being shamed or ridiculed

4. Preoccupied with social criticism or rejection

5. Is inhibited in new interpersonal situations because of feelings of inadequacy

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

7. Usually reluctant to take personal risks to engage in any new activities

Avoidant PD associated features

Shy, hypervigilant, often target of ridicule, low self-esteem and hypersensitivity to rejection, may fantasize about idealized relationships

Avoidant PD Prevalence

1.2-4%, equally common in men and women, related to generalized social phobia, comorbid with mood and anxiety, often starts in infancy or childhood some evidence for remission over life

Dependent PD

5 or more of the following:

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

2. Needs others to assume responsibility for most major areas of life

3. Has difficult expressing disagreement

4. Has difficulty initiating projects

5. Goes to excessive lengths to obtain nurturance and support from others

6. Feels uncomfortable or helpless when alone

7. Urgently seeks another relationship

8. Is unrealistically preoccupied with fears of being left to take care of himself

Dependent PD Associated features

Often characterized by pessimism, may avoid positions of responsibility, comorbid with mdd and anxiety

Dependent PD prevalence

0.3-2%, equally common in men and women, may be linked to early neglect and disruptions in attachment patterns, treatment involves pursuing more independent choices

OC PD

4 or more of the following:

1. Is preoccupied with details

2. Shows perfectionism that interferes with task completion

3. Excessively devoted to work and productivity

4. Is over-conscientious, scrupulous, and inflexible

5. Is unable to discard worn-out or worthless objects

6. Reluctant to delegate tasks or to work with others

7. Adopts a miserly spending style toward both self and others

8. Shows rigidity and stubbornness

OCPD Associated features

May be preoccupied with logic, difficulty prioritizing tasks, prone to upset if cannot control situation, relationships may have formal quality, comorbid is OCD

Difference between OCD and OCPD

OCD is ego-dystonic, OCPD is ego-systonic

Prevalence of OCPD

2-8%, more common in men than women

Affiliation

Desire for close relationships

Power

Desire for impact, prestige, or dominance

What disorder is cluster A associated with?

Schizophrenia spectrum disorders

How to qualify for a personality disorder trait specified

A person must exhibit significant impairment in self or interpersonal functioning, as well as one or more pathological personality traits

Overall lifetime prevelance of personality disorder

10%

Highest prevalent PDs

OCPD, antisocial, avoidant

Causes of schizotypal PD

Highly genetic

Treatment for schizotypal PD

Low dose of anti-psychotics or antidepressants may work

Two hypotheses for psychological factors of Antisocial PD

Lack of anxiety and fear, and difficulty shifting or reallocating their attention to consider the possible negative consequences of behavior

DSM IV Diagnoses for Intellectual Disorders vs DSM5

Autistics Disorder and Asperger’s Disorder for DSM IV, ASD for DSM5

DSM 4 Autistic Disorder Central Symptoms

Impaired Communication, Restrictive and Repetitive Behaviors Interests or Activities, Impaired Social Interaction

Key symptoms of impairment in social interaction

Marked impariment in nonverbal behaviors, absence of developmentally appropriate peer relations, lack of spontaneous seeking to share enjoyment, interests or achievements, lack of social or emotional reciprocity

Eye tracking and autism

Atypical scanning during encoding

Key symptoms in impairment in communication

Delay or total lack of spoken language, impairment in conversation, stereotyped or repetitive language, lack of make-believe or social imitative play

Key symptoms in restricted and repetitive behaviors

Preoccupations with patterns of interest, inflexible adherence to routine, stereotyped or repetitive motor mannerisms, preoccupation with parts of objects

Diagnosis of Autistic Disorder in DSM IV

6+ symptoms, 2 in impairment in social interaction, 1 in impairment in communication, 1 in restricted. Delays or abnormal functioning in one before the age of 3:

1. Social interaction

2. Language used in social communication

3. Symbolic/imaginative play

Key associated features with Autism

Self injury (not suicide) and savant performance

DSM-4 Autistic Disorder: Course/prognosis

Early signs are subtle, some symptoms have yearly onset, prognosis is poor: 1/3 achieve partial independence as adults

Best outcome of autism associated with:

1. Ability to communicate verbally by age 5 or 6

2. IQ>70

3. A later symptoms onset

DSM IV Autistic Disorder Prevalence

Large increases in diagnoses, 3-4 times more common among boys than girls, occurs in all ethnic, socioeconomic and age groups

Asperger’s central symptoms

Restrictive and repetitive behaviors, impaired social interaction (no impaired communication)

Asperger’s disorder does not have a significant delay in:

1. Language

2. Cognitive development

3. Self-help skills

4. Adaptive behaviors

5. Curiosity about environment

DSM5 ASD central symptoms

Restrictive and repetitive behaviors, impaired social interaction (no impaired communication)

Impairment in social interaction (ASD)

Marked impairment in nonverbal behaviors, absence of developmentally appropriate peer relations, lack of social or emotional reciprocity (no lack of spontaneous sharing of enjoyment)

Restricted and repetitive behaviors (ASD)

Highly restricted fixated interests, Inflexible adherence to routine, stereotyped or repetitive motor mannerisms, hyper or hypo reactivity to sensory input (no preoccupation of interests or parts of object)

Additional criteria of ASD

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

ASD specifiers

1. Intellectual impairment

2. Language impairment

3. Associated with known medical or genetic condition or environmental factor

Prevalence of ASD

1% of population (increasing), more common in boys (4xs), some concern about girls being under-diagnosed

Risk factors for ASD

Advanced parental age, low birth weight, exposure to certain meds in utero, high genetic heritability

Treatment for ASD

Medications not effective, interventions focus on enhancing daily living communication and social skills and reducing undesirable behaviors

Applied Behavior Analysi

Intensive behavior modification using operant conditioning techniques, focus on specific symptoms of autism:

1. Identify very specific target behaviors

2. Gain control over these behaviors using reinforcement and punishment

Theory of mind

A failure to appreciate that other people have a different point of reference, miss basic motivations to form attachment

Externalizing disorders

Norms violated at a younger age than is typical, importance of age of onset

Key features of an externalizing disorder

Rule violations, negativity, impulsivity, hyperactivity, attention deficits

Destructive and overt

Aggression (Cruelty to animals, fighting, bullying)

Non-destructive and overt

Oppositional (Temper tantrums, angry, defiant)

Covert and destructive

Property destruction (Stealing, firesetting, vandalism)

Covery and non-destructive

Status offenses (running away, truancy, cursing)

Irritability in early childhood

Problem at younger age, more problematic if dysregulated, predictive

Callousness in early childhood

Predictive, moderately stable, associated with conduct problems

ADHD Criteria

Persistent pattern of:

1. Inattention: careless mistakes, easily distracted, forgetful, difficulty organizing tasks

2. Hyperactivity and impulsivity: fidgets, unable to stay in seat, talks excessively, interrupts others

For at least 6 months need >=6 symptoms of inattention and/or hyperactivity and impulsivity

Several symptoms must be present before age 12 in at least two settings

Impairment

Social problems with ADHD

Very talkative, socially intrusive, parents and teachers teach kids with adhd differently

Oppositional Defiant Disorder (ODD) Criteria

A pattern of angry/irritable mood, argumentative/defiant behavior or vindictiveness

Needs >=4 of 8 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 during other disorder

Conduct Disorder Criteria (CD)

Repetitive pattern of violating basic rights of others: aggression to people and animals, destruction of property, deceitfulness or theft, serious rule violation

Over 12 months need >=3 symptoms across four categories

Impariment

For those 18 years or older, criteria for antisocial pd are not met

Prevalence and course of Externalizing Disorder

19% lifetime prevalence rate, boys have 2-10 times higher rates, prevalence declines with age

ADHD Epidemiology

Most are diagnosed ages 7-9. more common among boys than girls, 3-10% of American children have it while only 1-5% of European children have it. Increasing diagnosis