PSYC 300 - Module `10

Personality Disorders

Personality Disorders

Enduring problems with forming stable positive identity/close and constructive relationships 

• Extreme + inflexible traits

• Much more likely to be victims of violence (physical/sexual) 

• Predictor of poorer physical health 

General DSM-5 Criteria for Personality Disorders

1. During a pattern of experiences + behaviours that differ from expectations of one's culture. Manifested via 2+ of following: 

• Cognition

• Affectivity

• Interpersonal functioning

• Impulse control

2. Pattern is enduring, inflexible, and pervasive

• Displayed across all contexts (not just a reaction to environment)

3. Clinically significant distress/impairment 

4. Onset can be traced back to adolescence + early adulthood

• Pattern must be going on for at least a year 
  

Issues with DSM-5 Approach for Personality Disorders 

1. Disorders are not as stable as the definition implies

• Not stable over time/as enduring as DSM suggests

• ½ of people with diagnosis did not meet criteria 2 years ago 

• 99% do not meet criteria for same diagnosis after 26 years 

2. High rates of comorbidity amongst personality disorders 

• ½ of people with personality disorder meet criteria for another personality disorder 

3. Thresholds for defining diagnosis are arbitrary 

• Number of symptoms needed is arbitrary 

• People with diagnosis extremely varied in functional impairment 

• Personality symptoms vary along continuum (aside from schizotypal)

Alternative DSM-5 Model for Personality Disorders 

DSM-5 Committee on Personality and Personality Disorders recommended reducing number of personality disorders + diagnosing personality disorders based on extreme scores on personality trait measures 

• Diagnoses considered if pervasive impairments in functioning persists from early adulthood (long term dysfunction) 

• 5 personality trait domains + 25 more specific trait facets (based on 5-factor personality model) 

Excludes: 

• Schizoid

• Histrionic

• Dependant

• Paranoid

5 Main Domains of Personality Trait Measures

1. Negative Affectivity (vs. Emotional Stability) 

2. Detachment (vs. Extroversion) 

3. Antagonism (vs. Agreeableness) 

4. Disinhibition (vs. Conscientiousness) 

5. Psychoticism 

Pros of alternative approach

• Personality trait ratings are more stable over time than personality diagnoses

• Provide richer detail than categorical personality disorder diagnoses 

• Does not limit traits to specific category/disorder

• Personality traits predict important outcomes (happiness, quality of relationships, occupational outcomes, physical health, life expectancy) 

• Clinicians rate personality trait profiles as easier to discuss with clients + more helpful for treatment planning than traditional diagnostic system 

Culture and Personality

Must take into account individual’s ethnic, cultural, and social background 

Distinguish from: 

1. Difficulties with acculturation/learning social norms

2. Expression of values consistent with that person’s cultural background/context 

• Looking for behavioural patterns that are rigid + dysfunctional, rather than adaptive responses to one’s culture

Clinicians should: 

1. Attend to their own cultural background

2. Use of culturally-appropriate instruments (ex. Cultural Formulation Interview)

• Assesses impact of individual’s social and cultural upbringing on mental health  

3. Consult 

• Reflect on cultural experiences, biases

• Learn about individual’s culture

Common Risk Factors of all Personality Disorders

• High comorbidity with mood + anxiety disorders 

• Children in the Community Study

  • PDs more likely amongst individuals who experienced abuse/neglect 

  • Early childhood adversity = significantly increase risk 

  • Not always in extreme cases of neglect/abuse, sometimes just aversive parenting styles 

  • Disconnect in parenting + childs needs 

• Modestly-moderately heritable

3 Cluster of PDs

1. Cluster A (Odd/eccentric)

• Paranoid

• Schizoid

• Schizotypal 

2. Cluster B (Dramatic/erratic)

• Antisocial 

• Bordeline

• Histrionic

• Narcissistic

3. Cluster C (Anxious/fearful) 

• Avoidant 

• Dependant 

• Obsessive-compulsive

Cluster A (Odd/eccentric)

All have some degree of similarity to schizophrenia (no hallucinations) 

1. Paranoid: Distrust + suspiciousness of others

• most common in unwarranted suspicion of partner’s fidelity

2. Schizoid: Detachment from social relationships + restricted range of emotional expression 

3. Schizotypal: Acute discomfort with and capacity for close relationships, cognitive/perceptual distortions, eccentricities of behavior 

Paranoid PD vs Delusional Disorder

• Differ in rigidity of thinking 

• Delusional disorder: Paranoid delusions about being persecuted. Completely convinced it is happening 

• Paranoid PD: Fear, but degree of recognition it may not be happening.

Schizoid PD vs Anhedonia, Schizophrenia, and SAD 

• SAD: Want to engage in activities, too anxious

• Anhedonia: Lost interest in previously pleasurable activities

• Schizoid PD: Never wanted to do pleasurable activities

  • No positive symptoms (schizophrenia) 

  • Don't want to engage in social events

Low inter-rater reliability for this disorder specifically! 

Schizotypal vs schizoid

Schizotypal: Presence of cognitive + perceptual differences

• Most similar to schizophrenia! Mild form of schizophrenia

Cluster B (Dramatic/erratic)

Highly inconsistent behaviour 

1. Antisocial: Disregard for/and violation of the rights of others (aggressive, impulsive, callous) 

2. Borderline (BPD): Impulsivity and instability in relationships and mood

3. Histrionic: Excessive emotionality + attention seeking 

4. Narcissistic: Grandiosity, need for admiration, lack of empathy 

Antisocial PD

• Age at least 18 (Exception for childhood diagnosis)

• Pervasive pattern of disregard for the rights of others since the age of 15

• Conduct disorder before age 15 

  • Pattern of behaviour where basic rights of other people are taken away. Age-inappropriate violation of social norms

  • Cruelty to animals, excessive bullying, damaging property, hurting people

• Much more common in men than women

• High comorbidity with substance use disorder

• Strong heritability; Aversive family environment + genetic predisposition = likely to develop 

• Much of research is based on forensic setting → does not accurately capture non-incarcerated ASPD population 

Psychopathy

⅓ of people diagnosed w/ antisocial disorder show symptoms consistent with psychopathy

• Not a DSM diagnosis anymore - general description of behaviour!

• Assessed via Psychopathy Checklist-Revised (PCL-R) → 20 item scale + interview

Criteria:

1. Poverty of emotions (positive and negative) 

• Can display emotions, but not genuinely felt

• Charming/cunning in a way to manipulate

2. Cruelty and callousness

3. Impulsivity + no sense of shame

4. Extremely reward motivated 

Differences between Antisocial PD and Psychopathy

• Psychopathy associated w/ more affective/emotional symptoms

• ASPD requires diagnosis of conduct disorder before age 15

Borderline Personality Disorder (BPD)

Core Features: 

1. Impulsivity 

• Self damaging behaviours

2. Instability (in relationships, sense of self, mood) 

• Frantic efforts to avoid abandonment

• Recurrent suicidal gestures

Neurobiological Etiology of BPD

• High hereditary (genes account for 60% of variance for risk)  

• Decreased functioning of serotonin system (linked to impulsivity) 

• Increased activation of amygdala 

Environemmt Etiology of BPD

Main hypothesized influences: 

1. Emotional dysregulation 

• Parent separation, verbal/emotional abuse during childhood

2. Invalidation

• People with BPD are like roses! Need something different than tulip. If you parent them like a tulip, needs are not adequate met 

• Mismatch of parenting and the needs of the child 

• Individuals can simply be raised in an environment in what they need vs environment that leads to feelings of invalidation + misunderstood

Linehan’s Diathesis-Stress Theory

• BPD individuals have difficulty controlling emotions, experience dysregulation due to biological diathesis 

• When in family environment that discounts emotional experience, feels they need to increase expression/reactivity of emotions in order to be heard/listened to 

• Saying they are not okay in an environment that is telling them they are fine

Histrionic PD

• “Life of the party”. Difficult for themselves/others to sustain them. Frustration, disappointment

• Self worth based on ability to receive attention 

• Strong need to be the center of attention

• Inappropriate sexually seductive behavior

• Exaggerated, theatrical emotional expression

• Misreads relationships as more intimate than they are (ex. Someone you met 3 hours ago as “best friend”)

Narcissistic PD

1. Grandiose self-view

2. Self-centered

3. Sensitive to criticism 

4. Seeks out high-status partners 

In reality have very fragile self esteem, preoccupied how they are regarded by others

• Believe they know more than everyone else 

• Vs histrionic: Less charming, care less about how they make other feel and rather how others make them feel

• Overly indulgent parenting that promote child’s beliefs that they are special, high rates in those with narcissism 

Narcissism Etiology Models

1. Kohut’s Self-Psychology Model

2. Social Cognitive Model

Kohut’s Self-Psychology Model 

• Narcissism develops when children are not getting enough approval from parents 

• Mask fragile self esteem 

• Value only comes from what the parents get out of the child. Importance placed on child's performance/accomplishments (not who they are as a person) 

Social Cognitive Model 

• Narcissism: Inability to accurately judge other’s interpretations of themselves 

  • Also acknowledges narcissists have low self esteem 

• Ex. difficulty interpreting facial expressions 

• Too inwardly focused, in childhood don't pay enough attention to others to learn social cues + social reciprocity 

• Interpersonal relationships are a way to bolster inner insecurity

Cluster B (Dramatic/erratic) Gender DIfferences

• Females: Higher prevalence of histrionic and borderline personality disorder

• Men: Higher prevalence in narcissistic personality disorder 

Cluster C (Anxious/Fearful)

Worry, preoccupation, anxiety, overall negative affect levels of distress

1. Avoidant: Pervasive pattern of social inhibition. Feelings of inadequacy + hypersensitive to negative evaluation 

2. Dependent: Excessive need to be taken care of, very submissive, and fears of separation 

3. Obsessive Compulsive PD: Preoccupation with order, perfection, and control

Avoidant Personality Disorder

• Begins in early adulthood

• Core belief: utter failure, inept, unworthy 

• Intense fear of criticism/rejection

Extreme/chronic version of social anxiety disorder! 

• High comorbidity with SAD (most people with avoidant personality disorder meet criteria, but not all ppl with SAD meet criteria) 

• Can be diagnosed with both, will be diagnosed with SAD first 

Dependent PD

• Stems from belief that they wouldn't be able to take care of themselves on their own 

• Extreme difficult leaving abusive relationship → tend to stick with one relationship 

• Prefer having one person they are very all-in with, will urgently seek replacement if relationship ends

• difficulty making decisions, disagreeing, doing things alone, taking responsibility

Obsessive Compulsive Personality Disorder

• Not the same as obsessive-compulsive disorder!

  • Will not have obsessions or compulsions of OCD 

• High degree of perfectionism

• Intense need for control; Preoccupied with rules, details, schedules, and organization (even if they don't have consequences) 

• Overly focused on work

• Difficulty making decisions themselves, and reluctance to delegate decisions

• Serious, rigid, formal, inflexible (including for moral issues) 

• Most frequently comorbid with avoidant PD

Etiology of Anxious/Fearful Cluster

Not much available research!

1. Avoidant PD: Modelling parent’s fears

2. Obsessive-Compulsive PD: Coping with fears of losing control by overcompensation 

3. Dependent PD: Overprotective + authoritarian parenting style 

4. Disruption of early childhood attachment (severe neglect, rejection, parent death, excessive overprotectiveness) 

Treatment for Personality Disorders

Focus on outward manifestations of behavioural patterns (ex. Relationships, jobs) 

1. Medications 

• Avoidant PD: Anti-anxiety meds, antidepressants

• Schizotypal PD: Antipsychotic, occasionally antidepressants 

2. Psychotherapy 

• Psychodynamic (most useful in addressing root childhood problems) 

• Cognitive Behavioural (focus on negative core/cognitive beliefs, at the heart of each disorder) 

Borderline PD Treatment

Greatest efficacy for treatment!

• Medications: Antidepressants, mood stabilizers 

• Dialectical Behavioural Therapy (Linehan, 1987) 

Dialectical Behavioural Therapy

• Balancing unconditional, radical mindfulness-based acceptance with change (CBT)

• Individual therapy in combine with skills training 

  • Individual therapist on call all the time, ensure individual is implementing skills + not engaging in self-harming behaviours 

• Skills group: Emotion regulation, mindfulness, distress tolerance, interpersonal effectiveness

• DBT therapist also has a support group → constant worry about patient harming themselves, hurt by their behaviour 

  • Practice DBT skills in own life

Transference-Focused Therapy and Mentalization Therapy

• Emphasis on relationship w/ therapist + powerful feelings clients w/ BPD develop for therapist 

• Parallels therapist relationship with other relationships to manage relationships in healthy manner