Lecture 5: Personality Disorders

personality

Characteristic way of behaving, experiencing life and of perceiving and interpreting themselves, other people, events and situations

• Relatively stable over time

• Relatively stable over situations

• Cognition, emotion, behaviour

The Big Five

1. Openness <-> Traditionalism

2. Conscientiousness <-> Headlessness

3. Extraversion <-> Introversion

4. Agreeableness <-> Antagonism

5. Neuroticism <-> Emotional stability

Personality disorder

Enduring problems with forming a stable positive identity and sustaining close and constructive relationships.

• Personality traits are:

  • Extreme

  • Inflexible/rigid

  • Dysfunctional

• Typically: ego-syntonous (vs. ego-dystonous)

  • Cf. phobia vs OCPD

• Differential diagnostics

  • Other PD, autism, mental retardation, chronic syndrome disorder, circumstances

• DSM IV (axis removed from DSM-5):

  • Axis I: Syndrome disorders

  • Axis II: Personality

DSM general criteria for personality disorders

An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture. Manifests in 2+/4 domains:

• Cognition

• Affectivity

• Interpersonal functioning

• Impulse control

• Pervasive: inflexible, across many different situations

• Persistent: stable, long term, start early adulthood

• Pathological: distress/dysfunction

Onset in early adulthood; not better explained by another substance/somatic/mental disorder…

 

Problems with DSM-5-TR approach to personality disorders

• Not stable over time: ~50% don't meet criteria again after 2 years

  • In patients diagnosed with severe personality disorder, 99% don't meet criteria 16y later

  • Milder symptoms remain, but disorder are not as enduring as the DSM claims

• PDs are highly comorbid: 50% have another PD; some involve similar symptoms

• Arbitrary thresholds: number of symptoms is arbitrary; more of a continuum rather than yes/no, almost all disorders seem dimensional in nature

  • PD-NOS one of the most frequently used

  • ICD-11 switched to dimensional model

DSM disorders

Cluster A: 'odd, eccentric'

• Paranoid PD - distrusting

• Schizotypal PD - strange perceptions and behaviour; cognitive distortions, eccentric behaviour, lack of capacity for close relationships

• Schizoid PD - distant; detachment from social relationships, restricted range of emotional expression

Cluster B: 'dramatic, emotional, erratic'

• Antisocial - violating others' rights

• Borderline - instability in self-image, relations, emotions; impulsivity

• Histrionic - emotional, attention seeking

• Narcissistic - inflated ego, need for admiration, lack of empathy

Cluster C: 'anxious, fearful'

• Avoidant PD - socially inferior

• Dependent PD - submissive, clinging

• Obsessive-compulsive PD - perfectionistic, controlling

Other specified/unspecified PD; personality change due to medical condition.

DSM Alternative model

DSM AMPD: hybrid

• 5 dimensions (clinical version of big 5)

• 25 facets

• 7 categorical classifications retained!

Strengths:

• Ratings more stable over time than PD diagnoses

• Richer detail than categorical PDs

• Related to many psych. disorders

• Robustly predict outcomes like happiness, relationship quality, stress, occupational outcomes, physical health, life expectancy

• More useful in communicating with clients and planning treatment

ICD-11 personality disorder

An enduring disturbance characterised by:

• Problems in functioning of aspects of the self (identity, self-worth, accuracy of self-view, self-direction)

And/or

• Interpersonal dysfunction (ability to develop/maintain close and mutually satisfying relationships, understand others' perspectives, manage conflict in relationships)

Severity level.

5 dimensions:

• Negative affectivity (high neuroticism)

• Detachment (low extraversion)

• Dissociality (low agreeableness)

• Disinhibition (low conscientiousness)

• Anankastia (extremely high conscientiousness)

Specifier: Borderline Pattern

Epidemiology of PD

• General population fit DSM classification: 9–13%

• Outpatient care: 30–50%

• Inpatient clinics: 50–70%

• Prisons: 60–70%

Unstructured clinical interviews are not reliable, miss up to 50% of personality disorder diagnoses.

Consequences of PD

Treatable!

• High disease burden

• High consumption of care

• Low QoL

• High societal costs

Comorbidity of PDs

• Other mental disorders; associated with worse symptoms

• Other PD (50%):

  • Cluster B (e.g. antisocial + borderline)

  • Cluster C (e.g. dependent + avoidant)

  • Between clusters (e.g. borderline + dependent)

• Other syndromal disorders:

E.g. avoidant + alcohol abuse; obsessive-compulsive PD + depression; borderline + PTSD; PD + anxiety/depression/addiction

How is personality produced?

Aetiology

Early environment - adversity:

• Abuse (didn't predict BPD after controlling for genetic risk; maybe parents with genetic vulnerability more likely to abuse)

• Maltreatment

• Aversive parental behaviour

• Lack of parental affection

• Neglect

Biology:

• Heritability estimates: .35–.70

• Shared between PDs

• Neurotransmitter systems:

  • Dopamine (cognitive problems, cluster A)

  • Serotonin (anger, impulse control)

  • Mono-amine oxydase (MAO; agression)

• Brain areas:

  • Lack of frontal cortical control: impulses and emotions (mid brain)

  • Dysfunction amygdala: hyper-emotionality, hypo-emotionality

Levels of description

• Psychological:

  • Attachment

  • Attributional style

  • Coping styles

• Process:

  • Cognitive biases (attention, interpretation)

  • Core assumptions/beliefs/schemas

  • Emotion regulation

  • impulsivity

• Biological:

Endophenotypes:

• Neural circuits: size, organisation, connectivity

• Neurotransmitter systems

• Neuro-endocrine (e.g. HPA-axis tuning)

A: Paranoid PD

Symptoms:

4+ of following signs of distrust and suspiciousness from early adulthood in many contexts:

• Unjustified suspiciousness of being harmed/deceived/exploited

• Preoccupation with unwarranted doubts about loyalty/trustworthiness of friends or associates

• Reluctance to confide in others due to suspicion

• Reading hidden meanings into benign actions of others

• Bearing grudges for perceived wrongs

• Angry reactions to perceived attacks on character

• Unwarranted suspiciousness of partner's infidelity

A: Schizotypal PD

• Bizarre thinking and functional impairments less severe than in schizophrenia

Symptoms:

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships, as well as cognitive or perceptual distortions and eccentricities of behaviour, beginning by early adulthood and present in a variety of contexts, as indicated by 5+ of the following:

1. Ideas of reference (excluding delusions of reference)

2. Odd beliefs or magical thinking that influences behaviour and is inconsistent with subcultural norms (superstitiousness, belief in clairvoyance, telepathy, "sixth sense", children/adolescents - bizarre fantasies, preoccupations)

3. Unusual perceptual experiences, incl. bodily illusions

4. Odd thinking and speech (e.g. vague, circumstantial, metaphorical, overelaborate or stereotyped)

5. Suspiciousness or paranoid ideation.

6. Inappropriate/constricted affect

7. Behaviour/appearance that is odd, eccentric or peculiar.

8. Lack of close friends or confidants other than 1st degree relatives.

9. Excessive social anxiety that does not diminish with familiarity, associated with paranoid fears rather than negative judgements about self.

Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder or ASD.

schizotypy

• Multigenetic vulnerability

• -> Biochemical deviations

• -> Neurobiological deviations (endophenotypes)

  • Enlarged ventricles, less temporal lobe gray matter, neurotransmitter dysregulation

• Vulnerability -> Schizotypal traits and/or

• Psychotic decompensation: psychotic disorders, schizophrenia

There might be protective factors🤯.

~1/3rd of people diagnosed with schizotypal PD later diagnosed with schizophrenia

A: Schizoid PD

• Low inter-rater reliability

Symptoms:

4+ of the following signs of aloofness and flat affect from early adulthood across many contexts:

• Lack of desire for/enjoyment of close relationships

• Prefers solitude to companionship

• Little interest in sex

• Few/no pleasurable activities

• Lack of close friends

• Indifference to praise/criticism

• Flat affect, emotional detachment or coldness

B: Antisocial PD

• 5 times more likely in men🤯

• 3/4ths meet criteria for another disorder (commonly SUD)

• >50% of prison inmates

• Irresponsible behaviours: working inconsistently, breaking laws, being irritable, physically aggressive, defaulting on debts, being reckless, impulsive, not planning ahead

• Little regard for truth, little remorse for misdeeds

APD: symptoms

• Age 18+

• Conduct disorder before 15

• From 15, pervasive pattern of disregard for others' rights, indicated by 3+ of the following

  1. Repeated engagement in illegal behaviours

  2. Deceitfulness, lying

  3. Impulsivity

  4. Irritability and aggressiveness (for example, repeated physical fights or assaults)

  5. Reckless disregard for own safety and that of others

  6. Irresponsibility (unreliable employment or financial history)

  7. Lack of remorse

APD: causes

Gene-environment interaction:

• Genetic vulnerability for APD overlaps with SUD

• Social environment plays major role in genetic expression of vulnerability

  • Poverty, exposure to violence

  • In adolescents with conduct disorder, impoverished are 2x more likely to develop APD

psychopathy

Subgroup of APD (15–25%) is also 'psychopathic':

Measure: Psychopathy Checklist - revised (PCL-R); evaluation of interview by therapist + facts (file)

• Factor 1: Affect/Interpersonal (callous/unemotional, glib)

• Factor 2: Behaviour (antisocial, impulsive)

Psychopathy:

• Lack of positive/negative emotions

• Superficial charm, used to manipulate others for personal gain

• Lack of anxiety -> don't learn from mistakes

• Lack of remorse -> behave cruelly toward others, impulsively

Triarchic model of psychopathy:

Three core traits underpin symptoms of psychopathy:

1. Boldness (fearlessness)

2. Meanness (aggression and lack of remorse)

3. Disinhibition (impulsivity)

differences between APD and psychopathy

1. PCL-R doesn't include affective symptoms, like shallow affect and lack of empathy

2. DSM criteria for APD require symptoms before age 15

3. APD is categorical, psychopathy is dimensional

risk for psychopathy

Threat sensitivity: deficits linked to boldness

• High boldness <-> less reactivity in GSR and heart rate to aversive stimuli

  • Low GSR to aversive stimuli at 3 predicts psychopathy at 28

• Blunted neural responsivity to aversive stimuli in psychopaths

• Psychopaths don't learn to stop misconduct from punishment because they are insensitive to threats

  • High psychopathy <-> diminished classical conditioning when CS paired with aversive stimulus

  • No (expected) increase in amygdala activity

Lack of empathy (capacity to share emotional reactions of others): linked to meanness

• Men with psychopathy poor recognition of others' fear, other emotions well

• People with APD show less amygdala response when imagining others' pain compared to their own

• vmPFC, involved in processing social and moral info and in conditioning, less active in psychopaths

• Disruptions in amygdala-vmPFC connectivity when viewing others' fearful expressions predicted psychopathic traits

B: Histrionic PD

5+ of the following signs of excessive emotionality and attention seeking from early adulthood across many contexts:

• Strong need to be centre of attention

• Inappropriate sexually seductive behaviour

• Rapidly shifting, shallow expression of emotions

• Use of physical appearance to draw attention to self

• Speech that is excessively impressionistic and lacking in detail

• Exaggerated, theatrical emotional expression

• Being overly suggestible

• Misreading relationships as more intimate than they are

B: Borderline (BPD)

• Drastic emotional shifts

• Related to interpersonal hypersensitivity:

  • overly sensitive to small signs of rejection, prone to anger/aggression in response

  • Can't bear to be alone, fear of abandonment

  • Chronic feelings of depression and emptiness

• Most closely tied PD to distress in romantic relationships

• Transient psychotic/dissociative symptoms when stressed

• Highly impulsive, particularly in response to emotion states -> gambling, reckless spending, indiscriminate sexual activity, substance abuse

• Have not developed a clear, coherent sense of self - major swings in basic aspects of identity (e.g. shifting between careers)

• Likely to attempt suicide; self-harm (2/3rds)

• Adolescents diagnosed with BPD likely to not meet criteria when reassessed in adulthood

BPD: symptoms

Pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity, beginning by early adulthood and present in variety of contexts, indicated by 5+ of the following (polythetic criteria):

1. Frantic efforts to avoid real or imagined abandonment

2. A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation

3. Identity disturbance: markedly and persistently unstable self-image or sense of self

4. Impulsivity in 2+ areas that are potentially self-damaging (spending, sex, substance abuse, reckless driving, binge eating).

5. Recurrent suicidal behaviour, gestures or threats or self-mutilating behaviour

6. Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability or anxiety usually lasting a few hours, rarely more than a few days)

7. Chronic feelings of emptiness

8. Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights)

9. Transient, stress-related paranoid ideation or severe dissociative symptoms

BPD: neurobiological factors

• Regulatory control regions (PFC, ACC)

• Emotion response regions (amygdala, hippocampus)

Diminished connectivity between these two.

• Repetitive TMS to dlPFC -> short-term improvements in emotion regulation in BPD patients

B: Narcissistic (NPD)

• Grandiose view of their qualities, preoccupied with fantasies of great success

• Interpersonal relationships affected by lack of empathy, arrogance and envy, entitlement and high expectations of others

• View themselves as superior; overestimate attractiveness and contributions

• When interacting with others, primary goal is to bolster own self-esteem - value being admired over closeness

• Do a lot to gain admiration, pursue fame and wealth

• Predicts relationship problems, seek out high-status partners

NPD: symptoms

5+ of following signs of grandiosity, need for admiration and lack of empathy from early adulthood across many contexts:

• Grandiose view of one's importance

• Preoccupation with fantasies of success, power, brilliance, beauty, ideal love

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

• Extreme need for admiration

• Strong sense of entitlement

• Tendency to exploit others

• Lack of empathy

• Envious of others

• Arrogant behaviour or attitudes

NPD: causes

Parenting: overly indulgent parenting promotes beliefs that child is special and behavioural expressions of specialness are tolerated

• People with high levels of narcissism report parental overindulgence

• Parental tendencies to perceive their children as highly superior predicted narcissism

• But evidence that parental abuse or neglect is closely related to narcissistic personality disorder

Fragile self-esteem: Kohut model of narcissism

• Projected on the surface: self-importance, self-importance, self-absorption and fantasies of limitless success

• These mask a very fragile self-esteem

• Inflated self-worth and denigration of others are defences against feelings of shame

  • People with NPD experience shame more frequently

  • Show more reactivity to negative/positive feedback

• Social exclusion activates neural regions associated with pain (anterior insula, ACC): more activation in NPD - particularly sensitive to negative social interactions

• Fragile self-esteem predicts poorer important outcomes

C: Avoidant

• Restrained in social situations, extreme fear of saying something foolish, being embarrassed, showing signs of anxiety

• Often co-occurs with social anxiety disorder - genetic vulnerabilities overlap

Symptoms:

Pervasive pattern of social inhibition, feelings of inadequacy, hypersensitivity to criticism, indicated by 4+ of the following from early adulthood across many contexts:

• Avoidance of occupational activities that involve significant interpersonal conflict, because of fears of criticism, rejection, disapproval

• Unwilling to get involved with people unless certain of being liked

• Restrained in intimate relationships due to fear of being shamed/ridiculed

• Preoccupation with being criticised/rejected

• Inhibited in new interpersonal situations due to feelings of inadequacy

• Viewing self as socially inept, unappealing, inferior

• Reluctant to take risks or try new activities because they may prove embarrassing

C: Dependent

Excessive need to be taken care of, indicated by 5+ of the following from early adulthood across many contexts:

• Difficulty making decisions without excessive advice and reassurance from others

• Need for others to take responsibility for most major areas of life

• Difficulty disagreeing with others for fear of losing their rapport

• Difficulty doing things on own/starting projects because of lack of confidence

• Doing unpleasant things to obtain others' approval and support of others

• Feelings of helplessness when alone because of exaggerated fears of being unable to care for self

• Urgently seeking a new relationship when one ends

• Preoccupation with fears of having to take care of self

C: Obsessive-compulsive (OCPD)

• Perfectionist, preoccupied with details, rules, schedules, to the point of failing to complete tasks

• More oriented towards work than pleasure, social relationships suffer

• Reltionships impacted by demands that everything be done the right way - their way.

• Unable to discard worn out objects, even with no sentimental value, likely to be frugal

• Less interpersonal difficulties than other PDs - not tied to major problems in friendships, family, romantic relationships

Different from OCD: doesn't include obsessions and compulsions

OCPD: symptoms

Intense need for order, perfection and control, indicated by 4+ following from early adulthood across many contexts:

• Preoccupation with rules, details and organisation to the extend that the point of the activity is lost

• Extreme perfectionism interferes with task completion

• Excessive devotion to work to the exclusion of leisure and friendships

• Inflexibility about morals and values

• Difficulty discarding worthless items

• Reluctance to delegate unless others conform to one's standards

• Miserliness (adica zgarcenie ca stiu ca intrebi)

• Rigidity and stubbornness

Models of PD

• Learning/behavioural

  • Conditioning, modelling, contingencies

  • Linehan: emotion regulation

• Cognitive

  • Beck: cognitive model

  • Young: maladaptive schemas

• Psychodynamic

  • Mentalisation

  • Object-relations

Learning/behavioural models: conditioning

• Classical conditioning: "if I attach to a person, I'll get hurt"

• Operant conditioning: "if I force my way, I get what I want"

• Modelling: witnessing your parents resolve conflict with clashes over and over

Learning/behavioural models: Linehan’s Emotional Dysregulation model of BPD

Biological vulnerability -> difficulty controlling emotions + invalidating family environment (person's efforts to communicate feelings are disregarded/punished) -> BPD

Emotional dysregulation and invalidation interact with each other.

Cognitive models: Beck’s cognitive model

Beliefs about the world (schemas) affect the automatic thoughts that pop into our brain.

Cognitive models: Young’s schema theory

Extension on Beck's cognitive theory

• Basic needs (safety, autonomy, boundaries..) not met

• -> early maladaptive schemas

  • Were useful/adaptive in the past

  • 18 or so schemas (e.g. abuse/mistrust, abandonment/instability)

  • Coping with schemas: submission, avoidance, overcompensation

  • -> Multiple modes: vulnerable child, angry child, detached protector, demanding parent, healthy adult

Psychodynamic models: Mentalisation

• understanding the behaviour of the other (and yourself) in terms of their mental states

Hypothesis: mentalisation is learned as primary caretakers mirror and name the child's emotions

Psychodynamic models: Object-relations

• internalised representation of self in relation to the object (another person: father, mother, men etc.)

• In PD immature defence mechanism (e.g. splitting - all good/all bad)

Treatment of PDs

Roadblocks:

• Life threatening behaviours

• Therapy damaging behaviours

• Motivation

Requirements:

• Safe environment: clear structure, attachment figures

• Incentive/invitation to revise coping: clear rationale

• Possibility of new (positive) experiences

Is psychotherapy effective for changing personality?

Psychotherapy and other interventions -> significant changes in personality traits (e.g. neuroticism), often within 6 weeks.

• e.g. Programs enhancing emotion regulation skills address neuroticism

PDs: medications

Supplement to psychotherapy, treat accompanying depression, anxiety or cognitive symptoms.

• Antidepressants - depressive symptoms

• Antipsychotic drugs (risperidone, Risperidal) - some symptoms of schizotypal

Treatment: The Big Four

1. Dialectical Behavioural Therapy (DBT): 

Third wave, acceptance and change, skills training (emotion regulation etc.)

• Stabilises, works well in auto-mutilation

2. Schema (focused) therapy (ST):

Integrative: attachment theory, experiential therapy, cognitive therapy. Limited reparenting, imagery rescripting, chair dialogue (doesn't work),…

• Wide scope, demanding of capacities

3. Mentalisation Based Treatment (MBT):

Foster mentalisation: modelling, small steps etc.

• Simple, works well for severe cases

4. Transference Focused Psychotherapy (TPF):

Object-relations: the relationship with the therapist as working material

• Higher dropout rate

Intermittent explosive disorder (IED)

• Recurrent verbal/physical aggressive outbursts that are far out of proportion to circumstances

• Difference from conduct disorder: aggression is impulsive, not preplanned

Oppositional defiant disorder (ODD)

• Child doesn't meet criteria for conduct disorder (especially extreme physical aggressiveness) but

• Exhibits behaviours like losing temper, arguing with adults, repeatedly refusing to comply with requests from adults, deliberately doing things to annoy others, being angry, spiteful, touchy, vindictive

• Prevalence: 8%

• Often co-occurs with ADHD, but is different: ODD defiant behaviour doesn’t arise from attentional deficits or impulsiveness.

  • Children with ODD are more deliberate in their unruly behaviour than children with ADHD

• Conduct disorder is 3-4x more likely in boys

• Boys are only slightly more likely to have ODD

Conduct disorder

• Involves aggressive behaviours, serious rule violations (e.g. truancy), property destruction, deceitfulness

• Behaviour marked by callousness, viciousness, lack of remorse

  • DSM-5 includes a 'limited prosocial emotions' diagnostic specifier for children with callous/unemotional traits (shallow emotions, lack of feelings of remorse, empathy, guilt)

  • Children with conduct disorder and callous traits had more problems with symptoms, peers and families than children with conduct disorder and no callous traits

Conduct disorder: defining symptoms

Involves a pattern of repeated destructive and harmful behaviour taking different forms, including:

1. Aggressive behaviour (bullying, physically hurting animals/people)

2. Destroying property (vandalising a building, setting a fire)

3. Lying or stealing (shoplifting, breaking into a house and stealing items, lying about behaviour)

4. Breaking rules (skipping school, missing curfew)

Conduct disorder: comorbidity

• Substance abuse (conduct d. either predicts or co-occurs)

• Anxiety and depression are common (15–45%)

• Social anxiety/specific phobias predict conduct disorder

Conduct disorder: longitudinal course

• 7% of preschoolers exhibit symptoms of conduct disorder

• Conduct disorder symptoms at age 3 predict conduct disorder symptoms at age 6🤯, even accounting for ADHD/ODD -> important to assess early

• Moffitt: Two different courses:

  • Life-course-persistent pattern of antisocial behaviour: conduct problems at 3, serious transgressions into adulthood

  • Adolescence-limited: typical childhood, antisocial behaviour in adolescence, typical adulthoods

    • Result of maturity gap between physical maturation and opportunity to assume adult responsibilities/obtain rewards accorded such behaviour

    • Study: continued troubles with substance use, impulsivity, crime and mental health into mid 20s

    • In 30s, women had no more difficulties with violent behaviour, men did

    • Both women and men continued to have issues with substance abuse, physical health and economic issues

Conduct disorder: prevalence

• 5–6%

• 3-4x more common in boys than girls

• Adolescence-limited type > life-course-persistent type

Conduct disorder: prognosis

Half of boys don't fully meet criteria at later assessment, but continue to have some conduct problems

Conduct disorder: genetic influences

• Shared genetic factors with other disorders (ADHD, depression)

• Some genetic influences specific to conduct disorder, antisocial behaviour

• Twin studies: aggressive behaviour is more heritable than other rule-breaking behaviour

  • Genetic influence of rule-breaking behaviour depends on wealth of neighbourhood (genetics play more of a role in wealthy neighbourhoods)

• Combination of conduct disorder and callous/unemotional traits is more heritable than just conduct disorder

  • Children of biological mothers exhibiting antisocial behaviour are more likely to have callous/unemotional traits

    • Unless adoptive mother uses positive reinforcement -> parenting is a buffer for genetic propensity

  • Lower heritability of callous/unemotional traits in families with more parental warmth

• Aggressive/antisocial behaviours beginning in childhood (life-course-persistent) more heritable than behaviours that begin in adolescence

Conduct disorder: neurobiological influences

• Deficits in regions supporting emotion, particularly empathetic responses

• Children with callous/unemotional traits have difficulty perceiving distress and happiness on others' faces, but no difficulty perceiving anger

  • Reduced activation in regions associated with emotion and reward: amygdala, ventral striatum and PFC

• Children with callous/unemotional traits have difficulty learning to associate behaviour with reward/punishment (dysfunction in amygdala and ventral striatum)

Conduct disorder: psychological influences

• Children with conduct disorder (especially with c/u traits) are deficient in moral awareness

  • Moral awareness = sense of what is right/wrong; ability and desire to abide by rules and norms

  • Lack of moral awareness in adulthood figures in APD and psychopathy; risk factor

• Bidirectional relationship between parenting and c/u traits

  • Twin receiving harsher parenting more likely to have c/u traits -> may develop in part from environmental factors

  • c/u traits may contribute to decreases in parental warmth -> c/u traits predict lessening in parental warmth over time

• Social-cognitive approach:

  • Hostile bias: children more likely to interpret ambiguous acts as hostile, leading them to act more aggressively

Conduct disorder: peer influences

1. Acceptance/rejection by peers

Being rejected by peers -> aggressive behaviour (especially combined with ADHD)

• Bidirectional, children prone to react negatively are more rejected by peers -> more likely to engage in antisocial behaviour

2. Affiliation with delinquent peers

Modelling or coercion.

• Children with conduct disorder choose like-minded deviant peers, but also environmental factors lead to choosing deviant peers, which exacerbates conduct disorder

Treatment of conduct disorder

Family interventions:

Family checkup (FCU): prevents conduct problems and aggression in children

• Three meetings to assess and provide feedback to parents about children and parenting practices

• Associated with less disruptive behaviour even 2y later

Parenting management training (PMT): most effective treatment for conduct disorder and ODD

• Parents are taught to modify their responses so that prosocial rather than antisocial behaviour is consistently awarded

• Techniques like positive reinforcement and time-out, loss of privileges

• Most effective for conduct

 

Multisystemic treatment (MST):

• Delivering intensive and comprehensive therapy services in the community, targetting adolescent, family, school and peer group

• Based on view that conduct problems are influenced by multiple factors in family as well as interactions with other social systems

 

Prevention programs:

• Fast Track: reductions in later psychopathology and later delinquent behaviours (in part due to decrease in hostile attribution bias)