personality disorders

what is a personality?

• a unique, long-term pattern of inner experience and behavior

• described by traits

what is missing in personality disorders?

the flexibility in someone’s personality

what are the big five traits of personality disorders?

neuroticism, low extraversion, low agreeableness, low conscientiousness, and high openness

what is neuroticism?

negative affectivity

what is low extraversion?

detachment

what is low agreeableness?

antagonism

what is low conscientiousness?

disinhibition

what is high openness?

psychoticism

according to the DSM-5-TR, what is a personality disorder?

an enduring pattern of inner experience and behavior that…

• deviates markedly from the expectations of one’s culture

• is pervasive and inflexible across situations

• begins in adolescence or early adulthood and is stable over time

• leads to distress and impairment

what is the commonality and comorbidity of personality disorders?

• about 12% of adults in community samples are diagnosed

• patients average 2.8-4.6 personality disorder diagnoses

what are the three clusters of personality disorders?

• odd or eccentric

• dramatic, emotional, erratic

• anxious or fearful

what disorders are a part of the odd or eccentric cluster?

• paranoid - distrust, suspicion

• schizoid - detached, emotionally cold

• schizotypal - odd thinking, discomfort with closeness

what disorders are a part of the dramatic, emotional, erratic cluster?

• antisocial - disregards others’ rights

• borderline - instability of mood, self, and relationships

• histrionic - attention seeking, shallow emotion

• narcissistic - grandiose, entitled, low empathy

what disorders are in the anxious and fearful cluster?

• avoidant - inhibited, fears rejection

• dependent - needs to be taken care of

• obsessive compulsive - perfectionism, control

what are the genetic associations with the schizophrenia spectrum?

milder versions of psychotic-like features; shared genetic risk and dopamine markers (especially schizotypal)

what is treatment like for personality disorders?

• few seek help

• therapy aims to build trust and social skills

• it can be difficult for people to recognize the limits of their own thinking

what is antisocial personality disorder?

• a pervasive disregard for the rights of others

• failing to follow social norms, impulsive, reckless, agressive

to get a diagnosis of ASPD, what is required?

• a diagnosis of conduct disorder before age 15

• truancy, running away, cruelty, destroying property

what is the difference between ASPD and psychopathy?

ASPD is defined by behavior; psychopathy adds a callous, shallow emotional core

what is the two factor model of psychopathy?

• factor 1: interpersonal/affective

• factor 2: chronic antisocial lifestyle

what is factor 1 of the psychopathy two factor model?

• interpersonal facet

  • glibness/superficial charm

  • grandiose sense of self worth

  • manipulative

• affective facet

  • lack of remorse/guilt

  • shallow affect

  • callous/lack empathy

what is factor 2 of the psychopathy two factor model?

• lifestyle facet

  • need for stimulation/proneness to boredom

  • parasitic lifestyle

  • impulsivity and irresponsibility

• antisocial facet

  • poor behavioral controls

  • early behavioral problems

  • criminality

what is the SUMMARY of the two factor model of psychopathy?

factor 1 - interpersonal: callous, shallow, manipulative

factor 2 - criminal behavior: impulsive, poor behavioral controls

ASPD maps mostly onto factor 2

what is the prevalence of ASPD?

• 2-3.5%

• about 4x more common in men

• ~80% have a substance use disorder

what is the developmental pathway of ASPD?

conduct problems in childhood → ASPD in adulthood

what are the three explanations of ASPD?

genes, physiology, and family

what is the gene explanation for ASPD?

twin and adoption studies show genes explain roughly 40-50% of the variance in antisocial behavior — highly polygenic transmission

what is the physiology explanation for ASPD?

underarousal and fearlessness — a weak response to danger and punishment

what is the family explanation for ASPD?

harsh, inconsistent, high conflict family environments

what are interventions for ASPD?

• CBT: small/moderate gains in problem solving, impulse control, and offending

• correctional programs: moderate effects on recidivism

• medications can reduce aggression or impulsivity, not core traits

what are treatments for psychopathy?

there is weak evidence for treatment; programs targeting risk factors for offending show small effects

what do relationships look like in borderline PD?

frantic fear of abandonment; intense, unstable relationships that swing from idealizing to devaluing

what does self look like in borderline PD?

unstable identity; chronic emptiness; stress related paranoia or dissociation

what does emotion look like in borderline PD?

rapid mood shifts; intense, hard to control anger

what does behavior look like in borderline PD?

suicidal and self harming acts; impulsivity

what is the prevalence of BPD?

• 1.5-2.5%

• ~75% of diagnosed patients are women

• ~85% have another disorder

what is the course of BPD?

• a period of crisis and then (typically) improvement

• crises and suicide risk peak in young childhood

what is linehan’s 1993 biosocial model of BPD?

biological emotional vulnerability → emotional disregulation in the child → intense demands on the family → invalidation: parents punish, ignore, or dismiss emotions → only extreme outbursts get attention → repeat

what is the vicious cycle of BPD?

• vulnerability x invalidation

• attention to outbursts reinforces them

• skills for managing emotions are never learned

what is dialectical behavior therapy (DBT)?

• developed by Marsha Linehan

• CBT + acceptance and mindfullness

• accept yourself AND change

• goal: a life worth living

• individual therapy + weekly skills group + phone coaching

what are the four skill modules of DBT?

mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness

what is histrionic PD?

• needs to be the center of attention

• emotional but shallow; dramatic

• provocative style; constantly seeks reassurance

• prevalence is equal in males and females

what is narcissistic PD?

• grandiose, entitled, needs admiration, low empathy

• grandiose vs vulnerable forms

• ~1% prevalence

• seeks help for depression, not narcissism; hard to treat

what is an avoidant anxious disorder?

• feels inadequate, hypersensitive to rejection

• avoids people unless sure of being liked

• prevalence equal in men and women

what is dependent anxious disorder?

• excessive need to be taken care of

• can’t decide without reassurance; fears being alone; tolerates mistreatment

what is obsessive compulsive personality disorder (OCPD)?

• perfectionism, order, control

• rigid rules, can’t delegate, work over leisure, stiff relationships

• more likely in men

what is the treatment for anxious disorders?

CBT and schema therapy; offer moderate benefit

what are problems with the ten categories?

• hard to observe

• arbitrary thresholds

• too much overlap

• too much variety within a label

what are the DSM-5-TR alternative model (section III) dimensional alternatives for PD?

focuses on level of personality functioning and five trait domains (negative affectivity, detachment, antagonism, disinhibition, and psychoticism)

what are the ICD-11 dimensional alternatives for PD?

there is one personality disorder that have trait qualifiers (negative affectivity, detachment, dissociality, disinhibition, and anankastia)