Personality Disorders

personality disorders

• Enduring pattern of inner experience and behaviour that deviates markedly from expectations. Changes in two or more of: cognition, affectivity, interpersonal functioning, impulse control

• When certain traits are highly maladaptive, we might say that an individual has a personality disorder

• Inflexibility is a significant aspect of personality
  disorders

  • Most of us can alter our behaviour when the context demands it

  • Compared to most people, individuals with
    personality disorders have a small number of
    traits that are particularly prominent and
    inflexible

• Inflexible and pervasive across a broad range of personal and social situations

• Clinically significant distress or impairment

• Stable and of long duration, with onset traced back to at least adolescence or early adulthood

• Distress over personality traits is generally not a defining feature of personality disorders (they are usually egosyntonic), unlike virtually all other conditions (which are usually egodystonic)

• Prevalence of all personality disorders combined is about 9% of the population

  • Quite a bit of comorbidity across personality disorders

  • Prevalence in clinical populations is very high (30-45%)

• Prevalence and/or diagnosis of personality disorders varies by gender

  • Histrionic and borderline PD in women

  • Antisocial and narcissistic PD in men

• Some temporary or short-term states can look like enduring personality disorders

personality disorders - etiology

• Parent-child attachment is thought to affect an individual's later relationships and their way of approaching the world

• Borderline personality disorder in particular has been associated with maltreatment, abuse, and extremely insecure attachment

• Cognitive-behavioural explanations emphasize the role of early learning and maladaptive schemas

• Some moderate evidence of genetic contributions

  • Personality is fairly highly heritable, but personality disorders appear to be much less so

clusters of personality disorders

• Cluster A (Odd-Eccentric): Low Extroversion, Low Agreeableness

  • Paranoid personality disorder (0.4%)

  • Schizoid personality disorder (0.7%)

  • Schizotypal personality disorder (3%)

• Cluster B (Dramatic-Emotional-Erratic): High Extroversion, Low Agreeableness, Low Conscientiousness, High Neuroticism

  • Anti-social personality disorder (2-3%)

  • Borderline personality disorder (1.7%)

  • Histrionic personality disorder (3%)

  • Narcissistic personality disorder (<1%?)

• Cluster C (Anxious-Fearful): High Agreeableness, High Conscientiousness, High Neuroticism

  • Obsessive-compulsive personality disorder (1.7%)

  • Dependent personality disorder (1.7%)

  • Avoidant personality disorder (1.3%)

A - paranoid personality disorder

• Pattern of suspiciousness and distrust, interprets other's motives as malevolent

  • Suspects that others are exploiting, harming, or deceiving

  • Preoccupied with unjustified doubts about loyalty or trustworthiness

  • Reluctant to confide in others, fears it will be used against him or her

  • Reads hidden demeaning or threatening meanings into benign comments or events

  • Persistently bears grudges

  • More readily perceives attacks upon character or reputation

  • Recurrent suspicions without justification about fidelity

• Absence of frank delusions distinguishes paranoid PD from delusional disorder

• Negative beliefs about others are more plausible (even if not supported by evidence)

A - Schizoid Personality Disorder

• A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, as indicated by four or more of the following:

  • Neither desires nor enjoys close relationships, including
    being part of a family

  • Almost always chooses solitary activities

  • Has little, if any, interest in having s*xual experiences with
    another person

  • Takes pleasure in few, if any, activities

  • Lacks close friends or confidants other than first-degree
    relatives

  • Appears indifferent to the praise or criticism of others

  • Shows emotional coldness, detachment, or flattened
    affectivity

• Important differential diagnoses include psychosis, autism spectrum disorder, and social phobia

• Often associated with significant educational/vocational under-achieving compared to intellectual ability, but very little emotional distress

A - Schizotypal Personality Disorder

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

  • Ideas of reference (excluding delusions of reference)

  • Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness,
    belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations)

  • Unusual perceptual experiences, including bodily illusions

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

  • Suspiciousness or paranoid ideation

  • Inappropriate or constricted affect

  • Behavior or appearance that is odd, eccentric, or peculiar

  • Lack of close friends or confidants other than first-degree
    relatives

  • Excessive social anxiety that does not diminish with
    familiarity and tends to be associated with paranoid fears
    rather than negative judgments about self

• Schizotypal PD is listed in both the personality
  disorders section and the psychosis section of
  the DSM5

Cluster A vs Schizophrenia

• Cluster A disorders can be prodromal (occur prior to the onset) to schizophrenia

  • A diagnosis of a Cluster A PD in an adolescent would be considered a risk factor for later conversion to psychosis

• Distinguish between unusual thoughts and beliefs and delusions (bizarre or held with implausible conviction)

• Duration and intensity

• Cognitive impairment and grossly disorganized behaviour are not part of Cluster A PD’s

B - Antisocial Personality Disorder

• There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three or more of the following:

  • Failure to conform to social norms with respect to lawful
    behaviors as indicated by repeatedly performing acts
    that are grounds for arrest

  • Deceitfulness, as indicated by repeated lying, use of
    aliases, or conning others for personal profit or pleasure

  • Impulsivity or failure to plan ahead

  • Irritability and aggressiveness, as indicated by repeated physical fights or assaults

  • Reckless disregard for safety of self or others

  • Consistent irresponsibility, as indicated by repeated failure to
    sustain consistent work behavior or honor financial obligations

  • Lack of remorse, as indicated by being indifferent to or
    rationalizing having hurt, mistreated, or stolen from another

• The individual is at least age 18 years

• There is evidence of Conduct Disorder with onset before age
  15 years

• About 3% in the general population (three times as common in men than women)

  • About 40% of the prison population

• Higher fear threshold, low ability to learn from negative experiences

• Antisocial behaviour can be an adaptive reaction to life circumstances

psychopathy

• Avoidant Personality Disorder (APD) criteria includes observable
  behaviours, but little about inner experience (emotions, thoughts, etc)

• Most psychopaths qualify for a diagnosis of APD, but most individuals with APD do not qualify as psychopaths

• Psychopathy is not a DSM-5 diagnosis, but the term is widely used clinically and in research

• Psychopathy Checklist - Revised (PCL-R): Glibness/superficial charm, grandiose sense of self-worth, pathological lying, cunning/manipulative, lack of remorse or guilt, shallow affect (genuine emotion is short-lived and egocentric), callous/lack of empathy, failure to accept responsibility for own actions, need for
  stimulation/proneness to boredom, parasitic lifestyle, poor behavioral control, lack of realistic long-term goals, impulsivity, irresponsibility, juvenile delinquency, early behavior problems, revocation of conditional release, promiscuous s*xual
  behavior, many short-term marital relationships, criminal versatility

• 1% of the population

• New research is suggesting that many or even most psychopaths
  are not violent (although that is not to say they are harmless)

• There is no truth to the myth of the “brilliant” psychopath, IQ is completely independent of antisocial personality

• treating APD and Psychopathy

  • Little motivation to make changes

  • Some evidence suggests that treatment succeeds in creating
    better (less likely to be caught) psychopaths!

B - Borderline Personality disorder

• "People with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement." - Marsha Linehan

• Instability reflects dysregulation of emotions, cognitions, sense of self, etc

• Anxious-ambivalent or disorganized attachment style

  • Children desire safety, but inconsistent parenting results in beliefs that security is impossible

  • As adults, want intimacy but experience intense fear of abandonment

• Idealization and devaluation often occurs with professionals involved in their care

  • Staff splitting

• Dialectical behaviour therapy

  • An integrative approach involving aspects of CBT, mindfulness, and experiential therapy, often/mostly in group setting

  • Goal is emotional regulation and tolerance

  • Dialectics involve choices between opposing needs or desires, and recognition of dialectic aspect of emotions

Borderline Personality Disorder criteria

• A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity as indicated by five or more of the following:

  • Frantic efforts to avoid real or imagined abandonment

  • Pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

  • Markedly and persistently unstable self-image or sense of
    self

  • Impulsivity in at least two areas that are potentially self-
    damaging (e.g., spending, s*x, Substance Abuse, reckless
    driving, binge eating)

  • Recurrent suicidal behavior, gestures, or threats, or self-
    mutilating behavior

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

  • Chronic feelings of emptiness

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

  • Transient, stress-related paranoid ideation or severe
    dissociative symptoms

B - Histrionic Personality Disorder

• A pervasive pattern of excessive emotionality and attention seeking, as indicated by five (or more) of the following:

  • Is uncomfortable in situations in which he or she is not the center of attention

  • Interaction with others is often characterized by inappropriate s*xually seductive or provocative behavior

  • Displays rapidly shifting and shallow expression of emotions

  • Consistently uses physical appearance to draw attention to self

  • Has a style of speech that is excessively impressionistic and lacking in detail

  • Shows self-dramatization, theatricality, and exaggerated expression of emotion

  • Is suggestible, i.e., easily influenced by others or circumstances

  • Considers relationships to be more intimate than they actually are

• Often described as being the “life of the party”

  • Will do anything for attention, even things that reflect badly on themselves (unlike NPD)

  • Many people with borderline personality disorder also meet criteria for histrionic personality disorder

B - Narcissistic Personality Disorder criteria

• A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, as indicated by five or more of the
  following:

  • Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

  • Is preoccupied with fantasies of unlimited success, power,
    brilliance, beauty, or ideal love

  • Believes that he or she is "special" and unique and can
    only be understood by, or should associate with, other
    special or high-status people (or institutions)

  • requires excessive admiration

  • Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

  • Is interpersonally exploitative, i.e., takes advantage of
    others to achieve his or her own ends

  • Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

  • Is often envious of others or believes that others are envious of him or her

  • Shows arrogant, haughty behaviors or attitudes

B - Narcissistic Personality Disorder

• Characterized by an inflated sense of self-importance, a constant need for admiration, and a lack of empathy for others  

• Individuals often have a fragile self-esteem and may react negatively to criticism or perceived failures  

• Two psychoanalytic theories:

  • Kohut: Fixation on an earlier, normal stage of development, where other people are an extension of the self (selfobject)

  • Kernburg: Abnormal quality to early relationships makes individual relentlessly seek approval

• There is some very early evidence of altered brain functioning in people with NPD

  • That could reflect a genetic or a learning etiology

• Has a high overlap with borderline personality disorder and ASPD

C - Avoidant Personality Disorder

• A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by
  four (or more) of the following:

  • Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection

  • Is unwilling to get involved with people unless certain of being liked

  • Shows restraint within intimate relationships because of the fear of being shamed or ridiculed

  • Is preoccupied with being criticized or rejected in social situations

  • Is inhibited in new interpersonal situations because of feelings of inadequacy

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

  • Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

• The DSM acknowledges the APD is essentially the same thing as social phobia

  • Anxious-avoidant childhood attachment style

C - Dependent Personality Disorder

• A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, as indicated by five or more of the following:

  • Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others

  • Needs others to assume responsibility for most major areas of his or her life

  • Has difficulty expressing disagreement with others because of fear of loss of support or approval

  • Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or
    abilities rather than a lack of motivation or energy)

  • Goes to excessive lengths to obtain nurturance and support
    from others, to the point of volunteering to do things that are
    unpleasant

  • Feels uncomfortable or helpless when alone because of
    exaggerated fears of being unable to care for himself or herself

  • Urgently seeks another relationship as a source of care and
    support when a close relationship ends

  • Is unrealistically preoccupied with fears of being left to take
    care of himself or herself

• Some similarities with depressive disorders (worthlessness, pessimism, self-dislike), and anxiety disorders

  • Panic disorder is common in DPD

• Afraid of blame and/or rejection, and have learnt that deferring to others absolves them of responsibility

• “Co-dependence” is not a DSM term, but captures a fairly similar construct

C - Obsessive-Compulsive Personality Disorder

• A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, as indicated by four or more of the following:

  • Is preoccupied with details, rules, lists, order, organization, or
    schedules to the extent that the major point of the activity is lost

  • Shows perfectionism that interferes with task completion

  • Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)

  • Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)

  • Is unable to discard worn-out or worthless objects even when they have no sentimental value

  • Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things

  • Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes

  • Shows rigidity and stubbornness

• Often excessively deferential to authorities, and relationships seem
  formal and serious

• Distinguished from OCD by the absence of true obsessions and
  compulsions, and presence of rigidity in most areas of life

personality disorders - treatment

• Treatment prognosis is generally poor

  • Apart from BPD, there are no recognized empirically validated psychological treatments for any personality disorder

  • Acute distress is usually much less intense compared to other disorders, so motivation for treatment is low

  • Psychological treatment can take a very long time, and often focuses on learning new ways to respond (emotionally or behaviourally) in a close relationship

• Some evidence that personality disorders are more manageable following pharmacological treatment to lessen anxiety, stress, depression, etc

five traits (personality disorders)

• Neuroticism (emotional instability) vs emotional stability 

• Extraversion vs introversion 

• Openness (unconventionality) vs closedness (conventionality)

  • Transparency and honesty in relationships vs privacy and personal boundaries 

• Agreeableness vs antagonism 

  • Agreeableness – altruism, cooperation, and compassion, sensitive to the needs of others, helpful and cooperative 

  • Antagonism – disagreeableness, skepticism, and competition, not cooperative, perceived as suspicious, manipulative and uncooperative 

• Conscientiousness vs disinhibition 

  • Conscientiousness – responsible, organized, hard-working, goal-directed, and adhering to norms and rules 

  • Disinhibition – the tendency to act impulsively, take risks, and fail to follow through with plans and goals; associated with a lack of self-control and social norms