PSYC 372 unit 9

What is a personality disorder?

An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.

Key Feautres of personality disorders

• chronic problems in interpersonal relationships
• difficulties with identity or one’s sense of self
• rigidity in one’s use of the maladaptive interpersonal style
• pervasiveness of the problem—long-term and not localized to specific relationships
• PDs used to be called “character disorders”
- and the idea remains that these don’t really have symptoms per se, but traits
- whereas symptoms are thought to be transient/episodic, traits are more about who you are
- symptoms can be experienced alone (e.g., crying spells) but traits are interpersonal (e.g., neediness)

Why are personality disorders difficult?

• they’re difficult to research and assess/diagnose
  • paranoia prevents people from willingness to be identified
  • people don’t seek participation in studies due to distrust/disinterest
  • the transactional nature of the “symptoms” makes them hard to operationalize
  • experts disagree on how to classify them

• they’re difficult to treat
  • again, people avoid treatment due to a variety of issues
  • people sometimes don’t think anything is wrong
  • the issues are chronic and often lifelong
  • improvement tends to be very gradual if at al

General Personality disorder

A: enduring pattern of inner experience and outward behavior, which deviates markedly from the expectations of one’s culture, and which manifests with at least 2 of the following problem areas:
• cognition (i.e., ways of perceiving self, others, interactions, events)
• affectivity (i.e., range, intensity, stability, appropriateness of emotions)
• interpersonal functioning
• impulse control
B: pattern is inflexible and pervasive across a broad range of personal/social situations C: clinically significant distress or impairment
D: pattern is stable, long-term, and began in adolescence or young adulthood
E: not better explained by another mental disorder
F: not attributable to the physiological effects of a substance or medical issue

Clusters

Cluster A
• Paranoid
• Schizoid
• Schizotypal
(Awkward, Odd, Eccentric)

Cluster B
• Histrionic
• Narcissistic
• Antisocial
• Borderline
(Bold, Emotional, Erratic)

Cluster C
• Avoidant
• Dependent
• Obsessive-compulsive
(Concerned, Anxious, Worried)

Paranoid Personality Disorder

A: pervasive distrust and suspicion of others, as indicated by at least 4 of these:
1) unjustified suspicion that others aim to exploit/harm/deceive them
2) preoccupation with unjustified doubts about loyalty and trust of friends/associates
3) reluctance to confide in others due to worries information will be used against them
4) reads hidden demeaning/threatening meanings into benign comments or events
5) persistently bears grudges against others over perceived insults
6) perceives attacks on their character which are not apparent to others, quick to react angrily
7) recurrent unjustified suspicions about the fidelity of their sexual/romantic partners
B: not exclusively occurring within a psychotic or bipolar disorder

Schizoid Personality Disorder

A: detachment from social relationships and restricted range of expressed emotions, manifesting as at least 4 of these:
1) neither desires nor enjoys close relationships, including family
2) almost always chooses solitary activities
3) has little/any interest in having sexual experiences with others
4) takes pleasure in few/any activities
5) lacks close friends/confidants other than immediate relatives
6) appears indifferent to praise or criticism from others
7) shows emotional coldness, detachment, or flatness to others
B: not occurring exclusively in psychotic/bipolar disorders

Shizotypal Personality Disorder

A: social deficits marked by poor comfort/capability in close relationships, as well as cognitive/perceptual distortions or eccentricities, including at least 5 of these:
1) non-delusional ideas of reference (i.e., thinks things are about them which aren’t)
2) non-delusional beliefs which are odd/magical and deviate from common subcultures
3) unusual perceptual experiences, including bodily illusions
4) odd thinking and speech (e.g., vague, metaphor, analogy, peripheral)
5) suspiciousness or paranoia
6) inappropriate or constricted affect
7) behavior/appearance is odd, eccentric, or peculiar
8) lack of close friends/confidants other than immediate relatives
9) excessive paranoia about socializing which does not diminish with familiarity
B: not occurring exclusively within psychotic/bipolar or autistic disorders

Histrionic Personality Disorder

A: pervasive pattern of excessive emotionality and attention-seeking, beginning by
early adulthood, present in a variety of contexts, and including at least 5 of these:
1) uncomfortable with not being the center of attention
2) interactions are characterized by inappropriate sexuality, seduction, provocative behavior
3) displays rapidly shifting and shallow expression of emotions
4) consistently uses physical appearance to draw attention to oneself
5) style of speech is excessively impressionistic and lacking in detail
6) shows self-dramatization, theatricality, and exaggerated emotional expression
7) easily suggestible/influenced by others
8) considers relationships to be more intimate than they actually are

Narcissistic Personality Disorder

A: pervasive pattern of grandiosity, need for admiration, and lack of empathy,
beginning by early adulthood and including at least 5 of these:
1) grandiose sense of self-importance (e.g., exaggerates achievements and talents, sees self as
superior even if reality does not reflect this)
2) preoccupation with fantasies of unlimited success, power, brilliance, fame, love
3) believes in oneself as “special” and unique, only to be associated with others of greatness
4) requires excessive admiration
5) significant sense of entitlement to compliance or unreasonable treatment by others
6) is interpersonally exploitative, taking advantage of others for self-promotion
7) lacks empathy, unwilling to recognize/identify with the feelings of others
8) often envious of others or oppositely believes that others are envious of them
9) shows arrogant, haughty behaviors or attitudes

Antisocial personality disorder

A: pervasive pattern of disregard for and violation of the rights of others, occurring since at least age 15, and including 3 or more of these:
1) failure to conform to legal norms—repeatedly engaging in acts worthy of arrest
2) deceitfulness, lying, conning, or other methods of seeking dishonest profit/pleasure
3) impulsivity or failure to plan ahead
4) irritability, aggressiveness, and/or repeated physical fights/assaults
5) reckless disregard for safety of self and others
6) consistently irresponsible—failure to perform work roles or other obligations
7) lack of remorse/guilt, indifference, or rationalizations about having hurt/mistreated others
B: the individual is at least age 18
C: there is evidence of Conduct Disorder onset before age 15
D: not exclusively occurring within Schizophrenia/Bipolar

Borderline personality disorder

A: pervasively unstable regarding interpersonal relationships, self-image, and emotion; plus impulsivity, beginning by early adulthood, including 5 or more:
1) frantic efforts to avoid rejection and abandonment (either real or imagined)
2) alternating relationship extremes from idolizing to devaluation (i.e., savior then enemy)
3) identity disturbance, unstable sense of self
4) impulsivity in at least two potentially self-damaging areas:
(e.g., sexual behavior, spending, substance abuse, reckless driving, binge eating, etc.)
5) recurrent suicidal behaviors, gestures, threats, and/or self-mutilating behavior
6) affective instability / emotional reactivity (i.e., feelings are intense and rapidly shifting)
7) chronic feelings of emptiness
8) anger which is inappropriate, intense, difficult to control, and/or frequently displayed
9) transient paranoid ideation or dissociation linked to stressors

Avoidant Personality Disorder

A: pervasively socially inhibited, feels inadequate, and hypersensitive to criticism; beginning by early adulthood, indicated by 4 or more of these:
1) avoids highly interpersonal occupations for worries of criticism, disapproval, rejection
2) unwilling to get involved with people unless absolutely certain of being liked
3) shows restraint in intimate relationships for worries of being shamed/ridiculed
4) is preoccupied with being criticized and rejected in social situations
5) is inhibited in new social situations because of feelings of inadequacy
6) views self as socially inept, personally unappealing, or inferior to others
7) is unusually reluctant to take personal risks or engage in new activities because they may prove to be embarrassing

Dependent Personality Disorder

A: pervasive and excessive need to be cared for, leading to submissive and clingy
behavior, fears of separation; beginning by early adulthood, with 5 or more of:
1) difficulty making everyday decisions without excessive advice/reassurance
2) needs others to assume responsibility for most major areas of life
3) has difficulty expressing disagreement due to worries about losing support/approval
4) difficulty initiating projects or doing things on one’s own due to lacking confidence
5) goes to excessive or unpleasant lengths to obtain nurturance from others
6) discomfort or helplessness when alone due to worries about inability to care for self
7) urgently seeks another new relationship when a close relationship ends
8) unrealistically preoccupied with fears of being left alone to care for oneself

Obsessive-Compulsive Personality Disorder

A: pervasively preoccupied with orderliness, perfectionism, and control, at the expense of flexibility/openness/efficiency, beginning by early adulthood and including 4 or more of these:
1) preoccupied with details/rules/lists/order/scheduling—may miss the point of an activity
2) perfectionism which interferes with task completion
3) excessively devoted to work and productivity, to the exclusion of leisure activities
4) overconscientiousness, scrupulousness, and inflexibility regarding morals/ethics/values
5) unable to discard worn out or worthless objects even without sentimental value
6) reluctant to delegate tasks to others unless they submit to exact orders
7) adopts a miserly pattern of money usage; saving for catastrophes
8) rigidity and stubbornness

PD Prevalence Overview

• Estimates for being diagnosable with any PD range from 4-15%, with many estimates of lifetime prevalence landing around 9%
• Approximately 75% of those with a personality disorder have another comorbid disorder (frequently in the anxiety, mood, substance abuse, or sexuality categories)
• Of those with at least one diagnosed PD, many have two or more (estimates range widely from about 25% to 85% or higher)
• Cluster B is the least common (1.5% versus A=5.7% and C=6%) but most severe
• While one of the rarer PDs in the general population, Borderline Personality Disorder is highly over-represented in outpatient clinical samples (~10%) and psychiatric inpatients (~20%)

DSM model

• 3 clusters, 10 categories, and basically no diagnostic reliability
• the manual even admits that the categories do not function statistically

ICD model

• the current ICD has six PD categorical classifications:
• negative affect, detachment, dissociality, disinhibition, anankastia (i.e., perfectionism), and borderline

Ego Match

• “Ego Syntonic” refers to issues deemed fitting with the self (i.e., they don’t see a problem)
- e.g., narcissistic / antisocial personalities may not describe themselves as needing help or desiring change
• “Ego Dystonic” refers to issues which are deemed a mismatch (i.e., they do report a problem)
- e.g., borderline or obsessive-compulsive personalities may report suffering and desire for improvement

Horney’s Neurotic Trends

• Moving Away From People (i.e., Detached):
  • hermits, recluses, loners, or the completely mentally separated
  • similar to today’s OCPD, “schizoid,” and “schizotypal” PDs

• Moving Against People (i.e., Aggressive):
  • care primarily about themselves, an engaging mirage
  • similar to today’s “narcissistic,” “histrionic,” “antisocial,” and “paranoid” PDs

• Moving Toward People (i.e., Compliant):
  • desperate to be loved and accepted, apprehensive of assertiveness
  • similar to today’s “avoidant” and “dependent” PDs

Five factor model

• Openness (open-minded, tries new things, curious, vs. prefer routine/tradition, conservative)
• Conscientiousness (structured, orderly, dutiful, vs. spontaneous, unreliable, chaotic)
• Extroversion (outgoing, assertive, social, thinks aloud vs. reserved, shy, solo, thinks alone)
• Agreeableness (willing, trusting, cooperative, vs. argumentative, skeptical, stubborn)
• Neuroticism (emotions are strong, negative, unstable vs. emotions are calm, neutral, stable)

Dialectical Behavior Therapy

• a form of cognitive-behavioral therapy combined with mindfulness skills, this approach has gained significant attention over the past decade for treating borderline personalities
• developed largely by Marsha Linehan, the strategies are concrete, easy to train in new therapists, and (although easier said than done) can offer hope for change in some of the
most difficult clients.
• skills include balancing awareness of clients’ various mind states, using mindfulness relaxation, and tracking behaviors to better understand the intended outcome and points of breakdown

Cluster A

• Paranoid
• Schizoid
• Schizotypal
(Awkward, Odd, Eccentric)

Cluster B

• Histrionic
• Narcissistic
• Antisocial
• Borderline
(Bold, Emotional, Erratic)

Cluster C

• Avoidant
• Dependent
• Obsessive-compulsive
(Concerned, Anxious, Worried)