WK 10 - personality disorders

Definition for personality

The characteristic ways a person behaves and thinks

DSM-5 TR (2022) definition for personality

personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts

Kaplan & Saddock (1998) definition for personality

a person's totality of emotional and behavioural traits apparent in ordinary life, a totality that is usually stable and predictable

So personality is assumed to:

• Differ between individuals

• Be stable over time and context

definition for personality disorders

deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, is stable over time, and leads to distress or impairment

There are some problems in thinking about personality disorders

Many variables can be conceptualising in either categorical or dimensional terms

Dimensional model for personality disorders

• Disordered personality traits are an extreme form of normal traits, that is, the problem is in the degree of the trait

Categorical model for personality disorder

• Behavioural & ways of relating found in personality disorders are different qualitively from normal or healthy behaviours

PD generally viewed by most in the field as extremes of normally occurring traits, but DSM-5-TR remain

based within a categorical framework

Why does the DSM-5 remain in categorical framework?

for simplification and clarity

What is the disadvantage of using the categorical framework?

• result in over-simplification and distortion of reality

• PD may become reified, that is thought of as something as real as an infection, when that may not be so

DSM-5 diagnosis criteria for PD

Enduring pattern of inner experience & behaviour that deviates markedly from expectations of the individual's culture

DSM-5 diagnosis criteria for PD

Enduring pattern of inner experience & behaviour that deviates markedly from expectations of the individual's culture manifested in 2 or more of the following

• Cognition (ways of percieving self, others, events)

• Affectivity (range, intensity, lability, appropriateness)

• Interpersonal functioning

• Impulse control

DSM-5 diagnosis criteria for PD

More on diagnosis

• Pattern is inflexible and pervasive

• Significant distress and/or functional impairment

• Pattern is stable and onset can be traced back to adolescence or early adulthood

Prevalence of all personality disorders in general population

0.5 - 2.5% (some studies say 10%)

Prevalence in those recieving treatment

• 2 to 10% of those in outpatient treatment

• 10 to 30% of clinical populations in inpatient settings

The DSM view of the aetiology of personality disorders represents

a sort of theoretical stew, with the psychoanalytic theory represented by the narcissitic, social learning by the avoidant and bio-genetic by the schizotypal" (Widiger, 1993)

• DSM-5-TR  describes 10 specific personality disorders grouped into 3 clusters based on core features

Cluster A

• the odd or eccentric disorders

  • Paranoid, schizoid, & schizotypal PDs

• DSM-5-TR  describes 10 specific personality disorders grouped into 3 clusters based on core features

• Cluster B

•  the dramatic, emotional or erratic disorders

  • Antisocial, borderline, histrionic, & narcissistic PDs

• DSM-5-TR  describes 10 specific personality disorders grouped into 3 clusters based on core features

Cluster C

• the anxious or fearful disorders

  • Avoidant, dependent, or obsessive-compulsive PDs

Prevalence is higher in which PD? eg 1.4- 2.5%

paranoid, avoidant, obsessive-compulsive PD, borderline PD

Prevalence is lower in which PD? around 1%

schizoid PD, schizotypal, dependent, histrionic, narcissistic, antisocial

Key features of paranoid PD

• Excessively suspicious of others

• Interprets benign events or remarks as demeaning or threatening

• Often hostile, antagonistic, argumentative and bear grudges against perceived insults

• Difficulty with interpersonal relationships

key features of schizoid PD

• Detachment from and/or disinterest in social attachments, no friends, few/no sexual relationships

• Limited emotional expression in social situations, cold, aloof, flat affect

• Appears indifferent to praise or criticism

key features of schizotypal PD

• Social deficits & discomfort, lack of close friends

• Unusual beliefs/behaviours, ideas of reference (not at level of delusion), magical beliefs, unusual perceptions, suspicion and paranoia

• These unusual symptoms do not reach the level of psychosis; often seen as a mild subtype of schizophrenia

• Cultural awareness and sensitivity are important in evaluating the unusualness of beliefs and behaviour

Treatment for Cluster A

• Typically those with cluster A PDs do not seek treatment or don’t continue long

  • Problems with forming therapeutic relationships

  • Insight and motivation issues

Treatment of schizotypal PD

antipsychotic meds

What treatments are there for schizoid and schizotypal PDs?

social skills training

limitation of treatment for cluster A

very little research available to judge effectiveness of such treatments

Key features of avoidant PD

• Avoidance of relationships and work or other activities that involve social contact due to fears of criticism/rejection; feels restrained and inhibited in any existing social relationships due to such fears

• Extreme sensitivity to others opinions and preoccupation with their own perceived inadequacy

key features of Dependent PD

• Pervasive need to be taken care of and fear of losing significant others that leads to

  • Overly submissive and clingy behaviour

  • Overly passive behaviour

key features of Obsessive-compulsive PD

• Preoccupation with orderliness, organisation, rules and control. Things must be done the right way, often at the expense of actually accomplishing the stated goal

• Often very work-focused and neglect leisure and social activities

• May be very rigidly moralistic and with no possibility of exceptions or bending the rules

Prevalence of cluster C disorders in different genders

• Obsessive-compulsive PD more common in males; avoidant and dependent PD roughly equally prevalent in males and females

For Cluster C: Potential role of biological factors eg: difficult temprement interacting with

parental rejection, inadequate parental attachment or early losses

What may provide motivation for individuals to seek treatment in cluster C?

anxiety and distress

• Extensive overlap of cluster C PDs with anxiety disorders has influenced treatment approaches eg: CBT techniequs

• Use of cognitive restructuring, systematic desensitisation, relaxation techniques etc.

• Limited research but some support in avoidant PD

 

key features of histrionic PD

• Excessive, but shallow and rapidly shifting emotionality; flirtatious, provocative, dramatic presentation

• Attention-seeking behaviour, desire to be the centre of attention, may dress proactively to draw attention

• Style of speech may be impressionistic and theatrical, and lacking in detail

 

key features of narcissistic PD

• Pervasive pattern of grandiosity (inflated sense of self-importance), a need to be admired by others

• A tendency to exploit others for their own needs with little empathy for others

• A sense of entitlement, that is that they are owed special treatment and consideration

• Envious of others or think that others are envious of them

• Self-esteem is very fragile, often very sensitive to criticism

When was antisocial PD first recognised?

in 1812 by Rush

What term described the presentation of antisocial PD in 1835?

moral insanity

key features of antisocial PD

• Lack of concern for the rights or welfare of others and willingness to violate those rights

• Failure to comply with social norms, rules and laws

• A pattern of deceitfulness - lying, using aliases, conning others for profit/fun, malingering illness

• Irresponsibility, failure to honour obligations

• Impulsive behaviour, irritable, and aggressive behaviour

• Reckless disregard for safety of self and others

• Lack of remorse or empathy fro those they have harmed

• Onset of conduct disorder before age 15

DSM antisocial PD (ASPD)vs psychopathy

It overlaps with ASPD but more focus on personality traits less on observable behaviour

This distinction between antisocial PD and psychopathy was meant to…

increase reliability of the diagnosis, but many feel it has decreased the validity

psychopathy Decreasing the validity: That is that the DSM ASPD is somewhat different than the

disorder originally described with more focus on criminality. Many psychopaths engage in criminal behaviour but some don’t

• Psychopathic personality traits, measured by the revised psychopathy checklist (PCL-R, Hare, 1980)

1. Glibness-superficial charm

2. Grandiose sense of self-worth

3. Need for stimulation - proness to boredom

4. Pathological lying

5. Conning-manipulative

6. Lack of remorse

7. Shallow affect

8. Callous - lack of empathy

9. Parasitic lifestyle

10. Poor behavioural controls

11. Promiscuous sexual behaviour

12. Failure to accept responsibility for actions

13. Early behavioural problems

14. Lack of realistic long term goals

15. Impulsivity

16. Irresponsibility

17. Many short term marital relationships

18. Juvenile delinquency

19. Revocation of conditional release

20. Criminal versatility

• Psychopathy has been found to predict:

  • Higher levels of

recidivism, especially for violent and/or sexual offenses among an imprisoned population

• Psychopathy has been found to predict:

  • lower levels of

participation in a treatment program and fewer improvements

what gender is ASPD more common in

males

Genetic influences for ASPD

• Family, twin, adoption studies point to a genetic role in development of ASPD

• Eg Eysenck & Eysenck found concordance for criminality among identical twins at 55% compared to 13% for fraternal twins (1978)

Neurobiological influences for ASPD

the Underaroual hypothesis

The Underarousal hypothesis posits that psychopaths have

reduced levels of cortical arousal so they seek environmental stimulation (eg risky behaviour) to increase arousal levels

• Some limited empirical support for the underarousal hypothesis

Williams (1990) found that 15 year olds who later became criminals displayed lower physiological arousal (heart rate, skin conductance, low frequency brain waves). Other studies have found similar brain wave abnormalities among psychopaths

The fearfulness hypothesis for ASPD

• Psychopaths have higher fear thresholds so takes more to scare them. Lack of context-appropriate fear leads to ASPD

• Psychosocial influences for ASPD

Parenting styles (inconsistent parental discipline), operant conditioning paradigms

• Psychosocial influences

Cadoret et al. studied adopted children, found

risk of conduct disorder increased if biological parent had a history of ASPD and the adoptive home was characterised by chronic stress

Treatment for Antisocial PD

• Those with ASPD are unlikely to seek treatment (unless pushed to) or see themselves as having a problem

• May be manipulative and dishonest in treatment

• Outcomes tend to be poor, but some hope in early behavioural interventions

key features of borderline PD

• Unstable and intense relationships - alternates between idealisation and devaluation. Frantic attempts to avoid real or imagined abandonment

• Unstable affect, alternating severe despair, irritability or anxiety. Difficulty managing anger. Chronic feelings of emptiness and boredom

• Unstable self-image, poor sense of identity

• Impulsivity, behaviours that are self-damaging or risky eg overspending

• Recurrent suicidal behaviours

Causes of borderline PD

• heritability of temperament as well as psychosocial and environmental factors

Causes of borderline PD: a large role for psychosocial and environmental factors, particularly

early severe emotional trauma (physical and sexual abuse) which is reported by most people with the diagnosis (76-91%)

Borderline PD at high risk for

suicide (about 6-10% of those with the diagnosis), comorbid mood disorders, substance abuse, eating disorders

Treatment of borderline PD

• Use of medication to treat mood symptoms eg antidepressants

• Cognitive behavioural-based techniques - dialectical behavioural therapy

Evidence for dialectical behavioural therapy for borderline PD

• Some initial support for efficacy of DBT eg fewer suicidal thoughts, less anger, reduction in self-injury

• There is significant overlap and comorbidity between the different PDs

• For example it is estimated that of those diagnosed with antisocial PD

• 55.6% meet criteria for narcissistic PD, 44.4% for borderline PD, 33.3% for histrionic

• 27.8% for paranoid, 5.6% schizoid and schizotypal

• 16.7% for avoidant and 11.1% for dependent