Personality Disorders
Personality Disorders:
History of ‘personality’:
- Word appeared in 14th century
- Distinguished humans from inanimate objects
- Evolved from Ancient Roman ‘persona’
- Refers to mask worn by actors to portray a character
- Archetypes in Greek dramas
Definition of personality:
- An individual’s enduring pattern of responses to and interactions with others and the environment (Boyd & Bee, 2010)
- Trait – an enduring characteristic that reveals itself in a pattern of behaviour in a variety of situations
- Our personality characteristics are central to who we are as people
- Equally important to how we perceive other people and other experiences
- Stereotypes we hold about other people and groups are saturated with personality attributes
- i.e. ‘teachers are friendly’ ‘the English are polite’ ‘Americans are brash’
Disordered Personality:
- Personality disorders are typically referred to as a class of personality types that deviate from contemporary societal expectations (Berrios 1993)
- Are characterized by relatively stable patterns of maladaptive traits and behaviors
- Studies such as Grilo et al. (2004) suggest that compared to Major Depression Disorder (MDD) people with PDs after a two year period showed below clinical levels of the disorder at 23% (schizotypal) to 38% (OCD)
- People diagnosed with personality disorders are classified based on the traits that tend to cause them to feel and behave in socially dysfunctional ways
- These traits are often an extreme deviation from the way an average person in a particular culture perceives, thinks, feels, and relates to others
- They are often congruent with inner experiences, and are therefore subjectively perceived by the individual as appropriate or normative.
General criteria for a personality disorder (DSM-V):
- To diagnose a personality disorder, The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. The following criteria must be met:
- A. Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning.
- B. One or more pathological personality trait domains or trait facets.
- C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
- D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or sociocultural environment.
- E. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).
Development of personality disorders ( Battle et al 2004; Tacket et al 2009):
- Personality disorders can only be diagnosed at 18+
- Personality is thought to still be developing prior to this age
- For example, research has shown that rates of childhood maltreatment and trauma are higher in adults with personality disorders than in healthy controls, with approximately
- 73% of adult patients reporting various forms of childhood abuse (Battle et al. 2004).
- In a recent review of the literature on childhood risk factors for adult personality disorders, Tackett et al. (2009) conclude that factors such as parental conflict, low socioeconomic status, parental psychopathology, and maternal over-control can lead to developing PDs
- Genetic liability for PDs (Distel et al., 2009)
Personality disorders:
- Abnormalities in behaviour that impair social or occupational functioning
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- DSM-V groups them in three clusters
- Aimed at revision to the categories but revisions only made it into a separate chapter that encourages further research
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- Cluster A – Eccentric Cluster
- Schizotypal, Schizoid, Paranoid
- Cluster B – Dramatic Cluster
- Anti-Social, Narcissistic, Borderline, Histrionic
- Cluster C – Anxious Cluster
- Avoidant, Dependent, OCPD
Cluster A – Odd or Eccentric Cluster
Schizotypal- characterized by severe social anxiety, thought disorder, paranoid ideation, derealization, transient psychosis and often unconventional beliefs. Peculiar speech mannerisms and odd modes of dress are also symptoms of this disorder. 3-4% population
Schizoid- rare condition where people avoid social activities and consistently shy away from interaction with others. They also have a limited range of emotional expression. 2-4% of population.
Paranoid- is very suspicious of other people. They mistrust the motives of others and believe that others want to harm them. Additional hallmarks of this condition include being reluctant to confide in others, bearing grudges, and finding demeaning or threatening subtext in even the most innocent of comments or events. 2-4% of population.
Zoom in on paranoid personality disorder ( Esterberg et al. 2010):
- Charactersied by people displaying pervasive and enduring suspiciousness and guardedness.
- This suspiciousness is due to anticipated mistreatment and exploitation by others, who are seen as devious, deceptive, and manipulative
- People with PPD generally experience feelings of anger over presumed abuse, anxiety over perceived threats, and a heightened sense of fear that is often perceived by others as argumentative, stubborn, defensive, and uncompromising (Beck and Freeman 1990; Ward 2004).
- Individuals diagnosed with PPD are hesitant to confide in others, hostile when feeling schemed against, excessively concerned about confidentiality, overly jealous about the faithfulness of partners, and have a tendency to blame others or have difficulty in considering alternative perspectives.
Case study:
- A 36-year-old divorced worker, Nathan, developed severe depression after he was fired from his job and subsequently had severe alcohol problems. He presented himself to a general practitioner with somatic complaints, anxiety, compulsively washing his hands, fatigue, and disturbing inner feelings of hatred towards other people.
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- Nathan’s troubles started during his childhood. He reported that he was very aggressive towards other children and was involved in recurrent conflicts. At home he was constantly on guard. In his work relations, he was involved in severe interpersonal conflicts, reacting with aggressive attacks at the slightest offences. The last years he spent working, he was continuously involved in conflicts with his colleagues. The only person he stayed friends with was his brother-in-law who lived a hundred miles away.
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- Nathan’s case study illustrates important issues and characteristic features of the paranoid personality. First, they typically do not seek treatment unless they are in a crisis (fired from job) or because of additional pathology (depression). Second, when decompensated, or triggered, they most often get depression, panic attacks, OCD, or somatoform disorder (as in this case) or in other cases, an increase in alcohol abuse. His personality pathology is excessive aggression and mistrust.
PPD and conspiracy theories (Furnham and Grover 2022):
- There is a relationship between all personality disorder clusters and belief in conspiracy theories
- Particularly Clusters A and B (less C)
- Important to characterise the type of paranoia
- Overlap between paranoia as a general political attitude vs paranoia about harm to the individual self
- Both paranoia and belief in conspiracy theories are related to beliefs in authoritarianism (there are powerful systems controlling things behind the scenes)
- Also both linked to low perceived benevolence of social groups (the world is an unkind place)
Personality disorders:
Cluster B – Dramatic, Emotional or Erratic Cluster
Borderline Personality Disorder – emotional instability – the psychological term for this is affective dysregulation; disturbed patterns of thinking or perception – cognitive distortions or perceptual distortions; impulsive behavior; intense but unstable relationships with others
Anti-Social (Sociopaths) – characterized by impulsive, irresponsible and often criminal behavior; manipulative, deceitful and reckless, and won't care for other people's feelings
Narcissistic- characterized by a long-term pattern of exaggerated feelings of self-importance, an excessive need for admiration, and a lack of empathy toward other people.
Histrionic (possibly) – characterized by a pattern of excessive attention-seeking behaviors, usually beginning in early adulthood, including inappropriate seduction and an excessive need for approval
Zoom in on antisocial personality Disorder:
- Includes issues such as egocentricity (identity), absence of prosocial standards (self-direction), lack of concern for others (empathy), and use of dominance to control others (intimacy).
- A diagnosis of ASPD requires the presence of six of seven traits
- Antagonism (Manipulativeness, Callousness, Deceitfulness, and Hostility) and Disinhibition (Risk Taking, Impulsivity, and Irresponsibility)
- The DSM–5 AMPD includes a psychopathy specifier, which treats psychopathy as a specific variant of ASPD, described by a “lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviors”
- The specifier is characterized by low Anxiousness, low Withdrawal, and Attention Seeking.
Case study:
- Burton, age 18 years, was admitted for evaluation of antisocial behavior at the request of his adoptive parents. His early childhood had been chaotic and abusive. His alcoholic father had married five times and abandoned his family when Burton was 6 years old. Because his mother had a history of incarceration and was unable to care for him, Burton was placed in foster care until he was adopted at age 8.
- As a child, Burton lied, cheated at games, shoplifted, and stole money from his mother’s purse. He was sent to a juvenile reformatory at age 16. While there, he slashed another boy with a razor blade in a fight. In the hospital, the psychiatrists interviewed Burton and his adoptive parents, conducted an encephalogram (deemed normal), and measured his IQ at 112. He showed no interest in psychotherapy, insulted staff members, and left abruptly after a 16-day stay. He was described as “unimproved” on discharge.
Antisocial personality disorder and ADHD (Storebo and Simonsen 2016):
- ADHD is one of the most common childhood conditions (3-5%)
- Characterized by impulsiveness, attention deficits, hyperactivity, and difficulties in social interaction with parents, other children, and teachers
- More than 50% of children with ADHD have other psychiatric disorders, primarily behavioral problems, learning difficulties, anxiety, depression and personality disorders
- Conduct disorder, and criminal and antisocial behavior are prevalent in children with ADHD
- Studies of prison populations also show a great preponderance of diagnosis of adult ADHD
- Meta-analysis of 18 studies (n = 5,501) investigated different types of association between ADHD and antisocial personality disorder, CD, and criminality
- Children with both ADHD and CD were in increased risk of adult criminality, whereas children with ADHD only did not have this risk
- In a long-term prospective study by Satterfield et al. (2007), 44% of the ADHD boys with comorbid CD were arrested as adults
- 65% of the ASPD adults measured by DSM-IV also met the DSM-IV criteria for ADHD.
Personality Disorders:
Cluster C – Anxious or fearful
The Avoidant Personality Disorder is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and a hypersensitivity to negative evaluation
Dependent Personality Disorder is a strong need to be taken care of by other people. This need to be taken care of, and the associated fear of losing the support of others, often leads people with Dependent Personality Disorder to behave in a "clingy“ manner
OCD/OCPD – characterized by extreme perfectionism, order, and neatness; they find it hard to express their feelings. They have difficulty forming and maintaining close relationships with others.
Zoom in on dependent personality disorder:
- One of the most understudied personality disorders (.5% of population, diagnosed more in females, on the rise)
- In early history, was linked with Freud’s oral fixation stage
- In DSM-I it was called the “passive-aggressive personality, passive-dependent type,” characterized by “helplessness, indecisiveness, and a tendency to cling to others as a dependent child to a supportive parent”
- The core element of this disorder appears to be a view of the self as helpless and inept, along with a view of others who are seen as strong and competent
- Very heterogeneous condition
- must meet five of eight criteria for a diagnosis of DPD. Therefore, there are 93 possible combinations of symptoms. A person could also present with five, six, seven, or all eight symptoms, providing further variety in terms of severity
- Difficulty making routine decisions without input, reassurance, and advice from others.
- Requires others to assume responsibilities which they should be attending to.
- Fear of disagreeing with others and risking disapproval.
- Difficulty starting projects without support from others.
- Excessive need to obtain nurturance and support from others, even allowing other to impose themselves rather than risk rejection or disapproval.
- Feels vulnerable and helpless when alone.
- Desperately seeks another relationship when one ends.
- Unrealistic preoccupation with being left alone and unable to care for themselves. (American Psychiatric Association, 2013).
Case study:
- This case study looks at the patient of a 27-year-old, white female named Sally. She works as an administrative assistant whose work required extensive data entry. Sally’s mother used her network to get this stable job for her daughter. Sally is consumed with pleasing her mother and even asks for her mother’s advice on what to wear to the office each day. Sally consistently worries about pleasing others and her colleagues at work, even at the expense to herself, which leads to the diagnosis of dependent personality disorder. The degree to which her self-destructive passivity and compliance at work stemmed from her early experiences within the family are unclear, but her parents’ overprotectiveness likely played some role in the etiology of her personality pathology.
Dependent personality Disorder and physical abuse:
- 305 subjects consecutively admitted to an outpatient department of legal medicine for physical abuse (Loas et al., 2011)
- the subjects were divided into three groups: without personality disorders (WPD, N = 108), with non-dependent personality disorders (NDPD, N = 179) and with DPDs (DPD, N = 18)
- The rate of spouses among the perpetrators was significantly different between the three groups: 44.4% of the perpetrators were the spouse for DPD subjects versus 11.2% for WPD and 20.1% for NDPD.
Case study:
- Mary is a 26-year-old African-American woman who presents with a history of non-suicidal self-injury, specifically cutting her arms and legs, since she was a teenager. She has made two suicide attempts by overdosing on prescribed medications, one as a teenager and one six months ago; she also reports chronic suicidal ideation, explaining that it gives her relief to think about suicide as a “way out.”
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- When she is stressed, Mary says that she often “zones out,” even in the middle of conversations or while at work. She states, “I don’t know who Mary really is,” and describes a longstanding pattern of changing her hobbies, style of clothing, and sometimes even her job based on who is in her social group. At times, she thinks that her partner is “the best thing that’s ever happened to me” and will impulsively buy him lavish gifts, send caring text messages, and the like; however, at other times she admits to thinking “I can’t stand him,” and will ignore or lash out at him, including yelling or throwing things. Immediately after doing so, she reports feeling regret and panic at the thought of him leaving her. Mary reports that before she began dating her current partner she sometimes engaged in sexual activity with multiple people per week.
Case study:
- Magda (48) is distressed when I reschedule our appointment. "But we always meet on Wednesdays!" - she pleads, ignoring my detailed explanations and my apologies. She is evidently anxious and her voice trembles. In small, precise movements she rearranges the objects on my desk, stacking stray papers and replacing pens and pencils in their designated canisters.
- Anxiety breeds frustration and is followed by rage. The outburst lasts but a second and Magda reasserts control over her emotions by counting aloud (only odd numbers). "So, when and where are we going to meet?" - she finally blurts out.
- "On Thursday, same hour, same place" - I reiterate for the third time in as many minutes. "I must make a note of this" - Magda sounds lost and desperate - "I have so many things to do on Thursday!" If Thursday is not convenient, we can make it the next Monday, I suggest. But this prospect of yet another shift in her rigidly ordered universe alarms her even more: "No, Thursday is fine, fine!" - she assures me unconvincingly.
- A moment of uneasy silence ensues and then: "Can you give it to me in writing?" Give what in writing? "The appointment." Why does she need it? "In case something goes wrong." What could go wrong? "Oh, you won't believe how many things often go wrong!" - she laughs bitterly and then visibly hyperventilates. What for instance? She'd rather not think about it. "One, three, five..." - she is counting again, trying to allay her inner turmoil.
- Why is she counting odd numbers? These are not odd numbers, but prime numbers, divisible only by themselves and by 1(*).
Case study:
- Tyler is a 15 year old male who is currently living at home with his mother and younger sister. His mother describes Tyler as “always being an odd child” who had significant difficulty relating to his peers.
- Since childhood Tyler has been interested in paranormal experiences. His mother reports that his interest goes beyond mere curiosity that would be “normal for someone of his age”. Rather his preoccupations seem to dominate his life at the exclusion of other activities. For example, his mother expressed concern about Tyler’s intense fascination with ghosts. Tyler is extremely preoccupied with websites that advertise paranormal research, and he continually asks his mother to purchase ghost hunting equipment from them.
- Tyler says that since the age of eight he has been hearing a voice that says his name at night. This happens a couple of times a year and Tyler said that he finds these experiences frightening. In January of this year Tyler saw his surroundings turn from colour to black and white “as if all the colour had drained away”.
- Tyler looked unkempt, he only dresses in black and despite the warm weather he wore a coat into the interview and did not take it off.
Treatment (Beck et al 2016):
- Individuals with personality disorders likely have struggled since childhood or adolescence.
- They may not have clearly defined values and goals
- They tend to distort reality in many situations and contexts;
- They have rigid and highly dysfunctional beliefs and rules
- They tend to possess a much smaller set of behavioural, or coping, strategies (and these are more rigid)
- They often tend to act in ways that interfere with attaining their long-term goals.
- Cognitive behavioral therapy (CBT) (Beck, 2015)
- Cognitive behaviour therapy posits the existence of schemas, hypothesised mental structures that organise information.
- A.T. Beck et al. (2015) describes personality as a ‘relatively stable organisation composed of schema systems and modes’
- In CBT, the therapist works with the client to help them feel safe, providing direct evidence that they are an exception to the view that clients generally have about other people.
- Judicious use of self-disclosure can help clients feel more connected.
- Therapists offer positive reinforcement that contradicts clients’ core beliefs about the self.
- The therapist changes the behaviors that happen as an effect of faulty thinking
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- A large-scale RCT of patients with various personality disorders who self-harmed was conducted by Tyrer and colleagues (2003, 2004); patients who received CBT treatment were found to engage in less self-harm than those receiving treatment as usual (TAU).
- A meta analysis of several personality disorders that included five RCTs found that CBT resulted in improvements in symptoms and personality measures (Leichsenring & Leibing, 2003.
- Dialectical behavior therapy (DBT) can be considered a well-established treatment for borderline personality disorder (BPD)
- Efficacy in RCTs for chronically depressed older adults (Lynch et al. 2003) and eating-disordered individuals (Telch et al. 2001)
- CBT focuses on helping patients change their thoughts, feelings, and behaviors
- Psychotherapy focused on acceptance invalidated the seriousness of the patients’ suffering and the urgent need to produce change
- DBT is a dialectical philosophy that encourages the balance and synthesis of both acceptance and change
- The role of mindfulness in acceptance and appraisal