KW

LECTURE NOTES - Chapter 13

Selected Personality Disorders


Labeling and Personality Disorders

  • Can distract us from trying to understand the individual with the diagnosis

  • Can be useful for knowing what characteristics and behaviors tend to go together

  • Labels are necessary for describing clients, for research purposes, and for discussing disorders with precision


Normal Personality and Personality Disorders: Livesely and Colleagues 

  • Normal personality is having adaptive solutions to life tasks

  • According to the perspective of Livesley and colleagues

  • Three life tasks:

    • To form stable, integrated and coherent representations of self and others (to see yourself and others as they really are)

    • To develop capacity for intimacy (to have positive interpersonal relationships)

    • To engage in prosocial and cooperative behaviors (to function adaptively in society)


Normal Personality and Personality Disorders Millon’s Perspective

  • Criteria that distinguish ‘normal’ versus ‘disordered’ personality:

    • Rigid and inflexible 

    • Self defeating, vicious cycle that perpetuate troubled ways of thinking and behaving

    • Structural instability, fragility, ‘cracking’ under stress


Personality Disorder: Normal and Abnormal

  • There is not a sharp dividing line between normal and abnormal

  • Normal traits are associated with a range of psychopathologies

  • Having a mild degree of a few characteristics does not imply having a disorder

  • Disorders may be thought of as exaggerated versions of traits that are advantageous when in the normal range

  • Unusual, original, and creative: schizotypal 

  • Self-confident and proud: narcissistic


Personality Disorders

  • Extreme, inflexible personality traits

  • Cause subjective distress or impaired social and occupational functioning

  • Onset occurs in adolescence or early adulthood

  • Stable over a long period of time

  • Not due to mood or physical illness



Paranoid Personality Disorder

  • Suspicious of others

  • Expect to be mistreated or exploited by others

  • Reluctant to confide in others

  • Tend to blame others

  • Can be extremely jealous

  • Prevalence: Occurs most frequently in men


Paranoid Personality Disorder

  • Differential diagnosis and comorbidity

    • Hallucinations and full-blown delusions are not present

    • Less impairment in social and occupational functioning than paranoid schizophrenia


Schizoid Personality Disorder

  • No desire for or enjoyment of social relationships

  • Appear dull, bland, and aloof

  • Rarely report strong emotions

  • Have little or no interest in sex

  • Experience few pleasurable activities

  • Indifferent to praise and criticism 

  • Loners with solitary interests

  • Prevalence and comorbidity:

    • Prevalence < 1%

    • Slightly more common in men

    • Comorbid with schizotypal, avoidant, and paranoid personality disorders 


Schizotypal Personality Disorder

  • Eccentric behavior and appearance

  • Similar interpersonal difficulties (social detachment and restricted affect) of schizoid personality 

  • Key schizotypal features: eccentric thinking (considered identical to prodromal and residual phases of schizophrenia)

    • Odd beliefs or magical thinking (e.g., believe they have telepathic powers)

    • Recurrent illusions (e.g., sense the presence of a force not actually there)

    • Odd speech (using words in unusual or unclear fashion)

    • Ideas of reference (misinterpret event as having particular personal meaning)

    • Suspiciousness

    • Paranoid ideation

  • Prevalence about 3%

  • Slightly more frequent among men than women

  • Comorbidity is higher than any other personality disorder


Etiology of the Odd/Eccentric Cluster

  • Based upon family study research

  • Possible genetic links to schizophrenia

  • Could be linked to a history of PTSD and childhood maltreatment


Lorna Smith Benjamin on Personality Disorders

  • Personality disorders arise from disruptions in the attachment bond

    • Copy inward - the person does to themselves what others did to them when the person was a child

    • Copy outward - the person does to others what others did to them when the person was a child

    • Complementary copy - the person does what it takes to neutralize or undo the harmful effects of the way that the person was treated as a child


Narcissistic Personality Disorder (NPD)

  • An extreme pattern of arrogant, exploitative, entitled, and damaging behavior combined with a notable lack of empathy

  • Belief that one is superior even against evidence

  • Expect and needs admiration from others

  • Lack of empathy and compassion for others

  • Associated with other-oriented perfectionism

  • Expects special treatment and feels entitled: does not think rules apply to them; feels justified in taking advantage of others

  • Hitler, Mussolini, Stalin were severe narcissists

  • Difficult to treat

  • Pathological Narcissism (Pincus and colleagues)

    • Seven components of pathological narcissism:

      • Four factors assess narcissistic grandiosity (entitlement rage, exploitativeness, grandiose fantasy, and self-entitlement)

        • Three factors assess narcissistic vulnerability (contingent self-esteem, hiding the self, and devaluing)

        • Dark Triad of Narcissism (Paulhus and Williams)

        • The dark triad consists of the combination of narcissism, psychopathy, and Machiavellianism

          • Additional dimension added: sadism

  • Prevalence and comorbidity:

    • Prevalence < 1%, but may be considerably higher

    • Comorbid with BPD

  • Etiology:

    • Kohut view of emerging self: immature grandiosity and dependent over - idealization of others - failure to develop healthy self-esteem

    • Product of our times and system of values?



Narcissistic Rage

  • Often involves a response to criticism, even when it is justified or minor, and whether it is actual or imagined

  • May also be triggered when someone feels that they have been made to look foolish to someone else

  • It is a disproportionate response to the situation; the person with narcissism is likely to retaliate and may hold a grudge for a long time if not forever

  • One explanation is that the person’s image of themselves as being superior is a defense that they use to deal with underlying feelings of inadequacy; criticism challenges this false image


Antisocial Personality Disorder (APD)

  • Antisocial personality disorder has two main components, according to DSM-5 definition:

    • Conduct disorder present before age 15 (i.e., truancy, running away from home, theft, arson

      • Pattern of antisocial behavior that continues into adulthood

        • Irresponsible and antisocial behavior

        • Likely to work only inconsistently 

        • Break laws

        • Physically aggressive

      • Comorbid with substance use

      • Estimates 1% - 4% of general population have APD


Psychopathy

  • Psychopathy is related to APD but emphasizes psychological (thoughts and feelings) not just behavioral aspects:

    • Lack of remorse (‘without conscience’), no sense of shame

    • Superficially charming

    • Manipulates others for own personal gain, exploits people

    • Thrill seeking

  • 20% of people with APD score on the Hare Psychopathy checklist

    • 75 to 80% of convicted felons meet criteria for APD butt only 15 to 25% of convicted felons meet criteria for psychopathy


Etiology of APD and Psychopathy

  • Childhood roots of psychopathy

  • PCL-R distinguishes psychopathic children and youth from those without psychopathy

  • Psychopathic personality in adolescence predicts antisocial behavior in adulthood



Hare Psychopathy Checklist Revised (PCL-R) and Psychopathy

  • 20 item scale, maximum score = 40

  • Record review, information from others who know the person along with the individual him/herself

  • 1% incidence in general population (half as many women as men), 15-25% inn prison

  • 10-15% “almost” psychopathic

  • Lack empathy, grandiose

  • Fearless - mentally and physically 

  • Lack of fear about social and physical situations that would frighten most people

  • Surface charm


Etiology of APD and Psychopathy

  • Role of the Family:

    • Lack of affection

    • Severe parental rejection 

    • Physical abuse

    • Inconsistencies in discipling

    • Failure to teach child responsibility toward others

  • Limitations to research findings on family role in ASP and psychopathy

    • Harsh or inconsistent disciplinary practices could be reactions child’s antisocial behavior

    • Many individuals who come from disturbed backgrounds do not become psychopaths

  • Genetic correlates of APD

  • Criminality and APD have heritable components

  • Increase concordance for MZ compared to DZ twin pairs

    • Adoption studies also provide research evidence

  • Environmental influences:

    • Increased parental conflict and decreased negativity 

    • Decreased parental warmth predict antisocial behaviors

      • Families without antisocial tendencies may become harsh in their disciplining inn reaction to the child with antisocial tendencies


Etiology - Emotion and Psychopathy

  • Unresponsive to punishments/lack conditioned fear responses

  • Skin conductance inn resting situations

  • Skin conductance is less reactive when confronted or when anticipating intense or aversive stimuli

  • Less activity in the amygdala/hippocampal formation

  • Decreased prefrontal activity