Personality Disorders

Chapter 12: Personality Disorders

Lecture Outcomes

• Define and explain personality disorder.
• Understand and describe the three clusters of personality disorders.
• Understand the categorical and dimensional approaches to diagnosing personality disorders.
• Understand and discuss the clinical description, diagnostic criteria, causes, and management of:
  • Cluster A Personality Disorders:
    • Paranoid Personality Disorder
    • Schizoid Personality Disorder
    • Schizotypal Personality Disorder
  • Understand and discuss the clinical description, diagnostic criteria, causes, and management of:
    • Cluster B Personality Disorders
      • Antisocial Personality Disorder
      • Borderline Personality Disorder

Personality

• Personality: The characteristic ways a person behaves and thinks.
• Personality disorder: Enduring maladaptive patterns for relating (thinking, feeling, and behaving) to the environment and self, exhibited in a range of contexts that causes significant functional impairment or distress (for the person affected and/or for others).

Key Features of Personality Disorders

• Chronic & inflexible predispositions.
• Originate in childhood/early adulthood and continue throughout adulthood.
• Present in various contexts.
• Patients may not experience distress & often don’t seek treatment.
• Usually cause distress to others.
• High comorbidity with other disorders.
• Generally poor prognosis.

Categorical and Dimensional Models

Dimensional Model

• Extreme versions of otherwise normal personality variations.
• Personality exists on a continuum.

Categorical Model

• Ways of relating that are different from psychologically healthy behavior.
• Personality disorders viewed as distinct categories.
• Prior to DSM-5, personality disorders were assigned as all-or-nothing categories.

Prototypical Approach

• DSM-5 retained categorical diagnoses, but also introduced an Alternative Dimensional Model of Personality Disorders (Section III).
  • Individuals are rated on the degree to which they exhibit various personality traits.
  • Advantages: provide more information, more flexibility, avoid arbitrary decisions.
• DSM-5-TR: Ten specific personality disorders organized into three clusters.

Personality Disorder Clusters

• Table 12.1 Personality disorders
  • Cluster A - Odd or Eccentric Disorders
    • Paranoid personality disorder
      • A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent
    • Schizoid personality disorder
      • A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings
    • Schizotypal personality disorder
      • A pervasive pattern of social and interpersonal deficits marked by acute discomfort with reduced capacity for close relationships, as well as by cognitive or perceptual distortions and eccentricities of behaviour
  • Cluster B - Dramatic, Emotional or Erratic Disorders
    • Antisocial personality disorder
      • A pervasive pattern of disregard for and violation of the rights of others
    • Borderline personality disorder
      • A pervasive pattern of instability of interpersonal relationships, self-image, affects and control over impulses
  • Cluster C - Anxious or Fearful Disorders
    • Avoidant personality disorder
      • A pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation
    • Dependent personality disorder
      • A pervasive and excessive need to be taken care of, which leads to submissive and clinging behaviour and fears of separation
    • 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

DSM-5-TR Cluster A Personality Disorders (odd/eccentric)

• Paranoid Personality Disorder
• Schizoid Personality Disorder
• Schizotypal Personality Disorder

Paranoid Personality Disorder

• Clinical Description & Diagnosis
  • Pervasive, unjustified distrust and suspiciousness of others, such that their motives are interpreted as malevolent.
  • Begin by early adulthood and are present in various contexts.
  • Presence of four or more specific symptoms, for example:
    • Suspects that others are exploiting, harming, or deceiving them.
    • Doubts the loyalty & trustworthiness of friends/associates.
    • Reluctant to confide in others - fear the information will be used maliciously against them.
    • Persistently bear grudges.
    • Sensitive towards and quick to react towards criticism.
  • Does not occur exclusively during the course of schizophrenia, mood disorders with psychotic features, or another psychotic disorder.
  • Symptoms are not attributable to the effect of a substance or another medical condition.
  • Few meaningful relationships.
  • Excessive need for autonomy.
  • High risk of suicide attempts and violent behavior.
  • Poor overall quality of life.

DSM-5-TR Criteria

• A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
  • 1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
  • 2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
  • 3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
  • 4. Reads hidden demeaning or threatening meanings into benign remarks or events.
  • 5. Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights.
  • 6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
  • 7. Has recurrent suspicions, without justification, regarding the fidelity of a spouse or sexual partner.
• B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.

Causes & Management

• Will be covered during tutor classes

Schizoid Personality Disorder

• Clinical Description & Diagnosis
  • Pervasive pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings.
  • Begin by early adulthood and are present in various contexts.
  • Presence of four or more specific symptoms, for example:
    • Neither desires nor enjoys close relationships (including family relationships).
    • Almost always chooses solitary activities.
    • Has little/no interest in sexual experiences.
    • Takes pleasure in few/no activities.
    • Shows emotional coldness, detachment, or flattened affect.
  • Does not occur exclusively during the course of schizophrenia, mood disorders with psychotic features, another psychotic disorder, or autism spectrum disorder.
  • Symptoms are not attributable to the effect of another medical condition.
  • Homelessness is prevalent among these people.
  • They consider themselves to be observers, rather than participants in the world.
  • Does not have unusual thought patterns seen in other Cluster A personality disorders.

DSM-5-TR Criteria

• A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
  • 1. Neither desires nor enjoys close relationships, including being part of a family.
  • 2. Almost always chooses solitary activities.
  • 3. Has little, if any, interest in having sexual experiences with another person.
  • 4. Takes pleasure in few, if any, activities.
  • 5. Lacks close friends or confidants other than first-degree relatives.
  • 6. Appears indifferent to the praise or criticism of others.
  • 7. Shows emotional coldness, detachment, or flattened affectivity.
• B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder, and is not attributable to the physiological effects of another medical condition.

Causes & Management

• Will be covered during tutor classes

Schizotypal Personality Disorder

• Clinical Description & Diagnosis
  • Pervasive pattern of social and interpersonal deficits, cognitive distortions, and eccentric behavior.
  • Begin by early adulthood and are present in various contexts.
  • Presence of five or more specific symptoms, for example:
    • Odd beliefs or magical thinking (e.g., superstitiousness, clairvoyance, telepathy, ideas of references).
    • Unusual perceptual experiences (including bodily illusions).
    • Odd speech (e.g., vague, circumstantial, metaphorical, overelaborate).
    • Suspiciousness or paranoid ideation.
    • Inappropriate or constricted affect.
    • Odd, eccentric, peculiar behavior and dress/appearance.
    • Social anxiety and lack of close friends.
  • Does not occur exclusively during the course of schizophrenia, mood disorders with psychotic features, another psychotic disorder, or autism spectrum disorder.
  • Socially isolated.
  • Psychotic-like symptoms, but reality-testing remains intact.
  • Considered by some to be on a continuum with schizophrenia.
  • Increased risk for developing major depressive disorder.
  • Clinicians should be sensitive to religious and cultural practices (e.g., speaking in tongues, witchcraft) to avoid misdiagnosis.

DSM-5-TR Criteria

• A. 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:
  • 1. Ideas of reference (excluding delusions of reference)
  • 2. 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)
  • 3. Unusual perceptual experiences, including bodily illusions
  • 4. Odd thinking and speech (e.g. vague, circumstantial, metaphorical, overelaborate or stereotyped)
  • 5. Suspiciousness or paranoid ideation
  • 6. Inappropriate or constricted affect
  • 7. Behaviour or appearance that is odd, excentric or peculiar
  • 8. Lack of close friends or confidants other than first-degree relatives
  • 9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgements about self.
• B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder or autism spectrum disorder.

Causes & Treatment

• Will be covered during tutor classes

DSM-5-TR Cluster B Personality Disorders (dramatic, emotional, erratic)

• Antisocial Personality Disorder
• Borderline Personality Disorder
• Histrionic Personality Disorder
• Narcissistic Personality Disorder

Antisocial Personality Disorder

• Clinical Description & Diagnosis

  • Pervasive pattern of disregard for and violation of the rights of others.

  • Occurring since the age of 15 years.

  • Presence of three or more specific symptoms, for example:

    • Failure to conform to social norms (e.g., repeatedly performing acts that are grounds for arrest).
    • Deceitfulness (e.g., repeated lying, use of aliases, conning others).
    • Impulsivity or failure to plan ahead.
    • Irritable, aggressive, and reckless.
    • Consistent irresponsibility (e.g., in work or financial domains).
    • Lack of remorse.

  • Individual should be at least 18 years old.

  • Evidence of conduct disorder with onset before the age of 15 years:

    • 'Callous-unemotional' type of conduct disorder more likely to evolve into antisocial PD.

  • Does not occur exclusively during the course of schizophrenia or bipolar disorder.

  • May be very charming, interpersonally manipulative.

  • Substance abuse is common.

  • Long-term outcome is poor.

Psychopathy

• Non-DSM category similar to antisocial personality disorder.
• Less emphasis on overt behavior.
• Personality characteristics include superficial charm, grandiose sense of self-worth, pathological lying, manipulative, lack of remorse and empathy.
• People who score high on measures of psychopathy are more likely to commit crimes.
• However, not all psychopaths are criminals.
• In SA, 27% of criminals meet the criteria for antisocial personality disorder.
• Three distinct groups: Antisocial personality disorder, psychopathy & criminality.

Causes of Antisocial Personality Disorder

• Gene-environment interaction

  • Genetic factors present a vulnerability (e.g., aggressiveness, impulsivity).
  • Anti-social behavior may be triggered by specific environmental stressors.
  • Early antisocial behavior alienates peers who would otherwise serve as corrective role models.

• Psychological & Social dimensions

  • Failure to abandon an unattainable goal.
  • Reduced fear conditioning.
  • Coercive parenting – use of domination or intimidation to promote obedience.
  • Other environmental factors: parental depression, inconsistent parental discipline, lack of parental involvement, low social status

• Developmental influences

  • Antisocial behaviors escalate as children move into adulthood.
  • Antisocial behaviors decline around middle age (reason unclear).

Management of Antisocial Personality Disorder

• Rarely identify themselves as needing treatment.
• Cognitive-behavioral therapy (CBT) is often used
  • Directly addresses cognitive deficits.
  • Promotes prosocial behavior.
• Often incarceration is the only viable alternative.
• Prevention may be the best approach
  • Focuses on at-risk youth.
  • Includes parent training, skills training, and rewarding positive behavior.

Borderline Personality Disorder

• Clinical Description & Diagnosis
  • Pervasive pattern of unstable relationships, self-image, and affects and marked impulsivity.
  • Begin by early adulthood and present in various contexts.
  • Presence of five or more specific symptoms, for example:
    • Unstable and intense interpersonal relationships
    • Unstable self-image
    • Impulsivity (e.g., spending, sex, substance abuse, reckless driving)
    • Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior
    • Affective instability and marked reactivity of mood
    • Chronic feelings of emptiness
    • Transient-stress-related paranoid ideation or severe dissociative symptoms
  • Comorbidity rates are high with other mental disorders (e.g., mood disorders, eating disorders, and substance use).
  • Nearly 10% die by taking their own lives.
  • Positive long-term outcome.

DSM-5-TR Criteria

• A pervasive pattern of instability of interpersonal relationships, self-image, and affects and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
  • 1. Frantic efforts to avoid real or imagined abandonment (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
  • 2. A pattern of unstable and intense interpersonal relationships characterized by alternating extremes of idealization and devaluation
  • 3. Identity disturbance: markedly and persistently unstable self-image or sense of self
  • 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) (Note: Do not include suicidal or self-mutilating behavior covered in criterion 5.)
  • 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
  • 6. 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)
  • 7. Chronic feelings of emptiness
  • 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
  • 9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Integrative Model: 'Triple vulnerability’

• Generalized biological vulnerability
  • Genetic vulnerability to emotional reactivity
• Generalized psychological vulnerability
  • View the world as threatening → strongly react to threats
• Specific psychological vulnerability
  • Early trauma or abuse advance sensitivity to threats
• Stressors trigger both the biological & psychological vulnerability

Management of Borderline Personality Disorder

• More likely to seek treatment.
• Dialectical behavior therapy (DBT) is the most promising treatment
  • Focus on the dual reality of acceptance of difficulties and the need for change
  • Focus on interpersonal effectiveness
  • Focus on distress tolerance to decrease reckless/self-harming behavior
• Antidepressant medications provide some short-term relief.