pds

Personality disorders

What is personality?

  • Personality trait: a complex pattern of behaviour, thought, and feeling 

  • Personality: typical ways of acting, thinking, believing, and feeling (how we interact with the world around us)

    • Considered stable across time and many situations

    • Personality is made up of the traits

    • You present differently in class vs when you’re with your friends

Personality disorders

  • A long-standing pattern of maladaptive behaviours, thoughts, and feelings 

  • It used to be seen as a longstanding pattern that has to be present by adolescence 

  • Our way of thinking/feeling about ourselves can affect daily functioning and relationships

  • Often seen as exaggerated traits, big 5 personality traits

  • 10 distinct types included in DSM-5 - listed within 3 different clusters (A, B, C) and clustered within similarities of symptom presentation

  • Highly comorbid - the current way we organize these is inaccurate because a lot of them overlap

Most people experience their “way of seeing” as normative

  • When would an individual with a personality disorder present for treatment?

    • People tend to present for treatments when they have MDD, GAD, etc. and not their personality disorder

    • A lot of the functional impairments are related to other people, occupational difficulties

PD organization

  • Cluster A: odd-eccentric

    • Paranoid PD

    • Schizoid PD

    • Schizotypal PD

  • Cluster B: emotional dysregulation

    • Antisocial PD

    • Histrionic PD

    • Borderline PD

    • Narcissistic PD

  • Cluster C: anxious-fearful

    • Dependent PD

    • Avoidant PD

    • OCD PD

Cluster A disorders:

  • Odd or eccentric behaviours and thinking, in reality, but have symptoms and features like schizophrenia

  • Multiple situations across time must occur

  • You are not going to see episodes of personality disorders

    • Paranoid PD: pervasive unwarranted and maladaptive mistrust and suspicion (the relationship to schizophrenia is that it runs in families)

    • Schizoid PD: lack of interest and avoidance of relationships, emotional coldness towards others (relationship to schizophrenia is unclear)

      • Driven by the disconnect between wanting to form relationships

      • Lack of desire in social situations

    • Schizotypal PD: inhibited or inappropriate emotion and social behaviour, aberrant cognitions, disorganized speech (relationship to schizophrenia is strong, milder version of it)

      • Some level of paranoid thoughts, magical thinking, odd beliefs

      • Level of paranoia, magical thinking, some illusions that are short of hallucinations

      • Instead of saying “I see a dog on the chair” that would be a clear hallucination, but instead looking at the wall and saying there’s a pattern

Cluster B disorders:

  • Emotional dysregulation

    • Antisocial (ASPD)

    • Borderline (BPD)

    • Histrionic

    • Narcissistic

Antisocial PD

  • Pattern of disregard for others and not fitting into social norms

  • “Anti-society,” violation of others rights

  • The prison population has a high percentage of ASPD

  • Presence of conduct disorder (child externalizing behavioural disorder - harming other people, things, anger outbursts) before the age of 15:

  1. Failure to conform: specific rules, oppositional behaviours (repeatedly performing acts for arrest)

  2. Deceitfulness: using other aliases, not presenting yourself in an ethical manner

  3. Impulsivity, failure to plan: risk-taking behaviours

  4. Irritability and aggressiveness: shown through getting in physical fights, assaulting others

  5. Reckless disregard for the safety of self or others

  6. Consistent irresponsibility: failure to be able to sustain work obligations

  7. Lack of remorse: being indifferent to these behaviours (assaulting someone and not having empathy), trying to rationalize their behaviours

  • Treatment

    • Most do not believe they need treatment

    • Most treatments attempt to control anger and impulsive behaviours

      • Recognizing triggers

      • Developing alternative coping strategies

    • Some treatments also attempt to develop empathy

    • Drug treatment evidence inconclusive

Borderline PD

  • Most researched and known

  • A pervasive pattern of unstable relationships, unstable self

  • 5/9 symptoms required

  • High comorbidity with mood disorders (MDD), high rates of suicide, self-injury

  • 4 major categories of symptoms:

    • Cognitive dysregulation: identity disturbance and dissociation, difficulty knowing who they are and how they should act, struggle with forming a core sense of self/identity, chronic feelings of emptiness

    • Impulsivity: impulsive, reckless behaviours (excessive spending, risky sexual behaviours, substance use, binge eating)

    • Emotional dysregulation: reflects up and down emotions, difficulty controlling one’s emotions, difficulty identifying/managing emotions, intense emotions (anger out of proportion)

    • Interpersonal problem      s: consequences of the other processes, sense/ fear of being abandoned, reassurance seeking, efforts to try to avoid it happening, 

  • Theories of BPD *exam q

    • Biosocial model (Linehan)

    • Linehan was the leader in the research of BPD disorders, created the leading treatment and created DBT

    • Came out with a memoir about how she had BPD

      • Diathesis stress model, have high emotion sensitivity, more responsive to their environment.

      • Combo of being emotionally sensitive plus an invalidating environment

      • Extreme emotional reactions lead to impulsivity

      • Emotional experiences are discounted, and criticized by others (invalidating the environment)

      • Support from others is necessary to cope

  • Treatment of BPD

    • Dialectical behaviour therapy 

    • Extremely effective

      • Emotional regulation 

      • Mindfulness: focused on the present moment

      • Interpersonal skills training: communicate with others

      • Distress tolerance: what strategies can you use in a crisis

Narcissistic PD

  • A pervasive pattern of grandiosity, lack of empathy, and need for admiration

  1. Grandiose sense of self-importance: think they deserve recognition for nothing

  2. Preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

  3. Believes they are special, unique, and can only be understood by or associated with other special/high-status people

  4. Requires excessive admiration

  5. Sense of entitlement

  6. Interpersonally exploitative: exploit others for their gain

  7. Lacks empathy

  8. Arrogant, haughty behaviours or attitudes

Histrionic PD

  • A pervasive pattern of excessive emotionality and attention-seeking

  • Overlap in symptoms 

  • The driver of some of the symptoms is the desire/want/need for attention from others.s

  • To get attention, often will overly depend on others, and focus on themselves

  • Dramatic with some of their symptoms

  • Less than 1%

  • Not a lot of empirical evidence regarding the treatment

Cluster B review

  • The “emotion dysregulation” personality disorders.

  • Characterized by unstable relationships & impulsivity.

  • ASPD & BPD are well-studied whereas HPD & NPD are not.

  • DBT is an empirically supported tx for behaviour associated with BPD

  • Individuals with HPD & NPD almost always present for other problems, because the criteria are ego-syntonic.

Cluster C: anxious-fearful

  • Avoidant PD 

    • A pervasive pattern of extreme social inhibition, feelings of inadequacy, and sensitivity to rejection

      • Behaviours look like social withdrawal, not interacting with others

      • Driver of behaviour is sensitivity to rejection

      • Fear of negative evaluation

      • Want to make friends, but due to extreme sensitivity to being rejected by others.

  • Dependent PD

    • Pervasive and excessive need to be taken care of that lead to submissive, clingy behaviour, and fear of separation

  • Obsessive-compulsive PD *check the text for this desc.

    • Drive for orderliness, organization

    • What you think of as high perfection

    • Things need to be in a perfect, organized way

    • Rigidity 

Cluster c review

  • “Anxious-fearful” disorders

  • Include avoidant, dependent and obsessive-compulsive personality disorders

  • Generally characterized by a chronic sense of anxiety and fearfulness

  • Behaviors intended to ward off feared situations

  • Some cognitive-behavioral treatments shown to be effective

Problems with PD diagnoses

  1. Categorical/disease models: we use a more dimensional approach towards personality, does it make more sense to use a continuum model

  2. Criteria overlap:

  3. Subjective criteria/diagnostic reliability problems

  4. Gender and ethnic bias: women are more diagnosed with BPD and histrionic,

Alternative model in the DSM

  • Section III of DSM: “Emerging Measures and Models”

    • Hybrid dimensional/categorial system

    • General criteria for PD (based on dimensional scales)

      • Personality functioning in self-identity & interpersonal domains (empathy & intimacy)

      • Dimensional traits in 5 domains

      • Six possible personality disorder types: avoidant, schizotypal, antisocial, narcissistic, obsessive-compulsive

        • Antagonism v. agreeableness

        • Detachment v. extraversion

        • Disinhibition vs. conscientiousness

        • Negative affectivity vs. emotional stability

        • Psychoticism vs. lucidity