Week 9 Lecture notes (PSYCH338)

Hauora Hinengaro Me Te Oranga: Mental Health & Wellbeing
Mauiui Tuakiri: Personality Disorders
Today’s Overview

  • Personality basics

  • Personality disorder defined

  • Sample of Personality Disorders:

    • Paranoid

    • Narcissism

    • Obsessive-compulsive

  • Clinical issues

What is Personality?

The characteristic ways a person behaves and thinks.

A dynamic and organized set of characteristics possessed by a person that uniquely influences his or her cognitions, motivations, and behaviours in various situations.

More stable than fluctuating.

Like Plastic: Durable but changeable.

What are Personality Disorders?

According to DSM5: “An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood is stable over time and leads to distress or impairment.”

Importance: They matter beyond just being a personality.

Traits vs. Diagnosis
Personality Disorders (For Real)

Longstanding, pervasive, inflexible, extreme, and persistent patterns of behavior and inner experience.

Unstable positive sense of self.

Unable to sustain close relationships.

DSM5 retains 3-cluster format of the DSM-IV-TR.

Alternative DSM-5 Model for Personality Disorders included in the appendix of the DSM5.

Conceptualisation Principles for Personality Disorders (Millon & Davis, 1996)

  • are not diseases

  • are internally differentiated functional and structural systems (not entities)

  • are dynamic systems (not static)

  • consist of multiple units at multiple data levels

  • exist on a continuum

  • pathogenesis is not linear, but sequentially interactive

  • criteria should be logically coordinated with the systems model itself

  • may be assessed but not diagnosed

  • require strategically planned and combinatorial modes of tactical intervention

Categorical vs. Dimensional

“Kind” vs. “Degree”.

Personality disorders have traditionally been assigned as all-or-nothing categories.

DSM-5 retained categorical diagnoses but also introduced additional dimensional model of personality disorders.

Dimensional model: Individuals are rated on the degree to which they exhibit various personality traits.

DSM Evolution

DSM-I (1952): Includes personality pattern disturbances like Inadequate, Paranoid, Cyclothymic, and Schizoid.

DSM-II (1968): Similar categories as DSM-I.

DSM-III (1980): Introduces Cluster A (Paranoid, Schizoid, Schizotypal), and includes Axis I cyclothymic disorder.

DSM-IV (1994)/DSM-IV-TR (2000): Retains Cluster A and introduces Cluster B (Histrionic, Antisocial, Borderline, Narcissistic) and Cluster C (Compulsive, Avoidant, Dependent).

DSM-IV Appendix: Includes Passive-aggressive and Depressive personality disorders.

*DSM-III-R Appendix: Includes Self-defeating and Sadistic personality disorders.

Trait Facets and Domains

Trait Domains:

  • Negative Affectivity: Anxiousness, emotional lability, separation insecurity, depressivity

  • Detachment: Intimacy avoidance, withdrawal, restricted affectivity, anhedonia, suspiciousness

  • Antagonism: Hostility, deceitfulness, manipulativeness, grandiosity, attention seeking

  • Disinhibition/Compulsivity: Irresponsibility, impulsivity, distractibility, risk taking, rigid perfectionism, perseveration

  • Psychotism: Unusual beliefs & experiences, eccentricity, cognitive & perceptual dysregulation

Personality Disorders:

  • AnPD (Antisocial): Risk taking, deceitfulness

  • BPD (Borderline): Emotional lability, anxiousness

  • AvPD (Avoidant): Withdrawal, intimacy avoidance

  • SPD (Schizotypal): Eccentricity, unusual beliefs & experiences

  • NPD (Narcissistic): Grandiosity, attention seeking

  • OCD (Obsessive Compulsive): Rigid perfectionism, perseveration

DSM-5 Clusters

Cluster A (Odd/Eccentric):

  • Paranoid: Distrust and suspiciousness of others.

  • Schizoid: Detachment from social relationships, restricted emotion expression.

  • Schizotypal: Lack of capacity for close relationships, eccentric behaviour.

Cluster B (Dramatic/Erratic):

  • Antisocial: Disregard for/violation of other’s rights.

  • Borderline: Impulsive, emotion dysregulation, instability in relationships.

  • Histrionic: Excessive emotionality, attention-seeking.

  • Narcissistic: Grandiosity, need for admiration, lack of empathy.

Cluster C (Anxious/Fearful):

  • Avoidant: Social inhibition, feelings of inadequacy, sensitive to negative evaluation.

  • Dependent: Excessive need to be taken care of, submissive, fear separation.

  • Obsessive-compulsive: Preoccupied with order, perfection, and control.

Personality Disorders: Information/Stats

Gender distribution and gender bias in diagnosis.

Men more often show traits like aggression and detachment; women more often show submission and insecurity.

  • Antisocial – more often male.

  • Histrionic – more often female.

  • Clinician Bias?? (June Sprock 2000)*

Comorbidity is the rule, not the exception.

Often have two or more personality disorders or an additional mood or anxiety disorder or substance use.

Global Prevalence Rates of PD (Winsper et al, 2019)

The British Journal of Psychiatry (2019)

Review: The prevalence of personality disorders in the community: a global systematic review and meta-analysis

Prevalence Rates of PD According to Country Income Status

Any personality disorder

  • High-Income countries (n=20)

  • LMICS (n = 10)

Cluster A

  • High-Income countries (n=11)

  • LMICS (n = 8)

Cluster B

  • High-Income countries (n=11)

  • LMICS (n = 8)

Cluster C

  • High-Income countries (n=11)

  • LMICS (n = 8)

Why Personality Disorders are Clinically Important

Individual differences (and commonalities) in function (and dysfunction).

Inform the clinical picture.

Current problems, past difficulties, future challenges, situational issues.

Assessment, diagnosis, treatment.

Data reduction: Helps to understand the complexity of cases.

What Makes a Personality ‘Disordered’?

Tenuous stability under conditions of subjective stress.

Adaptive inflexibility.

A tendency to foster vicious circles.

Personality: Clinical Domains

Behavioural:

  • Expressive Acts

  • Interpersonal Conduct

Phenomenological:

  • Cognitive Style

  • Self-Image

  • Object Representations

Intrapsychic:

  • Regulatory Mechanism

  • Morphologic Organisation

Biophysical:

  • Mood/Temperament

What Makes a Personality Disorder ‘Difficult’?

Strong relationship between personality disorders and risk - A predisposing factor.

Severe structural impairments or deficiencies.

Less likely to change spontaneously.

Highly resistant to treatment.

Therapy-interfering behaviours.

Negative countertransference reactions.

Impact relationships (even professional ones**).

DSM-5 Clusters

  • A: Paranoid PD

  • B: Narcissistic PD

  • C: Obsessive-Compulsive PD

Cluster A: Paranoid Personality Disorder (PPD) Clinical Features

Pervasive and unjustified mistrust and suspicion.

Few meaningful relationships, sensitive to criticism.

Poor quality of life.

Paranoid Prototype

  • Irascible Mood/Temperament

  • Inviolable Self-Image

  • Projection Regulatory Mechanism

  • Mistrustful Cognitive Style

  • Defensive Expressive Behavior

  • Inelastic Morphologic Organization

  • Provocative Interpersonal Conduct

  • Unalterable Object Representations

PPD Causes (Adapted from Freeman et al, 2010)

Trigger Int/ext events + Emotion + Reasoning Search for meaning Persecutory belief

PPD Treatment

Few seek professional help on their own.

Treatment focuses on development of trust.

Cognitive therapy to counter negativistic thinking.

Lack of good outcome studies.

Cluster B: Narcissistic Personality Disorder (NPD) Clinical Features

Exaggerated and unreasonable sense of self-importance.

Preoccupation with receiving attention.

Lack sensitivity and compassion for other people.

Highly sensitive to criticism; envious and arrogant.

Narcissistic Prototype

  • Haughty Expressive Behavior

  • Rationalization Regulatory Mechanism

  • Insouciant Mood/Temperament

  • Exploitive Interpersonal Conduct

  • Expansive Cognitive Style

  • Contrived Admirable Self-Image

  • Spurious Morphologic Organization

  • Admirable Object Representations

NPD Causes

Causes are largely unknown, but theories abound…

Failure to learn empathy as a child “search” to meet empathetic needs.

Sociological view – product of the “me” generation.

Short-term hedonism, Individualism, Competitiveness.

NPD: Self-Perpetuating Processes - Illusion of Superiority

Persons with NN traits are conditioned to think of themselves as admirable and able

➔ Waste little effort in actually acquiring these virtues.

Persons with NN traits realise that they cannot live up to ‘self-made publicity’

➔ Fear (and avoid) real world challenges while still boasting

➔ Retain the illusion without fear of disproof

➔ However, risk slipping behind others in achievements with their deficits becoming more pronounced over time

➔ (Given their belief in their superiority is primary) the disparity between their actual and illusory competence becomes painful

NPD: Self-Perpetuating Processes - Lack of Self-Control

May take liberties with rules and reality due to unrestrained childhood discipline and confident of their worth.

Also, sense of being ‘special’ or ‘deserving’.

NPD: Self-Perpetuating Processes - Social Alienation

Lack of skilful give-and-take interactions in social life.

➔ Learned to devalue others.

➔ Predisposed to assume that others views are false rather than check one’s own beliefs. More disagreements with others

➔ More they are convinced of their own superiority.

➔ Become isolated and alienated.

Their pathological behaviour ‘invites’ condemnation

NPD: Self-Perpetuating Processes - Low Empathy

No access to one’s own or other’s mental worlds

➔ Low empathy

➔ Superiority/competitive aspects.

➔ Avoided/impaired intimate relationships.

➔ loneliness/emptiness/isolation/boredom.

➔ few/no opportunities to practise Theory of Mind.

NPD: Self-Perpetuating Processes - Biased Social Information-Processing

Persons with NN traits do not ask for help and pursue grandiose goals in order to avoid negative mood states.

➔ Reinforces beliefs about personal value.

➔Worsens as the emphasis is on self-evaluation rather than on other states of mind or other’s states of mind.

➔ Accept only grandiosity-confirming information while ignoring internal or external data that may falsify it.

NPD Intervention

Relationship, relationship, relationship…

Encourage ‘other’ focus.

Accept that human imperfections are inevitable and also NOT a sign of weakness or failure.

Target domains:

  • Cognitive style

  • Self-image

  • Expressive behaviour

  • Interpersonal conduct

  • Undo substantial illusions.

  • Encourage integration (and acceptance) of normative feedback from others.

  • Acquire discipline and self-control.

  • Engaging in ‘hard work’ may assist the development of other achievements rather than envy and resentment.

  • Reduce social inconsiderations.

  • Controlling self- aggrandizing behaviour negates condemnation Make benefits to self (& others?) clear…

NPD: Personality-Informed Therapy Process

Focus exclusively on developing a working alliance/relationship.

Increase insight into behaviour.

Explore development and significance.

Clarify undesirable consequences.

Integrate adaptive behavioural and cognitive alternatives.

Cluster C: Obsessive-Compulsive Personality Disorder (OCPD) Clinical Features

Excessive and rigid fixation on doing things the right way.

Highly perfectionistic, orderly, and emotionally shallow.

Unwilling to delegate tasks because others will do them wrong.

Difficulty with spontaneity.

Often have interpersonal problems.

Obsessions and compulsions are rare.

OCD vs OCPD

OCD, which was previously classified as an anxiety disorder, involves distressing obsessions and compulsions, while OCPD involves rigid personality traits that generally don’t cause distress.

OCD:

  • Unwanted thoughts, repetitive behavours causing subjective distress

  • Obsessions, Compulsions & Fear

  • Can be lengthy, but not life-long

OCPD:

  • Characterological rigid traits not necessarily distress to the person

  • Perfectionism, rigid/stubborn, controlling

  • Life Long, personality pattern

Obsessive-Compulsive Prototype

*Conscientious

*Constricted

*Self-Image

*Reaction-Formation

*Cognitive Style

*Dynamic Mechanism

*Compartmentalized

*Concealed

*Architecture Organization

*Intrapsychic

*Contents

*Respectful

*Interpersonal Conduct

*Solemn

*Mood/Temperament

*Disciplined

*Expressive Emotions

OCPD Self-Perpetuating Process: Pervasive Rigidity

Dread making mistakes

➔don’t take risks

➔ avoid disapproval

➔ restrict self to familiar situations where approval is likely

Less likely to view things from another perspective

➔ have sharply defined interests

*Prevented from experiencing new perspectives and new ways to approach environment.

OCPD Self- Perpertuating Process: Guilt and Self- Criticism

Contain a ‘merciless’ internal conscience > doubt and hesitation

‘Proper’ behaviour well-maintained = avoid irresponsibility

Own persecutor and judge

OCPD Self-Perpetuating Process: Creation of Rules and Regulations

Intense struggle to control impulses toward defiance

External authority = less energy needed to control contrary urges

Boundaries for change and growth curtailed

OCPD Interventions

Identify and stabilize self-other conflict

Encourage decisive actions

Loosen pervasive rigidity

Reduce preoccupation with rules

Moderate guilt and self-criticism

Alter constricted cognitive style

Adjust perfectionistic behaviours

Brighten solemn-downcast mood

Summary of Personality Disorders

Long-standing patterns of behavior

Begin early in development and run a chronic course

Disagreement exists over how to categorize personality disorders

Categorical vs. dimensional, or