Psych 360 Chapter 15
- Personality disorders
o Enduring problems with forming a stable positive identity and sustaining close and constructive relationships
o Broad range of symptoms involving problems in thinking, affect, impulse control and interpersonal functioning
o Influence many domains of functioning over one’s lifetime
o DSM-5 provides criteria for personality disorder in general as well as 10 specific personality disorders
o The 10 personality disorders are classified into 3 clusters
§ Odd/eccentric (cluster A)
§ Dramatic/erratic (cluster B)
§ Anxious/fearful (cluster C)
o General personality disorder
§ An inflexible pattern of inner experience and behavior distinct from cultural expectations, and influences at least 2 of the following
· Cognition about the self and others
· Affect
· Interpersonal functioning
· Impulse control
§ The pattern
· Is inflexible
· Is pervasive across situations
· Causes significant distress or impairment
§ Onset by early adulthood and persistence for a long duration
§ Not explained by another mental disorder, by a substance, or by a medical condition
o Prevalence
§ About 1 out of 10 people meet diagnostic criteria for a personality disorder
§ Important to consider whether patterns of behavior are unusual for a person’s cultural background
§ Tend to co-occur with psychological disorders
· Commonly encountered in treatment settings
· 40% of outpatients meet criteria for a personality disorder
· Associated with more severe symptoms
§ When using structured interviews, inter-rater reliability is adequate to good for most diagnoses
- Problems with DSM-5 approach to personality disorders
o Personality disorders are not stable over time
§ About half of people achieve remission 2 years later
§ 99% remit when re-assessed after 16 years
§ People may still have some symptoms after remission
· Many will relapse
o Personality disorders are highly comorbid with each other
§ More than 50% meet criteria for another personality disorder
§ High rates of overlap in symptoms and concerns
o Thresholds for diagnosing personality disorders are arbitrary
§ Many people with subsyndromal symptoms also experience problems in their sense of identity and their relationships
§ People who meet diagnostic criteria vary widely in their symptoms and functional impairment
§ Personality disorders may actually vary along a continuum
- Common risk factors
o Personality disorders share genetic vulnerability
o Environmental factors
§ Early adversity
§ Childhood abuse or neglect
§ Aversive or unaffectionate parental style
- Dramatic/erratic cluster (cluster B)
o Antisocial personality disorder
§ Pervasive disregard for the rights of others
· Aggressive, impulsive, and callous traits
§ Pattern of irresponsible behaviors
· Working inconsistently, breaking laws, being irritable and physically aggressive, defaulting on debts, being reckless and impulsive, neglecting to plan ahead
§ Little regard for truth and little remorse for misdeeds
§ 5x more common in men
§ 75% also meet criteria for another disorder
· Substance use is very common
§ Clinical description of psychopathy
· Clinical/personality concept that pre-dates DSM diagnosis of antisocial PD
· Not a DSM disorder
· Compared to antisocial PD:
o Does not require symptoms before age 15
o Includes more affective symptoms (e.g., lack of empathy)
· Focus on internal thoughts and feelings
o Poverty of emotion
§ Negative emotions
· Lacks shame, remorse, and anxiety; does not learn from mistakes
§ Positive emotions
· Merely an act used to manipulate others; superficially charming
· Three core traits:
o Boldness
§ Social poise and calm demeanor
o Meanness
§ Lack of empathy for others
o Impulsivity
§ Behave irresponsibly for thrills
§ DSM-5 criteria
· Pervasive pattern of disregard for the rights of others since the age of 15 as shown by at least three of the following
o Repeated law breaking
o Deceitfulness, lying
o Impulsivity
o Irritability and aggressiveness
o Reckless disregard for own safety and that of others
o Irresponsibility, as seen in unreliable employment or financial history
o Lack of remorse
§ Etiology of antisocial personality disorder
· Interactions of genes and the social environment
o Overlap with genetic risk for substance use disorders
o Social environment
§ Poverty, exposure to violence
o Family environment interacts with genetics
§ Polymorphism of the MAO-A gene predicts psychopathy among males who had experienced childhood physical or sexual abuse or maternal rejection
· Psychological risk
o Insensitivity to fear and threat
§ Difficulty learning from experience to avoid trouble
· Weakened classical conditioning
§ Lack of fear or anxiety, behaviorally and physiologically
· Lower levels and less reactive skin conductance
· Blunted neural responsivity to aversive stimuli
§ Poor attention to threat when pursuing rewards/goals
o Deficits in empathy
§ Not in tune with the emotional reactions of others
o Borderline personality disorder
§ Impulsivity and instability in relationships and mood
· E.g., gambling, reckless spending, impulsive sexual activity, and substance abuse
§ Difficulty being alone, fears of abandonment, chronic feelings of depression and emptiness
§ High degree of emotional sensitivity
§ High levels of stress (e.g., relationship conflicts)
§ Suicidal behavior and non-suicidal self-injury is common
§ DSM-5 criteria
· Presence of 5 or more of the following signs of instability in relationships, self-image, and impulsivity from early adulthood across many contexts:
o Frantic efforts to avoid abandonment
o Unstable interpersonal relationships in which others are either idealized or devalued
o Unstable sense of self
o Self-damaging, impulsive behaviors in at least two areas
o Recurrent suicidal behavior or gestures, or self-injurious behavior
o marked mood reactivity
o chronic feelings of emptiness
o recurrent bouts of intense or poorly controlled anger
o during stress, a tendency to experience transient paranoid thoughts and dissociative symptoms
§ etiology of BPD
· neurobiological influences
o diminished connectivity of brain regions involved in emotion experience
§ prefrontal cortex, anterior cingulate cortex, amygdala
§ could help explain poor control over emotions and impulsivity when emotions are present
· parenting interacts with child vulnerability
o Linehan’s biosocial theory of BPD
§ Biological (possibly genetic) vulnerability interacts with a family environment that is invalidating
· Person’s feelings are discounted and disrespected
§ Emotional dysregulation and invalidation interact in a dynamic fashion
· Genetic vulnerability and abuse
o Although abuse is common, it does not appear to be a driving force in risk for BPD
o Genetically driven impulsivity, emotionality, or risk-seeking in the parents could increase the risk that both abuse and BPD will occur
o Histrionic personality disorder
§ Overly dramatic and attention-seeking behavior
§ Often use their physical appearance to draw attention to themselves
§ Self-centered, overly concerned with their physical attractiveness, and uncomfortable when not the center of attention
§ Inappropriately sexually provocative and seductive
§ Easily influenced by others
§ DSM-5 criteria
· Presence of 5 or more of the following signs of excessive emotionality and attention seeking from early adulthood across many contexts
o Strong need to be the center of attention
o Inappropriate sexually seductive behavior
o Rapidly shifting and shallow expression of emotions
o Use of physical appearance to draw attention to self
o Speech that is excessively impressionistic and lacking in detail
o Exaggerated, theatrical emotional expression
o Being overly suggestible
o Misreading relationships as more intimate than they are
o narcissistic personality disorder
§ grandiose view of self
· preoccupied with fantasies of great success
§ self-centered
· demands constant attention
· lacks empathy
· feelings of arrogance, envy, entitlement
· view themselves as superior to others
§ primary goal of interaction with others is to bolster their own self-esteem
· value being admired more than gaining closeness
· tendency to seek out high status partners
§ may be vindictive and aggressive when faced with a competitive threat or a put-down
§ DSM-5 criteria
· Presence of 5 or more of the following signs of grandiosity, need for admiration, and lack of empathy from early adulthood across many contexts
o Grandiose view of one’s importance
o Preoccupation with one’s success, brilliance, beauty
o Belief that one is special and can be understood only by other high-status people
o Extreme need for admiration
o Strong sense of entitlement
o Tendency to exploit others
o Lack of empathy
o Envy of others
o Arrogant behavior or attitudes
§ Etiology
· Parenting
o Overly indulgent parents foster children’s belief that they are special
o Parental tendencies to see their children as highly superior to others predicts children’s narcissistic traits
· Fragile self-esteem
o Inflated self-worth and denigration of others defend against feelings of shame
o Sensitivity to negative social interactions
o Associated with higher levels of neuroticism and depression
o characterized by symptoms that range from
§ rule-breaking behavior
§ exaggerated emotional displays
§ highly inconsistent behavior
§ inflated self-esteem
- odd/eccentric cluster (cluster A)
o paranoid personality disorder
§ DSM-5 criteria
· Presence of 4 or more of the following signs of distrust and suspiciousness from early adulthood across many contexts
o Unjustified suspiciousness of being harmed, deceived, or exploited
o Unwarranted doubts about the loyalty or trustworthiness of friends or associates
o Reluctance to confide in others because of suspiciousness
o The tendency to read hidden meanings into the benign actions of others
o Bearing grudges for perceived wrongs
o Angry reactions to perceived attacks on character or reputation
o Unwarranted suspiciousness of the partner’s fidelity
o schizoid personality disorder
§ DSM-5 criteria
· Presence of 4 or more of the following signs of aloofness and flat affect from early adulthood across many contexts
o Lack of desire for or enjoyment of close relationships
o Almost always prefers solitude to companionship
o Little interest in sex
o Few or no pleasurable activities
o Lack of friends
o Indifference to praise or criticism
o Flat affect, emotional detachment, or coldness
o schizotypal personality disorder—the only cluster A disorder to be recommended for retention in the alternative model
§ DSM-5 criteria
· Presence of 5 or more of the following signs of unusual thinking, eccentric behavior, and interpersonal deficits from early adulthood across many contexts
o Ideas of reference
o Odd beliefs or magical thinking, e.g., belief in extrasensory perception
o Unusual perceptions
o Odd thought and speech
o Suspiciousness or paranoia
o Inappropriate or restricted affect
o Odd or eccentric behavior or appearance
o Lack of close friends
o Social anxiety and interpersonal fears that do not diminish with familiarity
§ Characterized by
· Eccentric thoughts and behavior
· Interpersonal detachment
· Suspiciousness
§ Some develop more severe psychotic symptoms over time, and a small portion develop schizophrenia
§ Similarities with schizophrenia
· Overlap in genetic vulnerability
· Deficits in cognitive and neuropsychological functioning
· Enlarged ventricles
· Less temporal lobe gray matter
· Neurotransmitter dysregulation
o these PDs are different than schizophrenia
§ bizarre thinking and functional impairments are less severe
§ hallucinations are not present
§ full-blown delusions are not present
- anxious/fearful cluster (cluster C)
o avoidant personality disorder
§ fear of criticism, rejection, and disapproval
§ avoids social situations due to fear of negative feedback
§ restrained and inhibited in social situations
· feelings of inadequacy, inferiority
§ beliefs of incompetence and inferiority
· avoids taking risks or trying new activities
§ high comorbidity with social anxiety disorder
· similar genetic vulnerability
§ DSM-5 criteria
· A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to criticism as shown by 4 or more of the following from early adulthood across many contexts
o Avoidance of occupational activities that involve significant interpersonal contact, because of fears of criticism or disapproval
o Unwilling to get involved with people unless certain of being liked
o Restrained in intimate relationships because of the fear of being shamed or ridiculed
o Preoccupation with being criticized or rejected
o Inhibited in new interpersonal situations because of feelings of inadequacy
o Views self as socially inept, unappealing or inferior
o Unusually reluctant to try new activities because they may prove embarrassing
o dependent personality disorder
§ excessive reliance on others
§ intense need to be taken care of
· discomfort with being alone
§ subordinate needs to ensure protective relationships are not threatened
§ urgently seek new relationship when one ends
§ view themselves as weak
· turn to others for support and decision making
§ likely to develop depression after interpersonal losses
§ DSM-5 criteria
· An excessive need to be taken care of, as shown by the presence of at least 5 of the following from early adulthood across many contexts
o Difficulty making decisions without excessive advice and reassurance from others
o Need for other to take responsibility for most major areas of life
o Difficulty disagreeing with others for fear of losing their support
o Difficulty doing things on own or starting projects because of lack of self-confidence
o Doing unpleasant things as a way to obtain the approval and support of others
o Feelings of helplessness when alone because of fears of being unable to take care of self
o Urgently seeking new relationship when one ends
o obsessive compulsive personality disorder
§ Perfectionistic
§ Preoccupied with rules, details, schedules, and organization
· Often to the extreme of being unable to finish projects
· Serious, rigid, formal, and inflexible
§ Overly focused on work
· Little time for leisure, family, and friends
§ Reluctant to make decisions or delegate
§ Compared to OCD
· Does not have the obsessions/compulsions of OCD
· Symptoms often co-occur and share genetic vulnerability
§ DSM-5 criteria
· Intense need for order, perfection, and control, as shown by the presence of at least 4 of the following from early adulthood across many contexts
o Preoccupation with rules, details, and organization to the extent that the point of an activity is lost
o Extreme perfectionism interferes with task completion
o Excessive devotion to work to the exclusion of leisure and friendships
o Inflexibility about morals and values
o Difficulty discarding worthless items
o reluctance to delegate unless others conform to one’s standards
o miserliness
o rigidity and stubbornness
o prone to worry and stress
- alternative DSM-5 model for personality disorders
o listed in section III of the DSM as an “emerging approach” requiring further study
o reduced number of personality disorders
§ includes 6 of the 10 DSM-5 personality disorders, excluding:
· schizoid, histrionic, dependent, and paranoid
o hybrid dimensional + categorical model
o two types of dimensional personality scores
§ 5 personality trait domains
§ 25 specific personality trait facets
§ Evaluated using self-report items
§ Profile of extreme scores are used for diagnosis
o Strengths of the alternative model
§ Personality trait ratings are more stable over time than diagnostic categories
§ 25 dimensional scores provide richer detail than categorical diagnoses
§ Personality traits are related to many psychological disorders and predict important outcomes
§ Clinicians rate the personality trait profile as easier to discuss with clients and more helpful for treatment planning
- Treatment of personality disorders
o Often enter treatment for a condition other than PD
o Presence of PD predicts slower improvement in psychotherapy
o Psychotherapy is the treatment of choice
§ Evidence that personality traits can change
§ Often supplemented with medications
§ Psychodynamic theory
· Childhood problems are at the root of PD
§ Cognitive theory
· Negative cognitive beliefs are at the root of PD
· Help person become more aware of beliefs and challenge maladaptive cognitions
- Treatment of schizotypal PD
o Antipsychotic and antidepressant medications
§ Helpful for reducing unusual thinking
- Treatment of avoidant PD
o Same treatments as social anxiety disorder
o Antidepressant medications
o CBT
§ Challenge negative beliefs
§ Social skills training
§ Exposure to feared situations
- Treatment of borderline PD
o “difficult to treat”
§ Interpersonal problems play out in therapy
§ Therapists often endorse feeling overwhelmed, inadequate, and at the same time, overly involved
§ Suicide is always a serious risk
o Goals of treatment:
§ Reduce symptoms, suicidality, and risk of self-harm
o Psychodynamic therapy
§ Transference focused therapy
· Helps client consider parallels between response to therapist and experiences in other relationships
§ Mentalization based therapy (MBT)
· Helps client to be more reflective about feelings, and those of other people, so as not to automatically act without thinking when emotions or interpersonal stressors occur
o Dialectical behavior therapy
§ Combines client-centered empathy and acceptance with cognitive behavioral problem-solving, emotion-regulation techniques, and social skills training
§ Dialectics
· Constant tension between any phenomenon and its opposite, which is resolved by creating a new phenomenon
§ Group and individual therapy sessions
§ Four stages
· Addressing dangerously impulsive behaviors (e.g., suicidal actions)
· Modulating extreme emotionality and coaching the client to tolerate emotional distress
· Improving relationships and self-esteem
· Promoting connectedness and happiness