DIMENSIONAL VS CATEGORICAL

Transcription

1 CHAPTER 12 PERSONALITY DISORDERS (PP ) 1 Cat v Dim Clusters Paranoid Overview Statistics Schizoid Comorbidity Gender Related Constructs Personality Disorders Cluster A Schizotypal Causes Antisocial Cluster B Treatment Avoidant Borderline Cluster C Narcissistic Histrionic Dependent Last 2 Obsessive Compulsive Psychopathy PsyDev Bio Psy CBT Prevention PERSONALITY DISORDERS: OVERVIEW (PP ) The Nature of Personality and Personality Disorders Enduring and relatively stable predispositions (i.e., ways of relating and thinking) Predispositions inflexible and maladaptive, cause distress and/or impairment Coded on Axis II of DSM-IV General Symptoms of PDs Difficulty getting along with other people: irritable, demanding, hostile, fearful, or manipulative. Patterns of behaviour deviate markedly from society's expectations and remain consistent over time. Disorder affects thought, emotion, interpersonal relationships, and impulse control. Pattern is inflexible and occurs across broad range of situations. Pattern is stable or of long duration, beginning in childhood or adolescence. Cause distress and/or impairment 3 DIMENSIONAL VS CATEGORICAL Current DSM-IV uses categorical approach to Personality Disorders (+1) Discrete types of PD Each with its own unique collection of symptoms & characteristics Critical threshold for symptoms defines presence of condition Dimensional approach proposed by many, especially psychologists Personality traits, including those associated with PDs fall along a continuum (weak to strong) Pattern of scores on dimensions of clinical importance Several dimensional models (+2), including Big 5 (+2 +3) 4 PD CLUSTERS 5 6 DSM-IV and DSM-IV-TR define three clusters of PDs Cluster A: Odd or eccentric cluster Paranoid: mistrust, suspicious Schizoid: solitary, detached Schizotypal: suspicious, isolated Cluster B: Dramatic, emotional, erratic cluster Antisocial: irresponsible, lack remorse Borderline: unstable, disturbed Histrionic: dramatic, sensational Narcissistic: self-importance Cluster C: Fearful or anxious cluster Avoidant: fear rejection Dependent: clingy, submissive Obsessive-Compulsive: perfectionistic, orderly 1

2 7 PD: FACTS AND STATISTICS (PP ) Prevalence of Personality Disorders Canadian data on prevalence of PDs lacking (Health Canada, 2002) About 0.5% to 2.5% of general US population Rates higher in inpatient and outpatient settings Rates for specific PDs (+1) Origins and Course of PDs Thought to begin in childhood Tend to run a chronic course if untreated Co-Morbidity Rates High Much overlap between clusters (T ) Gender Distribution and Gender Bias in Diagnosis Gender bias exists in diagnosis of PDs (+3) Such bias may result from criterion or assessment gender bias 8 9 CO-MORBIDITY OF PDS 10 A B C GENDER BIAS IN DIAGNOSIS OFPDS Test-retest reliabilities are often poor Schizotypal.11 Dependent.15 Narcissistic.32 Histrionic.40 Avoidant.41 Interrater reliabilities good PDs may not lend themselves as well to objective assessment as other conditions Problem with self-reports 11 2

3 SCHEMA FOR CLUSTER A PDS (PP ) 13 A: PARANOID PD (PP ) 14 Pervasive and unjustified mistrust and suspicion DSM-IV (+1) Biological and psychological contributions are unclear May result from early learning that people and world are dangerous Treatment Options Few seek professional help on their own Treatment focuses on development of trust Cognitive therapy to counter negativistic thinking Lack good outcome studies showing that treatment is efficacious Model (+2) 15 SUMMARY OF PARANOID PD (P 474) 16 A: SCHIZOID PD (PP ) Pervasive pattern of detachment from social relationships Very limited range of emotions in interpersonal situations DSM-IV Criteria (+1) Etiology unclear Preference for social isolation resembles autism Treatment Options Few seek professional help on own Focus on value of interpersonal relationships, empathy, and social skills Treatment prognosis generally poor Lack good outcome studies showing that treatment is efficacious Model (+2)

4 SUMMARY OF SCHIZOID PD (P 474) 19 A: SCHIZOTYPAL PD (PP ) 20 Behaviour and dress odd and unusual Most socially isolated and may be suspicious of others Magical thinking, ideas of reference, and illusions common Risk for developing schizophrenia high in this group Many also meet criteria for major depression DSM-IV criteria (+1) Schizoid personality: Phenotype of schizophrenia genotype? Left hemisphere and more generalized brain deficits Treatment Main focus on developing social skills Treatment also addresses comorbid depression Medical treatment similar to that used for schizophrenia Treatment prognosis generally poor 21 SUMMARY OF SCHIZOTYPAL PD 22 CLUSTER B Cluster B PDs Dramatic, Emotional, Erratic, Annoying Types Antisocial PD Borderline PD Histrionic PD Narcissistic PD 23 B: ANTISOCIAL PD 24 (PP ) Fail to comply with social norms and violate rights of others Irresponsible, impulsive, deceitful Lack conscience, empathy, remorse DSM criteria (+1) and warning signs (+2) Long history of interest: Cleckley criteria (+3) Related construct: Psychopathy (+4 to ) 4

5 25 WARNING SIGNS OF ANTISOCIAL PD 26 Defiance and disregard for social norms or rights of other people Regularly perform illegal acts that are grounds for arrest Show little empathy for others Lack remorse for persons they hurt Tend to be self-absorbed (i.e., concerned with themselves) Often appear superficial Show difficulties in fulfilling responsibilities and commitments (e.g., work or financial obligations) Habitually lie or are manipulative Use aliases and con people for personal profit or pleasure Frequent physical aggression and conflict with others Have had serious behavioural problems in childhood and teenage years Blame others or offer rationalizations for antisocial behaviour Impulsive May be accompanied with unusually early age of drug and/or alcohol abuse Problems with legal system CLECKLEY CRITERIA 27 ANTISOCIAL PD & PSYCHOPATHY Superficial charm and good intelligence 2. Absence of delusions and other signs of irrational thinking 3. Absence of nervousness and other psychoneurotic manifestations 4. Unreliability 5. Untruthfulness and Insincerity 6. Lack of remorse or shame 7. Inadequately motivated antisocial behavior 8. Poor judgment and failure to learn from experience 9. Pathological egocentricity and incapacity for love 10. General poverty in major affective reactions 11. Specific loss of insight 12. Unresponsive in general interpersonal relations 13. Fantastic and uninviting behavior 14. Suicide rarely carried out 15. Sex life impersonal, trivial, and poorly integrated 16. Failure to follow any life plan Psychopathy Previously known as Sociopathy Much work by Hare Psychopathy CheckList (PCL +1): Two factors: Affective and Social Deviance Antisocial PD & Psychopathy overlapping constructs (+2 +3) Psychopathy and Criminal Behaviour Interpretation of PCL scores (+4): > 29 = Psychopath Distribution of PCL scores in prison population (+5) Correlates with increased levels of criminal activity (+6) and recidivism (+6) Included in several objective measures to predict recidivism, such as HCR-20 (+7)

6 PCL AND PDS PCL Score DSM ratings Total Factor 1 Factor 2 Interpers SocDev Paranoid Schizoid Schizotypal Histrionic.33*.37*.27 Narcissistic.39*.49*.24 Antisocial.71*.40*.83* Borderline Avoidant -.30* -.33* -.20 Dependent * RELATIVE TO NORMALS... PCL SCORES OF INMATES % N = 120 (CSC) ANTISOCIAL PERSONALITY DISORDER (P. 458) 5-year violent reoffence rate Rate PCL-R 70% > 29 50% % <20 Historical (Past) H1. Previous Violence H2. Young Age at First Violent Incident H3. Relationship Instability H4. Employment Problems H5. Substance Use Problems H6. Major Mental Illness H7. Psychopathy H8. Early Maladjustment H9. Personality Disorder H10. Prior Supervision Failure RISK ASSESSMENT: HCR-20 Clinical (Present) C1. Lack of Insight C2. Negative Attitudes C3. Active Symptoms of Major Mental Illness C4. Impulsivity C5. Unresponsive to Treatment Risk Management (Future) R1. Plans Lack Feasibility R2. Exposure to Destabilizers R3. Lack of Personal Support R4. Noncompliance with Remediation Attempts R5. Stress 35 ANTISOCIAL PD & OTHER CONSTRUCTS ASPD, Conduct Disorder, & Early Behaviour Problems Many have early histories of behavioural problems, including Conduct Disorder Many come from families with inconsistent parental discipline and support Families often have histories of criminal and violent behaviour MMPI Psychopathic Deviant Scale (#4) Most common personality measure in clinical settings, including forensic settings PsyDev Scale: 1 of 10 primary clinical scales on MMPI (+1) Profiles of inmates show peak on PD scale, both for males (+2 +3) and females (+4), some quite extreme (+5 +6) 36 6

7 PSYCHOPATHIC DEVIANT SCALE Generally poor social adjustment Alienated from society, from family, and perhaps even from selves Relationships are shallow, unstable, and characterized by considerable turmoil Have difficulties with society in general Fail to appreciate and follow rules Resent authority figures (e.g., parents, teachers, police) Difficulties at school, at work, with legal system, and with alcohol or drug abuse Angry and impulsive, with poor tolerance for boredom Fail to learn from negative experiences BERZECKI ET AL (1988) BARBOPOULOS ET AL (2006) 39 MMPI-2 PROFILES OF FEMALE INMATES Jeffrey Dahmer Charles Manson MMPI Profile 41 7

8 NEUROBIOLOGICAL CAUSES (PP ) Prevailing Neurobiological Theories Genetic contribution Rushton et al. (1986): r = similarity of aggression scores Monozygotic.40 Dizygotic.04 (same sex) Early temperament: impulsive, uninhibited, unconcerned with social rewards, low in anxiety Underarousal hypothesis: cortical arousal too low (+1) Cortical immaturity hypothesis: cerebral cortex not fully developed, perhaps especially frontal lobes (+2) Testosterone and aggression (+3 +4) Fearlessness hypothesis: psychopaths fail to respond with fear to danger cues Gray s model of behavioural inhibition and activation year-old boys later convicted of crime showed relatively low arousal PET scans illustrate reduced activation in a murderer s frontal cortex Normal Murderer 47 Intrauterine Testosterone and Aggression in Men and Women (Resnick, 1993) Zuckermanet al. (1978): Some aspects of sensation seeking consistently increased in males relative to females Analyzed Sensation Seeking Scale scores from 422 British twin pairs, including 51 opposite-sex pairs Elevated SS scores in females from opposite-sex pairs. Results significant for disinhibition, experience seeking, and overall sensation seeking. No such effect for Males Findings consistent with hypothesized in utero hormonal influences on later behavioral development, although psychosocial explanations of increased SS in opposite-sex female twins possible Psychological and Other Environmental Factors Poverty and Obstetrical complications (below) Parenting (+1) Imitation (+2) 48 8

9 Haapsalo and Pokelo (1999) concentrated on longitudinal studies into effects of parenting. Evidence strongly supports following as antecedents of criminal behavior: Punitive child-rearing practices and attitudes Lack of love, rejection Poor monitoring, lack of supervision Family disruption: marital conflict, divorce Deviant parental characteristics: criminality, substance abuse, mental problems McCord (1979) found that characteristics (as measured between 5 and about 13 years of age) such as following predicted child s criminality Lack or casual supervision of child Mother s lack of affection for child Conflict between parents 49 GENDER AND IMITATION OF AGGRESSION 50 DIATHESIS-STRESS MODELS Common model for clinical disorders: disorder emerges from contribution of predisposition (biological or otherwise) and environmental stressors Predisposition = Diathesis Stressor = Stress Only when exposed to both factors does disorder emerge Can be applied to understanding of aggression Biological predisposition and maltreatment (+1): MAOA (Xchromosome) and Male aggression Gender and intrauterine cocaine exposure (+2) Bendersky et al (2006) Aggression in 5 year old children, some exposed to cocaine intra-uterine Effect of cocaine exposure stronger for boys, perhaps especially for those in disadvantaged circumstances Teacher Ratings of Aggression at 5 years Cocaine Unexposed Exposed Difference Boys Girls Difference ANTISOCIAL PD: TREATMENT (P 458) Treatment Few seek treatment on their own Antisocial behaviour predictive of poor prognosis, even in children Emphasis placed on prevention and rehabilitation Often incarceration is only viable alternative Prevention programs have shown some success (+1) Also some notable failures (+2) Some success with Cognitive Behavioral Approaches to treatment of offenders (not necessarily Antisocial PD or Psychopaths) (+3 +4) 54 9

10 PREVENTION PROGRAMS Yoshikawa analysed outcome of 40 evaluation studies of intervention programs that met following criteria: Intervention involved children most at risk of delinquency, such as children with low birth weight and those living in low-income families Intervention took place between prenatal stage (i.e. prior to birth) and primary school entry Researchers studied effects of intervention on juvenile delinquency or risk factors for long-term juvenile delinquency Combined family support and early education showed most promising outcomes Cognitive abilities of children and parenting abilities improved Later antisocial behavior also reduced 55 Bad Outcomes & Summer Camp Attendance Teacher Reports Of Delinquency HARMFUL INTERVENTIONS 56 Cambridge-Somerville Youth Study Strong methods: matching, random assignment, Comprehensive: boys young (~10yrs), long, counsellors 2x a month, youth camp, No immediate effects 30 year follow-up: harmful effects (Iatrogenic) (top graph) Why? Deviancy training through peer interactions Several similar findings Bottom graph (Dishion et al) CBT AND OFFENDING BEHAVIORS CBT strategies for 6 kinds of offending behaviors Routine Activities Theory and Property Offences Train problem-solving and decision-making skills Social interaction Social skills training (e.g., for delinquents) Loss of Self-Control and Violence Self-regulation of expressive (vs. instrumental) aggression Addictive behaviors Change strategies and relapse prevention Self-Image Attitude Change and Values Education Perspective taking, moral reasoning training, 57 Effective Programs Clear theoretical basis and empirical support Assessment of offenders to assign to treatment Target offending behavior or dynamic risk factors Structured programs with clear, directive approach CB focus, skills oriented, multi-modal Community based, rather than institutional High treatment integrity CBT PROGRAMS 58 Effectiveness Primary outcome variable is Recidivism Early reviews in mid 1970s negative: e.g., Lipton et al. (1975) nothing works Poor methodology: e.g., drop studies with weaker outcomes) Other studies report more positive results: 50% of studies showed advantage for therapeutic intervention ( ) EFFECTIVENESS OF CBT Current reviews use meta-analysis Summarize large number of studies on given topic (e.g., treatment and recidivism) Calculate common measure for all studies Effect size = (Mean Treatment Mean Control) / SD Aggregate measures across studies Average reduction of 10% in recidivism across all studies Reaches 20-30% reduction in studies meeting certain desirable criteria (-1) Studies related to anger and other relevant constructs also show benefits (+1) 59 CBT & ANGER (BECK & FERNANDEZ, 1998 META-ANALYSIS) Inmate Studies N Effect Size (d) Gaertner (1984) Kennedy (1992) Macpherson (1986) Napolitano (1992) Rokach (1987) Smith & Beckner (1993)

11 EFFECTIVENESS OF CBT Future Research Needs Replication and extensions Other countries (most in NA) Different populations: ethnic groups, gender Isolate role of different components of programs Relation to different forms of offending Role of addictive behaviors and treatment Practical and Policy issues Acceptable levels of risk in offenders How methods can be applied in agencies 61 SUMMARY OF ANTISOCIAL PD (P 475) 62 B: BORDERLINE PD (PP ) Pattern of unstable moods and relationships Impulsivity, fear of abandonment, coupled with very poor self-image Self-mutilation and suicidal gestures not uncommon Most common PD in psychiatric settings Comorbidity rates high (slide 10) DSM Criteria (+1) Borderline PD runs in families Early trauma and abuse seem to play some etiologic role Treatment Options Few good treatment outcome studies Antidepressant medications provide some short-term relief Dialectical B: BORDERLINE PD (PP ) behaviour therapy is the most promising psychosocial approach Dialectical Behavior Therapy (Linehan) POST SCL Score PRE WL DBT 65 SUMMARY OF BORDERLINE PD 66 11

12 B: HISTRIONIC PD (PP ) Patterns of behaviour are overly dramatic, sensational, and sexually provocative Often impulsive and need to be center of attention Thinking and emotions perceived as shallow Common diagnosis in females DSM Criteria (+1) Etiology largely unknown Is Histrionic PD sex-typed variant of antisocial personality? B: HISTRIONIC PD (PP. 464) Treatment Options Few good treatment outcome studies Treatment focuses on attention seeking and long-term negative consequences Targets may also include problematic interpersonal behaviours Little evidence that treatment is effective 69 SUMMARY OF HISTRIONIC PD 70 B: NARCISSISTIC PD (PP ) Exaggerated and unreasonable sense of self-importance Preoccupation with receiving attention Lack sensitivity and compassion for other people Highly sensitive to criticism Tend to be envious and arrogant DSM Criteria (+1) Linked to early failure to learn empathy as child Sociological view: Narcissism as a product of the me generation

13 NARCISSISTIC PD (PP ) Treatment Extremely limited treatment research Focuses on grandiosity, lack of empathy, unrealistic thinking Treatment may also address co-occurring depression Little evidence that treatment is effective 73 CLUSTER C Cluster C Fearful or Anxious Cluster Types Avoidant PD Dependent PD Obsessive-Compulsive PD 74 C: AVOIDANT PD (PP ) Extreme sensitivity to opinions of others Highly avoidant of most interpersonal relationships Interpersonally anxious and fear rejection DSM Criteria (+1) Numerous factors proposed Early development: difficult temperament produces early rejection Treatment Several well-controlled treatment outcome studies exist Treatment similar to that used for social phobia Treatment targets include social skills and anxiety SUMMARY OF AVOIDANT PD 77 C: DEPENDENT PD (PP ) 78 Excessive reliance on others to make major and minor life decisions Unreasonable fear of abandonment Tend to be clingy and submissive in interpersonal relationships DSM Criteria (+1) Still largely unclear Linked to early disruptions in learning independence Treatment Options Research on treatment efficacy lacking Therapy typically progresses gradually Treatment targets include skills that foster independence 13

14 79 80 SUMMARY OF DEPENDENT PD C: OBSESSIVE-COMPULSIVE PD (PP ) Excessive and rigid fixation on doing things right way Tend to be highly perfectionistic, orderly, and emotionally shallow Obsessions and compulsions rare DSM Criteria (+1) Largely unknown Treatment Options Data supporting treatment are limited Treatment may address fears related to need for orderliness Other targets include rumination, procrastination, and feelings of inadequacy SUMMARY OF OBSESSIVE-COMPULSIVE PD 83 DISCUSSION OF PDS 84 PDs Under Study (Pp ) Proposed DSM PDs Sadistic SD Self-defeating PD New Categories of DSM PDs Under Study Depressive PD Negativistic PD Summary (Pp ) PDs Long-standing, ingrained ways of thinking, feeling, and behaving Disagreement About How to Categorize PDs Categorical vs. Dimensional, or some combination DSM-IV Includes 10 PDs Three clusters: A, B, or C Causes of PDs difficult to identify Treatment of PDs often difficult 14