Chapter 10 Personality Disorders.

Chapter 10 Personality Disorders http://www.flickr.com/photos/oldredhead/4269161279/sizes/z/ 1

1. Do you have one consistent personality? For example, are you always introverted or extraverted? 1. Yes 2. No http://rlv.zazzle.com/consistently_inconsistent_shirt-p2354465083047446547cb2_210.jpg 2

Personality trait An enduring pattern of perceiving, relating to, and thinking about the environment and others. APD Borderline Histrionic Narcissistic Paranoid Schizoid Schizotypal 3 Avoidant Dependent OCD

Nature of PD s A longstanding maladaptive pattern of inner experience and behavior dating back to adolescence or adulthood 2010 Clipart.com, a division of Getty Images. 4

Nature of PD s Manifest in at least two areas: Cognition Affectivity Interpersonal functioning Impulse control 5

Nature of PD s http://www.flickr.com/photos/silvergelatin/3381570166/sizes/m/in/photostream/ Evident in various personal and social situations Causes distress or impairment 6

CLUSTERS A Eccentric B Dramatic C Anxious http://www.flickr.com/photos/24124989@n00/3736005746/sizes/m/

http://www.flickr.com/photos/jilliancorinne/4312741732/sizes/z/ Cluster A Odd and eccentric behaviors Paranoid Schizoid Schizotypal Paranoid Schizoid Schizotypal 8

Cluster B Overdramatic & emotional Antisocial Borderline Histrionic Narcissistic http://www.flickr.com/photos/peter_trudelle/2162035414/sizes/m/in/photostream/ APD Borderline Histrionic Narcissistic

http://www.flickr.com/photos/brymo/2443867112/sizes/z/ Cluster C - Anxious, fearful behaviors Avoidant Dependent Obsessive-Compulsive Avoidant Dependent 10 OCD

1. Yes 2. No 2. Have you known anyone who seemed to have no conscience? http://www.rickbrotherton.com/blog/blogmedia/061220_dexter.jpg 11

Antisocial and Borderline Most extensively researched Specific theoretical perspectives treatment approaches APD Borderline 12

History Philippe Pinel (1801) - Defect of moral character Hervey Cleckley (1941) - Psychopathy Robert Hare (1997) Psychopathy Check List (PCL-R) DSM-IV Goes beyond psychopathy traits. APD 14

Distinction Criminal: A legal term, not a psychological concept. APD: Illegal or immoral behavior such as stealing, lying, or cheating. APD http://www.delllaw.com/dl/images/criminal.jpg 15

DSM-IV primary criteria Must be long standing APD 16

DSM-IV primary criteria At least 3 : repeated aggressiveness recklessness that endangers others deceitfulness lack of remorse consistent irresponsibility (not honor financial obligations) APD 17

Disorder of Will Will exists on a continuum Will is inferred Dividing line arbitrary APD 18

Characteristics Inadequately motivated antisocial behavior Absence of a conscience and sense of responsibility to others Emotional poverty APD 19

Crimes Aimless and random Difficult to understand reason They do not understand it. No rational purpose Perversely impulsive APD 20

Biological Perspective Frontal lobe abnormality may lead to deficits in planning actions and considering moral implications of actions Diminished autonomic response to social stressors May be a genetic predisposition Genetic-environment interaction, with heritability as high as 56 percent APD 22

Defects in Learning Less likely to learn to avoid punishment Possibly because of chronic under arousal, They seek stimulation rather than avoid it. Lykken (l957) suggests that they don't avoid shock like normals Under arousal hypothesis is supported by Schachter and Latane (l964), When they increased their arousal by using adrenaline, they avoided it at the same rate as normals. They can learn to avoid relevant punishment, which was loss of a quarter. Schmauk (l970) APD 23

Psychological Perspective Neuropsychologically-based deficits in learning and attention Response modulation hypothesis Unable to process information that is not relevant to their primary goals Lack of emotional reactivity Unable to process information not relevant to their primary goals. Little response to aversive stimuli Low self-esteem leads to need to prove competence by aggression APD 24

Sociocultural Perspective Family - Lee Robins (1966)- Divorce, conflict, inconsistent discipline, parental conflicts in parenting style, parents with antisocial traits Childhood Abuse And Neglect - Goleman (1995) and Luntz & Widom (1994) 50 percent greater arrests among adults who were neglected 100 percent greater arrests among those who were physically abused APD 25

Treatment Treatment is rarely sought except in legal context Goal- Help the client feel bad about himself! Techniques - Confrontational, refuse to believe client s fabrications, point out selfish and self-defeating behaviors Group therapy may be helpful because peers are not easily taken in APD 26

3. Do you believe that you can fall in love with someone in an instant? Yes No 3B Would you marry someone on that basis? Yes No http:// http://www.true.com/magazine/images/storyphotos/dating_falldates.jpg 27

Borderline Broad category A pattern of poor impulse control Essential feature is instability in Interpersonal relationships Behavior Mood Self-image http://www.egrupos.net/albumphoto/308808/photo_41.jpg Borderline 28

Borderline Intense interpersonal relationships Splitting- Perceiving other people as being all good or all bad. Feelings of emptiness Anger, rage Identity confusion Shifting goals, plans, partners Poor boundaries with others Risky-taking, self-injurious behaviors Parasuicidal (gesturing to gain attention) http://www.svusd.k12.ca.us/schools/schs/gallery/images/split.jpg Borderline 29

Theories Physical or sexual abuse, especially in women, leads to expectation of harm from others Childhood caregiver interaction Emotionally unavailable Inconsistent treatment Failed to validate their thoughts and feelings Failed to protect from abuse Anxious attachment style with mother http://www.albdreamgirl.at/img/borderline-kunst01.jpg Borderline 30

Vulnerable temperament + Traumatic early childhood experiences + Triggering events in adulthood Biopsychosocial http://www.helpinganimals.com/photos/240-humanabuse.jpg Borderline 31

Biological http://www.ikbenverlegen.nl/afbeeldingen/amygdala.jpg Childhood sexual abuse may alter sympathetic nervous system that leads to hypersensitivity and impulsivity in adulthood Hippocampus smaller Amygdala smaller Borderline 32

Psychodynamic Failure in development of self (ego) Caused by mother who is both overinvolved with child and inconsistent in emotional relatedness Child does not develop an independent, real self Child develops distorted perceptions of others known as splitting (0thers are either all good or all bad) Child s false self is fused with distorted perception of others Borderline 33

Cognitive-behavioral Splitting Low sense of selfefficacy Lack of confidence Low motivation Inability to seek longterm goals Modern pressures on family. Diminished social cohesion and mental cohesion. Unstable family patterns. Borderline 34

Treatment CHALLENGING AND COMPLEX Likely not to remain in treatment long If they do, unstable relationships with therapist TECHNIQUES Confrontive or Supportive Dialectical Behavioral Theory - Integrates confrontive and supportive May need medication Borderline 35

4. Do you know any one who is too emotional? 1. Yes 2. No 4B How does it make you feel? 1. Anxious 2. Irritated 3. Frustrated 4. Other http://albernstein.com/127ad1b0.gif 36

HISTRIONIC PERSONALITY DISORDER A personality disorder characterized by exaggerated emotional reactions, approaching theatricality, in everyday behavior. Melodramatic. Histrionic 37 Clip art copyright 2002 www.arttoday.com. Used with permission.

Histrionic 39

Histrionic Seek admiration by playing continually to unknown audiences Dramatic, attention-getting behavior Superficially charming, warm, and gregarious, Fleeting, shifting emotional states More commonly diagnosed in women Flirtatious and seductive Need for immediate gratification Easily influenced by others Superficial relationships Viewed by others as insincere and shallow Lack analytical ability Histrionic 40

Cognitive-Behavioral Theory Feelings of inadequacy and need for others Global nature of thinking underlies diffuse, exaggerated and changing emotional states Histrionic 41 http://www.nbc.com/days_of_our_lives/family_tree/images/sami_brady_400x255.jpg

Treatment Goals Learn how to think more objectively and precisely Learn self-monitoring strategies Learn impulse control Acquire assertiveness skills Histrionic 42

5. How would you know if you loved your self too much? 1. Others tell you, you re proud 2. You are unfulfilled 3. Spend more time on yourself than others 4. Other http://lifewise.canoe.ca/living/2005/02/23/30_narcissist-01.jpg 43

Narcissistic Narcissus - Greek legend about boy who fell in love with his reflection in a pond Unrealistic, inflated sense of self-importance stemming from grave self-doubt Continuous self-absorption, by fantasies of unlimited success, power and/or beauty, and by exhibitionistic needs for constant admiration, egotistical, arrogant. Lack of sensitivity to other people s needs Criticism, the indifference of others, and threats to esteem characteristically receive exaggerated response of rage, shame, humiliation, or emptiness Exploitative of others Common feature of other PDs, especially histrionic and borderline Narcissistic 44

Narcissistic Subtypes Noting the many types of behaviors involved, Millon and colleagues proposed subtypes. Elitist narcissists feel privileged and empowered, and tend to flaunt their status and achievements. Amorous narcissist tends to be sexually seductive, yet avoids real intimacy. Unprincipled narcissists are much like antisocial individuals in that they tend to be unscrupulous, arrogant, and exploitative. Compensatory narcissists tend to be negativistic, seeking to counteract their deep feelings of inferiority. They try to create illusions of being superior and exceptional. Narcissistic 45

Theories Freudian - Stuck in early psychosexual stages Psychodynamic - Adult expression of childhood insecurity and need for attention due to failed parent-child relationship Cognitive-Behavioral - They are not special and exceptional like they think they are Lack insight into or concern for feelings of others Grandiose sense of self clashes with real world failures Narcissistic 46

Treatment Psychodynamic & Cognitive-Behavioral Corrective developmental experience Empathic support and recognition Guides client to more realistic view of others Reduce grandiosity More adaptive goal-directed behaviors Enhance ability to relate to others Avoid demands for special attention Develop more realistic view of self. Narcissistic 47

Cluster A - odd and eccentric behaviors Paranoid Schizoid Schizotypal http://www.flickr.com/photos/jilliancorinne/4312741732/sizes/z/ 48

Paranoid Guarded Project negativity and damaging motives onto others Attribute their problems to others Low self-efficacy Paranoid 49

Paranoid Distrust of others Suspicious of others Hypersensitivity to slight Hyper vigilant: scan for and selectively perceive cues that validate prejudicial ideas and attitudes. Paranoid 50

Cognitive-Behavioral Treatment Counter erroneous thinking Establish trusting relationship Increase feelings of self-efficacy Reduce vigilant and defensive stance Insight into other s perspectives Approach conflict assertively Improve Interpersonal Skills Paranoid 51

Indifference to social and sexual relationships, Defect in capacity to form social relationships, Absence of desire for social involvement, Indifference to both praise and criticism, Insensitivity to the feelings of others, Lack of social skills, prefers to be alone Schizoid 52

Schizoid A very limited range of emotional experience and expression. No desire to love or be loved Cold, reserved, withdrawn Reclusive Not likely to seek therapy Schizoid 53

Schizotypal Peculiarities and eccentricities of thought, behavior, appearance, and interpersonal style, Long-standing oddities severe enough to be noticed Constricted, inappropriate affect May be latent schizophrenia Ideas of reference, magical thinking Social isolation Peculiar communication Treatment: Parallels interventions commonly used in treating schizophrenia Schizotypal 54

Cluster C - Anxious, fearful behaviors Avoidant Dependent Obsessive-Compulsive http://www.flickr.com/photos/brymo/2443867112/sizes/z/ 55

Desires, but is fearful of, any involvement with other people Want to enter social relationships or new activities, Strong desire for acceptance and affection. Fear of ridicule, involvement and rejection Avoid social interaction Avoidant 56

Avoidant Avoidant Terrified at the prospect of being publicly embarrassed. Unwilling to take even small risks unless they are given strong guarantees of uncritical acceptance Restrained and guarded interpersonal interactions Feel pain of emotional isolation 57

Psychodynamic Avoidant Theories Fear of attachment Cognitive-Behavioral Avoidant Hypersensitive as a result of childhood rejection or extreme parental criticism Belief that they are unworthy of regard Expect not to be liked Avoid getting close to avoid inevitable rejection Distorted perceptions of experiences with others 58

Cognitive-Behavioral Treatment Break negative cycle of avoidance Confront and correct dysfunctional attitudes and thoughts Graduated exposure to social situations Learn skills to improve chance of intimacy Avoidant 59

Dependent Extremely passive Tends to cling to other people, Unable to make any decisions or to take independent action. Allow others to assume responsibility for significant areas of one's life Fear of abandonment Despondent without others Unable to initiate activities Go to extreme to gain approval of others Devastated when relationships end Dependent 60

Dependent theories Psychodynamic Fixated at oral psychosexual stage because of parental overindulgence or neglect Object Relations Insecure attachment to parents led to fear of a abandonment Low self-esteem leads them to rely on others Cognitive-behavioral Thinking they are inadequate and helpless, they find someone to take care of them Dependent 61

Cognitive-Behavioral Treatment Therapist and client develop structured ways to increase client independence in daily activities Identify skill deficits and improve functioning Therapist must avoid becoming an authority figure or making client dependent on therapist Dependent 62

Obsessive-Compulsive Demand perfection in themselves and others. So overwhelmed with their concern for neatness and minor details that they have trouble making decisions or getting things accomplished. Intensely perfectionistic Nothing pleases them, however excellent the outcome. Often procrastinate in important matters, Rigid behavioral patterns Fanatical concern with schedules Stingy with time and money Tendency to hoard worthless objects Low level of emotionality OCD 63

OCD 64

Theories Freudian- Fixation at anal psychosexual stage Psychodynamic - Prior learning and cognitive experiences Cognitive-behavioral Distorted world view Failure to achieve unrealistic standard of perfection makes them feel worthless Treatment - Difficult to treat. Therapy may reinforce ruminative tendencies. OCD 65

Do PD s Exist? Little evidence for consistency Traits have little merit Then the PDs have little basis OCD 66

Evidence for PDs? Descriptions seem convincing Evidence is merely anecdotal. 67

Advise for an under aroused individual with an antisocial father? Find a job that is very stimulating but constructive (i.e. police work, etc.). 68

Personality Disorder Types Antisocial/Psychopathic Avoidant Borderline Obsessive-Compulsive Schizotypal Avoidant Dependent OCD APD Borderline Histrionic Narcissistic Paranoid Schizoid Schizotypal DSM-5 http://www.dsm5.org/proposedrevisions/pages/proposedrevision.aspx?rid=469 69

Personality Traits Negative Emotionality: Introversion: Antagonism: Disinhibition: Compulsivity: Schizotypy: DSM-5 http://www.dsm5.org/proposedrevisions/pages/proposedrevision.aspx?rid=469 70

Personality Traits 0 = Very little or not at all 1 = Mildly Descriptive 2 = Moderately Descriptive 3 = Extremely Descriptive DSM-5 http://www.dsm5.org/proposedrevisions/pages/proposedrevision.aspx?rid=469 71

General Diagnostic Criteria Definition: Personality disorders represent the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual s cultural norms and expectations. DSM-5 72

General Diagnostic Criteria A. Adaptive failure is manifested in one or both of the following areas: 1. Impaired sense of self-identity as evidenced by one or more of the following: I. Identity integration. ii. Integrity of self-concept. iii. Self-directedness. DSM-5 73

General Diagnostic Criteria 2. Failure to develop effective interpersonal functioning as manifested by one or more of the following: i. Empathy. ii. Intimacy. iii. Cooperativeness. iv. Complexity and integration of representations of others. DSM-5 74

General Diagnostic Criteria B. Adaptive failure is associated with extreme levels of one or more personality traits. C. Adaptive failure is relatively stable across time and consistent across situations with an onset that can be traced back at least to adolescence. D. Adaptive failure is not solely explained as a manifestation or consequence of another mental disorder E. Adaptive failure is not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma) DSM-5 75

Personality Assessment Format 1 TYPE MATCH PROFILE Indicate the degree to which the patient matches each of the following types: 5 (very good) 4 (good) 3 (moderate) 2 (slight) 1 (no) Antisocial/Psychopathic: Avoidant: Borderline: Obsessive-Compulsive: Schizotypal: DSM-5 76

Personality Assessment Format 1 LEVEL OF PERSONALITY FUNCTIONING Indicate the level of personality functioning that most closely characterizes the patient: 0 - No Impairment 1 - Mild Impairment 2 - Moderate Impairment 3 - Serious Impairment 4 - Extreme Impairment DSM-5 77

Personality Assessment Format 1 TRAIT PROFILE List traits scored as 3 (Extremely descriptive): List traits scored as 2 (Moderately descriptive): PERSONALITY DISORDER (301.xx) Does the patient meet the general criteria for personality disorder? NO YES DSM-5 78

Personality Assessment Format 2 LEVEL OF PERSONALITY FUNCTIONING Indicate the level of personality functioning that most closely characterizes the patient: 0 - No Impairment 1 - Mild Impairment 2 - Moderate Impairment 3 - Serious Impairment 4 - Extreme Impairment DSM-5 79

Personality Assessment Format 2 TRAIT PROFILE List traits scored as 3 (Extremely descriptive): List traits scored as 2 (Moderately descriptive): DSM-5 80

Personality Assessment Format 2 TYPE MATCH PROFILE Indicate the degree to which the patient matches each of the following types: 5 (very good) 4 (good) 3 (moderate) 2 (slight) 1 (no) Antisocial/Psychopathic: Avoidant: Borderline: Obsessive-Compulsive: Schizotypal: PERSONALITY DISORDER (301.xx) Does the patient meet the general criteria for personality disorder? NO YES DSM-5 81

DSM-5 Self: Identity Integration, Integrity of Self-concept, and Selfdirectedness Interpersonal: Empathy, Intimacy and Cooperativeness, and Complexity and Integration of Representations of Others As with the General Diagnostic Criteria for Personality Disorder, when applying these dimensions diagnostically, the self and interpersonal difficulties must: A. be multiple years in duration B. not be solely a manifestation or consequence of another mental disorder C. not be due solely to the direct physiological effects of a substance or general medical condition D. not be better understood as a norm within an individual s cultural background DSM-5 http://www.dsm5.org/proposedrevisions/pages/proposedrevision.aspx?rid=469 82

Self and Interpersonal Functioning Continuum 0 = No Impairment 1 = Mild Impairment 2 = Moderate Impairment 3 = Serious Impairment 4 = Extreme Impairment DSM-5 http://www.dsm5.org/proposedrevisions/pages/proposedrevision.aspx?rid=469 83

And in conclusion...? Personality disorders are Chronic and persistent Hard to explain Difficult to treat Subject to much further study 84