Personality disorders Personality disorder defined: An enduring maladaptive pattern of inner experience and outward behavior, involving impaired: (two or more of the following) sense of self emotional experience and expression goals capacity for empathy and/or intimacy impulse control resulting in psychological pain for the individual or others Characteristic areas of impairment: disrupted social relationships, troublesome behavior across situations, behavior that is repeatedly associated with negative life outcomes resistance to change often comorbid with other disorders Not diagnosed in adolescence; seen as developing in these formative years traditionally seen as hard to treat The contributions of Theodore Millon Ph.D.
Three clusters of personality disorders: Cluster A: oddities and eccentricities of behavior Paranoid, schizoid, schizotypal Cluster B: dramatic, emotional, and erratic behavior Antisocial, borderline, histrionic, narcissistic Cluster C: anxious and fearful behavior Avoidant, dependent, obsessivecompulsive Cluster C: Avoidant Dependent Obsessive Compulsive Cluster B: (the dramatic personality disorders) Antisocial Borderline Histrionic Narcissistic Cluster A: Paranoid Schizoid Schizotypal
The Categorical Approach The DSM listing is a categorical approach assumes that: Problematic personality traits are either present or absent disorder is either displayed or not not markedly troubled by personality traits outside of that disorder these assumptions are frequently contradicted in research AND clinical practice 7 Comer, Fundamentals of Abnormal Psychology, 7e 8 The problem of overlapping personality diagnoses Many confusing overlaps risk of overdiagnosis due to: overlaps mistaking present distress as rigid and long-term overuse of Personality disorder NOS The problem of overlapping personality diagnoses many theorists and clinicians challenge the use of a categorical approach disorders differ more in degree than in type of dysfunction indicates need for a dimensional approach In which each trait is seem as varying along a continuum
The problem of overlapping personality diagnoses Leading researchers proposed some dimensional systems for the DSM-5 there were three or four very good systems proposed The proposals were met with concern and criticism in the clinical field for the time being, the DSM has retained the old categorical approach, recognizing dimensions only by rating of PD by severity allowing crossover diagnosis A dimensional system is now in the DSM-5 assigned for further study more on the Dramatic Personality Disorders The behaviors of people with these disorders are so dramatic, emotional, or erratic that it is difficult for them to have giving, satisfying relationships These personality disorders are more commonly diagnosed than the others antisocial and borderline personality disorders have received the most research of any of the PDs The causes of the disorders are not well understood; the outcomes are well understood and problematic for self and others Antisocial Personality Disorder ASP defined as a persistent disregard and violation of others rights Pattern of lying, recklessness, sexually promiscuity, and impulsivity A disregard for others cruel sadistic violent Antisocial Personality Disorder historically called as psychopathy or sociopathy (pejorative: psychopath, sociopath ) Along with substance-related disorders, this is the disorder most linked to adult criminal behavior Almost always associated with patterns of conduct problems before the age of 15 (required for Dx)
Antisocial Personality Disorder up to 3.5% of people in the U.S. but note that these rates are based on categorical criteria four times more common in men than women because people with ASP are often arrested, studies on antisocial patterns focus on prison populations and the correctional system Antisocial Personality Disorder high rates of alcoholism and other substance use Children with conduct disorder and an accompanying ADHD have a heightened risk of developing antisocial personality disorder solitary acts of cruelty a big risk factor some observations about Antisocial Personality Disorder Cognitive: ASP involves attitudes that trivialize the importance of other people s needs Biopsychological factors: low levels of trait anxiety and arousal (more likely to take risks and seek thrills) pain insensitivity low responsiveness to social reward Treatments for Antisocial Personality Disorder cooperation with treatment a big issue Treatment is typically ineffective without significant legal or financial consequences treatment is usually mandated Cognitive therapy guides clients to think about moral issues and the needs of other people CBT and other treatments have some good behavioral outcomes, but poor outcomes on the ASP itself Hospitals and prisons as therapeutic communities?
Borderline personality disorder a pervasive pattern of instability in interpersonal relationships, selfimage, and affect, with marked mood lability and impulsivity. Indicated by five or more symptomatic patterns: Borderline personality disorder frantic efforts to avoid real or imagined abandonment a pattern of unstable and intense interpersonal relationships identity disturbance impulsivity in at least two areas that can cause self-harm recurrent suicidal or parasuicidal behavior Borderline personality disorder affective instability due to marked reactivity of mood chronic feelings of emptiness (meaninglessness) transient, stress-related paranoid ideation or severe dissociative symptoms Borderline personality disorder inappropriate, intense anger or difficulty controlling anger prone to bouts of anger, which sometimes result in physical aggression and violence Just as often, however, impulsive anger is directed inward (self-harm)
Borderline personality disorder Pattern of self-defeating behavior. Substance abuse and mood disorder Emergency room presentation frequently form intense conflict-ridden relationships Overlap with antisocial personality Borderline personality disorder Between 1.5% and 2.5% of the general population are thought to suffer from this disorder (REMEMBER THIS IS CATEGORICAL) Close to 75% of those diagnosed are women The course of the disorder varies In the most common pattern, the instability reaches a peak during young adulthood and then gradually wane with advancing age 39 some observations about Borderline Personality Disorder Research: overly reactive amygdala underactive prefrontal cortex lower brain serotonin activity Close relatives are 5 times more likely than the general population to have the disorder Comer, Fundamentals of Abnormal Psychology, 7e 41 Theories a form of bipolar disorder? PTSD?
Treatment for Borderline Personality Disorder It appears that psychotherapy can eventually lead to some degree of improvement for people with this disorder It is extraordinarily difficult, for a therapist to strike a balance between empathizing with a patient s dependency and anger and challenging his or her way of thinking Treatment for Borderline Personality Disorder Antidepressant, mood stabilizing, antianxiety, and antipsychotic drugs can calm their emotional and aggressive storms BUT use of drugs on an outpatient basis is controversial Most clients seem to benefit from a combination of drug therapy and psychotherapy Treatment for Borderline Personality Disorder Over the past two decades, an integrative treatment approach, called dialectical behavior therapy, has received more research support than any other treatment for this disorder This approach is derived from a cognitive-behavioral model and borrows heavily from humanistic and psychodynamic approaches DBT is often supplemented by the clients participation in social skill-building groups Issues in treatment Personality disorders as very hard to treat. Non-traditional treatment methods that work: Directive & Structured Role-modeling Behavioral restrictions Extending realms of positive behavior Tolerance, patience, compassion for difficult behavior Dialectical behavior therapy
Conclusions on BPD Therapy problem or problem therapists? progress in treatment methods Conclusions Most dangerous Dxs: Antisocial Borderline Paranoid Notable developmental effects: lessening severity with age Psychotherapy is possible... Medications can help...