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Personality Disorders
Personality is the totality of emotional and behavioral traits apparent in a person’sordinary life that is usually stable and predictable.
Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and the self that are exhibited in a wide range of contexts.
A personality disorder
deviant from cultural standards
rigidly pervasive
onset in adolescence or early adulthood
stable over time,
lead to unhappiness and impairment
maladaptive behavior in at least two:1.Affect 2. Cognition 3. Impulse control4. Interpersonal functioning
Cluster A:
odd and eccentric
more common in biological relatives of client with schizophrenia
Types Paranoid - distrust and suspiciousness Schizoid - detachment from social relationships Schizotypal -acute discomfort in close relationships,
cognitive or perceptual distortions, and eccentric behavior
Cluster B:
dramatic, emotional, erratic, defenses of dissociation, acting out, denial, and splitting
Types Antisocial - distrust of other and violations of their rights,
often co-morbid with substance use disorders Borderline - instability in interpersonal relationships, self-
image, affect, and impulse control, often co-morbid with mood disorders
Histrionic - excessive emotionality and attention-seeking, often co-morbid with somatization
Narcissistic - grandiosity, a need for admiration, and a lack of empathy
Cluster C:
These persons are anxious or fearful, and tend to utilize the defenses of isolation,passive aggression, and somatization
Types Avoidant - social inhibition, feelings of inadequacy, and
hypersensitivity to negative evaluation Dependent - submissive and clinging behavior related to
an excessive need to be taken care of Obsessive-compulsive - preoccupation with
orderliness, perfectionism, and control
Diagnostic Considerations
low inter-rater reliability with personality disorders
require a longitudinal versus a time-limited assessment approach
Psychological testing can be helpful
+Coding
principal diagnosis if focus on PD
should rarely be applied to children and adolescents because personality patterns are evolving during and don’t reach a state of constancy until late adolescence/young adulthood. - Symptoms should be present for a full yr in adolescence in order to diagnose
+ Borderline Personality Disorder
a pattern of instability in interpersonal relationships, self-image, and affect, featuring impulsive behavior
Characterized by extremely unstable affect, mood, object relations, and self-image
frantic efforts to avoid abandonment failed to successfully negotiate task of separating from primary caregivers
while maintaining an internalized sense of being cared for
often in crisis due to their intense feelings of anger, emptiness, and hopelessness that occur when stressed
Other features include anxiety, transient psychotic symptoms, suicidal or self-mutilating behaviors, and substance abuse.
Core features: highly variable mood and impulsive behavior
+Prevalence of BPD
5.9%
most common personality disorder found in clinical settings
In clinical samples, most frequent in females but in population, males and females have equal rates
+Assessment
Determine through a social history whether the client’s presenting problems result from patterns of interaction with others
Assess for recent stressors; determine whether isolated situation or part of a general pattern
Is the client’s presenting problem an outcome of conflicted interactions with significant others? If so, is this an isolated situation, or part of a general pattern?
Does the client maintain positive relationships with some significant others (such as friends, family, and co-workers), or are most relationships conflicted?
Influence of any substances that may account for the symptoms of anxiety and depression.
Medical condition
For older adolescents and young adults, determine whether relatively less severe identity concerns are related to a developmental phase
The client’s manipulative behavior must be related to a desire for nurturance rather than a desire for power, profit, or personal gain
+Assessment
Is the client under the influence of any substances that might account for the symptoms of anxiety and depression?
Is there evidence of a history of hypomanic or manic episodes? Of depressive episodes?
If the client is an older adolescent or young adult, are identity concerns related to a developmental phase?
If the client displays manipulative behaviors toward others, including the social worker, are they related to a desire to elicit nurturance or for power or personal gain?
What cultural conditions may be affecting the client’s relationship-seeking behavior?
What environmental conditions may be affecting the client’s relationship-seeking behavior?
+Co-Morbidity
mood disorders, substance related disorders, eating disorders (notably bulimia), PTSD and other anxiety disorders, dissociative identity disorder, and attention deficit hyperactivity disorder
Symptoms of depression characteristic of BPD - emptiness, self-condemnation, abandonment fears, hopelessness, self-destructiveness, and repeated suicidal gestures
mood swings that resemble bipolar disorder (the interpersonal conflicts are a differentiating factor)
+ Suicidality and Self-Mutilation
55% of inpatients have histories of suicide attempts, although suicide rate is 5-10%
Reasons for self-mutilation: express anger, punish oneself, generate normal feelings when experiencing depersonalization, or distract oneself from painful feelings
+Risk and Protective Factors
37.1% genetic and 62.9% environmental influences
Psychodynamic formulationSeparation-individuation phase fixation – can’t distinguish between self and
others
have failed to successfully negotiate the delicate task of separating from primary caregivers while maintaining an internalized sense of being cared for.
Trauma in the social environment in childhood
+Course
Variableone-third recover ten years after initial diagnosisLow SES do worsea “natural course” recovery rate of 3.7% per yearclients receiving intervention recover at a rate seven
times that of persons who do not receive intervention 25% recovery rate per year for clients receiving
intervention.
Substance use -risk
+Intervention
40-60% drop out prematurely
Components: establishing and maintaining a therapeutic framework
and alliance responding to crises and monitoring the client’s safety providing education about the disorder consistent supportive or insight-oriented therapy coordinating intervention provided by other providers
+Indications for partial or brief inpatient hospitalization Dangerous, impulsive behavior that can’t be managed in an
outpatient setting
Non-adherence with outpatient intervention and a deteriorating clinical picture
Complex comorbidity that requires intensive clinical assessment of response to intervention
Symptoms of sufficient severity to interfere with functioning, work, or family life that are unresponsive to outpatient intervention
Transient psychotic episodes associated with loss of impulse control or impaired judgment
+Contract for services
timing and frequency of sessions,
plans for crises management,
after-hours availability (if any)
expectations about scheduling, attendance, and payment.
+ Dialetical behavior therapy
CBT and social learning, mindfulness
assumes core difficulty of clients is affective instability
"dialectical" intervention needs to address both biological and environmental aspects of the disorder/self-acceptance and change
intensive, one-year outpatient intervention that combines weekly individual sessions with weekly skills-training groups
purpose of group– to teach adaptive coping skills in the areas of emotional regulation, distress tolerance, interpersonal effectiveness, and identity confusion, and to correct maladaptive cognitions.
+Modality of DBT
individual therapy, a formal skills-training group, a therapist consultation team, some form of coaching (usually by telephone), and a treatment length of at least six months for outpatient clients and two months for inpatient clients.
+ Psychodynamic Intervention
draws from three major theoretical perspectives: ego psychology object relations self-psychology
+ Exploratory-supportive continuum of interventions
Supportive strengthening of defenses, development of self-esteem, validation of feelings, internalization of the therapeutic relationship creation of a greater capacity to cope with disturbing feelings
Exploratory make unconscious patterns more consciously available increase affect tolerance, build a capacity to delay impulsive action provide insight into relationship problems develop reflective functioning toward a greater appreciation of internal motivation in
the self and others
+Difficulty Prescribing Medication
disorder’s symptom heterogeneitydiagnostic unreliabilitypresence of comorbid disorders, and the
potential for self-destructiveness.
+Types of medication
SSRI’s – mood and impulsive symptoms Small, positive effects
For symptoms in cognitive dimension (suspiciousness, illusions, depersonalization, or transient hallucinations), antipsychotics
Review of antidepressant, anti-anxiety, antipsychotic, anticonvulsants, and lithium medications, either modest or no symptom relief
+Critique
DSM doesn’t mention how long symptoms have to last
May meet the criteria in 126 different ways
Division between clinical disorders and personality disorders questionable High co-morbidity Psychodynamic vs. atheoretical Recovery rates
+Critique for personality disorders
Personality disorders appear to describe the total person, rather than a particular aspect of the person or the result of person-in-environment processes