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Personality Disorders 101. Mike Pett MSW;RSW Advanced Practice Clinician Complex Mental Illness Program. Objectives for the Presentation. - Common Pathways of Offending for SMI population -Personality Disorders Defined -Cluster B personality disorders: - PowerPoint PPT Presentation
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Personality Disorders 101Mike Pett MSW;RSW
Advanced Practice Clinician
Complex Mental Illness Program
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Objectives for the Presentation
-Common Pathways of Offending for SMI population
-Personality Disorders Defined
-Cluster B personality disorders:
Borderline, Narcissistic, and Anti-social/Psychopathic
-Treatment of Personality Disorders
-Question Period
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Conventional Path to Offending: Part 1.
Biological: TemperamentFamily history
Cognitive ability
Psychological:Antisocial attitudes
Social:Poor parent-child rel’nsSocial learning of antisocial behaviour
Conduct Disorder
ASPD/Psychopathy
Substance Use
Andrews & Bonta 2006
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Proximal motivations (the “weather”)
Conventional Path to Offending: Part 2
Peterson et al. 2010
High Risk Individual
Instrumental
Reactive
Motives: material gain, sexual, power, jealousy, revenge
Motives: anger, intoxication, perceived threat, emotional stressor
Disadvantaged Motives: minor crimes for food, shelter
Substances Motives: obtain drugs of abuse
+ Paths to Offending in SMI
Positive Symptoms
Serious Mental Illness
Disorganization
High Risk Individual
(ASPD)Instrumental
Reactive
Disadvantaged
Substances
SMI vs. Gen Pop:
•Higher rate of Conduct dis.
•Higher rate of ASPD
•Higher rate of substance
•Higher rate of poverty
The direction of these relationships is unclear
The proportion of each motivation is unclear
+ The False Dichotomy
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Personality Disorders 101
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Personality Disorder Clusters
Cluster A (“mad”)SchizoidSchizotypalParanoid
Cluster B (“bad”)BorderlineAntisocialNarcissisticHistrionic
Cluster C (“sad”)
Obsessive-Compulsive
Avoidant
Dependent
+ Activity: Personalities ‘R Us
Corporate Structure:
President: ?
Vice President: ?
Personnel: ?
Advertising: ?
Legal Department: ?
Research: ?
Customer Service: ?
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Personalities ‘R Us Corporate Structure
President: Narcissist
Vice President: Paranoid
Personnel: Borderline
Middle Management:
Advertising: Histrionic
Research: Schizo-typal
Legal Department: Anti-social
Customer Service: Passive-Aggressive
+ Borderline Personality Disorder
Recorded on Axis II of the DSM-IV
Defined by the DSM-IV:
“an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment”
Not the result of:
Cultural and social expectations
Another mental disorder
A substance or general medical condition
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Borderline Personality Disorder: What is it?
DSM-IV:
“ A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.”
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Borderline Personality Disorder: DSM-IV Criteria
Five or more of the following:
Frantic efforts to avoid real or imagined abandonment A pattern of unstable and intense interpersonal
relationships characterized by alternating between extremes of idealization and devaluation
Identity disturbance: markedly and persistently unstable self-image or sense of self
Impulsivity in at least two areas that are potentially self-damaging
Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior
Affective instability due to a marked reactivity of mood Chronic feelings of emptiness Inappropriate, intense anger or difficulty controlling
anger Transient, stress-related paranoid ideation or severe
dissociative symptoms
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Borderline Personality Disorder: Instability & Impulsivity
Instability of: Mood Self-image and identity– overdetermined by the
environment Interpersonal relationships
Marked impulsivity (5 S’s):
1. Spending
2. Sex
3. Substance use
4. Speeding (reckless driving)
5. Satiety (binge eating)
(6.) Suicidal/self-harm behavior (has its own criterion)
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Borderline Personality Disorder: Demographics & Course
Female > Male (3:1) 2% of community samples ; 15-25% of clinical
populations; 13-56% of hospitalized substance abusers
Completed suicide in ~8-10% (particularly high if comorbid substance use)
High rates of functional deficits, mental health utilization costs
Rocky course during first decade of treatment (high drop out rates); but many improve by second decade of treatment
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Borderline Personality Disorder: Etiology
Environmental:Invalidating Caregivers
Biological:Emotional
Vulnerability
Emotional Dysregulation
Most researched is Marsha Linehan’s biosocial theory
• High sensitivity/reactivity to emotional stimuli
• Slow return to baseline
• Indiscriminately rejects internal emotional experiences
• Punishes emotional expressions and intermittently reinforces emotional escalation
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Anti-social Personality Disorder vs. Psychopathic Personality Disorder
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“All psychopathic personalities are anti-social but not all anti-social personalities are psychopathic”
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Derived from Greek
psych (soul, breath hence mind)
pathos (to suffer)
A constellation of affective, interpersonal, and behavioral characteristics that include grandiosity, a callous disregard for others, a lack of empathy, and highly impulsive and irresponsible behavior
Differentiation from Sociopathy and Antisocial Personality Disorder
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– Superficial charm & good “intelligence”– Absence of delusions / irrational
thinking– Absence of “nervousness”– Unreliability– Untruthfulness and insincerity– Lack of remorse or shame– Inadequately motivated antisocial
behavior– Poor judgment / failure to learn by
experience
– Pathologic egocentricity / incapacity for love– General poverty in major affective reactions– Specific loss of insight– Unresponsiveness in general interpersonal
relations– Fantastic and uninviting behavior with drink
& sometimes without– Suicide rarely carried out– Sex life impersonal, trivial, and poorly
integrated– Failure to follow any life plan
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Operationalized the construct of psychopathy in the PCL and PCL-R instruments
Factor 1: Interpersonal and affective characteristics
Factor 2: Impulsive and antisocial behaviors
Prevalence of psychopathy:
~ 1% of general population
~ 20-25% of prison population
Robust predictor of violent and non-violent criminal behaviors in adult male offenders (e.g., Harris, Rice, & Cormier, 1991; Hemphill, Hare, & Wong, 1998; Salekin, Rogers, & Sewell, 1996)
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PsychopathyPsychopathyPsychopathyPsychopathy
Factor 1Factor 1Arrogant & Deceitful Arrogant & Deceitful Interpersonal StyleInterpersonal Style
Factor 4Factor 4Antisocial BehaviorAntisocial Behavior
Factor 4Factor 4Antisocial BehaviorAntisocial Behavior
Factor 2Factor 2Deficient AffectiveDeficient Affective
ExperienceExperience
Factor 3Factor 3Impulsive & IrresponsibleImpulsive & Irresponsible
Behavioral StyleBehavioral Style
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1. Glibness / Superficial Charm
Insincere and shallow interactional style
Charming, phony, or superficial
2. Grandiose Sense of Self-Worth
Inflated view of abilities and self-worth
Can appear domineering, opinionated, and arrogant
4. Pathological Lying
Deceitful, lying “just for kicks”
5. Conning/Manipulative
Uses deception to cheat, exploit, or manipulate others
Misrepresentation for personal gain
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6. Lack of Remorse or Guilt
Lack of concern for the consequences of their actions on others
7. Shallow Affect
Unable to experience a normal range and depth of emotion
“Play acting” emotions
8. Callous/Lack of Empathy
Disregard for the feelings, rights, and welfare of others
Cynical and selfish
16. Failure to Accept Responsibility for Own Actions
Usually have excuses for behaviors that hurt others
Rationalize or minimize past transgressions
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8. Need for Stimulation / Proneness to Boredom
Chronic and excessive need for novel and exciting stimulation; exciting and risky activities; “on the go”
9. Parasitic Lifestyle
Exploitation of others for basic needs and obligations
13. Lack of Realistic, Long-Term Goals
Inability or unwillingness to formulate plans and commitments; living “day to day” and changing plans frequently
+ Factor 3-cont
14. Impulsivity
Behaviors are unpremeditated and lacking in reflection; doing things on the spur of the moment; opportunistic15. Irresponsibility
Habitual failure to honor obligations and commitments to others
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10. Poor Behavioral Controls
12. Early Behavioral Problems
18. Juvenile Delinquency
19. Revocation of Conditional Release
20. Criminal Versatility
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11. Promiscuous Sexual Behavior
17. Many Short-Term Marital Relationships
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Best Practices for Treatment of Borderline and Anti-social personality disorder
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Dialectical Behaviour Therapy for Borderline Personality Disorder (Linehan, 2007)
Mindfulness
Interpersonal effectiveness
Distress Tolerance
Emotion Regulation
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Best Practices for Psychopathy and Anti-social Personality Disorder
“Nothing Works”
vs.
“What Works”?
+ Watch Dexter!
+ “Most Best” Menu of Treatment Strategies Substance Use Treatment
Pharmacological treatments for impulse control/cravings.
I.M. medication for chronic non-adherence.
Anger Management.
Assertive outreach
Crisis intervention
Critical time intervention
Volunteerism
+ Most Best Treatment Options.
CTO’s, probation, bail orders as leverage points to motivate recovery.
Drug Treatment Court/Mental Health Diversion in cases of precontemplation/low motivation in terms of mental health and addiction treatment.
Community placement should be in safe, pro-social neighborhoods where exposure to criminal activities and substance use is limited.
Re-training/Re-schooling
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Questions and Comments