Personality Disorders

Chapter 9

General Symptoms

Problems must be part of an enduring pattern of inner experience and behavior that deviates significantly from the expectations of the individual’s culture.

Patterns must be evident in two or more of the following domains:– Cognition-ways of thinking of self and others– Emotional Responses– Interpersonal Functioning– Impulse Control

Pattern of maladaptive experience and behavior must also be:– Inflexible and pervasive across a broad range of personal and social

situations.– Source of clinically significant distress or impairment in social,

occupational or other important areas of functioning. Stable and of long duration, with an onset that can be traced back at

least to adolescence or early adulthood.

Similar observations in all subsets of the disorder

Behavioral patterns associated with significant social and occupational impairment.

Presence of pathological personality traits during adolescence is associated with an increased risk for development of other mental disorders later in life.

– Negative emotionality-predicts onset of depression or anxiety disorder– Impulsive or antisocial personality traitspredicts increased risk of alcohol abuse.

Personality disorder represent the early onset of more serious forms of pathology: Presence of co-morbid personality disorder can interfere with the treatment of other

disorders.

Ego-syntonic vs. Ego-dystonic

– Ego-dystonic-person with the disorder is distressed by their symptoms and uncomfortable with their situation.

– Ego-syntonic-(personality disordered)-do not see themselves as disturbed and their ideas or impulses are acceptable to them, primarily due to a lack of insight.

General Definition

Over-all definition is difficult as the personality disorders by nature are:

Controversial Difficult to Reliably Identify Poorly understood Etiology Little evidence of successful treatment

Personality (def)-enduring pattern of thinking and behavior that define the person and distinguish him or her from other people, including expressing \emotion as well as hw one thinks about themselves and other people.

Typical Symptoms and Associated Features

Social Motivation – can be described in terms of maladaptive variations

with regard to needs for affiliation and power.– Affiliation-the desire for close relationships with other

people– Power-the desire for impact, prestige or dominance

Cognitive Perspective of Self and Others– Distortions of our perceptions of self and others. – Inappropriate evaluation of relationships– Lack of empathy

Temperament and Personality Traits

Temperament refers to a person’s most basic, characteristic styles of relating to the world, especially those styles that are evident during the first year of life.

Five Factor Model of Personality Neuroticism Extraversion Openness to Experience Agreeableness Conscientiousness

Context and Personality

Development and Persistence of individual differences have two important qualifications:– Differences may not be evident in all

situations. – People with personality disorders do not

always exhibit the traits associated with the disorder.

Consequences of exhibiting certain traits in a social context.

. Classification

Organized into three basic clusters on the basis of broadly defined characteristics

Cluster A: includes people who often appear odd, eccentric or asocial.

. Cluster B: includes people who appear dramatic, emotional or erratic behavior and all are associated with difficulty sustaining interpersonal relationships.

Cluster C: includes people who often appear anxious or fearful

Cluster A: subtypes

Paranoid Personality Disorder -characterized by the pervasive tendency to be inappropriately suspicious of other people’s motives and behaviors.

Schizoid Personality Disorder -defined by a pervasive pattern of indifference to other people.

Schizotypal Personality Disorder -peculiar patterns of behavior rather than emotional restriction and social withdrawal associated with schizoid personality disorder.

Cluster B: Subtypes

Anti-social Personality Disorder-persistent pattern of irresponsible behavior that begins during childhood or adolescence and continues into adulthood.

Borderline Personality Disorder-diffuse category whose defining feature is a pervasive pattern of instability of mood and interpersonal relationships.

Histrionic-characterized by pervasive pattern of excessive emotionality and attention seeking behavior.

Narcissistic Personality Disorder-pervasive pattern of grandiosity

Cluster C: Subtypes

Avoidant Personality Disorder-pervasive pattern of social discomfort.

Dependent Personality Disorder-pervasive pattern of submissive and clinging behavior

Obsessive Personality Disorder-pervasive pattern of orderliness, perfectionism, and mental and interpersonal control at the expense of flexibility, openness and efficiency.

Personality Disorder Not Otherwise Specified

Allows for a non-specific diagnosis in addition to the 10 specific subtypes.

Category used for people that meet the general diagnostic criteria for a personality disorder without meeting the specific criteria for one of the subtypes.

May be the most frequently used diagnosis

Epidemiology

Prevalence-over-all life-time prevalence for having at least one Axis II disorder is between 10-14%.

Gender Differences

Stability over life time.

Schizotypal Personality Disorder

Criteria– Symptoms of schizotypal Personality disorder represent early

manifestations of the predisposition to develop the full-blown disorder (Schizophrenia )

– Pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as cognitive and perceptual distortions, and eccentricities of behavior beginning by early adulthood and present in a variety of contexts as indicated by five (or more) of the traits listed in table 9-3. For example:

- -Odd thinking and speech --Suspiciousness or paranoid ideation --Inappropriate emotional responses such as uncontrolled

giggling at a funeral --Lack of close friends --Excessive Social anxiety

Etiology

Primarily genetic.

First degree relatives of schizophrenic patients are considerably more likely than people in the general population to exhibit schizotypal personality disorders.

Treatment

People with these disorders do not seek treatment because they do not see their own behavior as a source of distress (ego-syntonic)

A relatively high proportion of patients drop out of treatment before it is completed.

Therapeutic effects of medication are positive, but tend to be modest. Usually treated with anti-psychotic drugs to alleviate cognitive problems and social anxiety.

Do not respond well to insight oriented therapy.

Borderline Personality Disorder

Criteria– Faulty Development of the ego structure.– Splitting-tendency to see people and events alternately as

entirely good or entirely bad.– Pervasive pattern of instability in self image, in interpersonal

relationships, and mood.– Significant overlap with symptoms of histrionic, narcissistic,

paranoid, dependent and avoidant personality disorders.– Poor impulse control– Substance abuse– Co-morbidity with Depression

Etiology

Most common theory focuses on the environment, specifically the negative consequences of parental loss or neglect during childhood.

Animal literature supports this assertion in observed behavior of monkeys separate from mothers as infants (Harlow)

Childhood sexual abuse

Treatment

Psychodynamic therapy to include transference relationship

Emphasis on therapist acceptance of the patient, both personally and as a client.

Medication-broad spectrum of drugs used to treat specific symptoms such as antipsychotics, anti-depressants, lithium and anticonvulsants.

No evidence that drug therapy is particularly effective for treatment of any of the borderline features.

Anti-social Personality Disorder

Criteria– Impulsive, self centered, pleasure seeking people

who seemed completely lacking in certain primary emotions such as anxiety, shame and guilt.

– Often intelligent, superficially charming, as well as chronically deceitful, unreliable and incapable of learning from experience.

– Required presence of conduct disorder prior to age 15

Etiology

Biological Factors– Interaction of genetic and environmental factors based on adoption

studies. Social Factors

– Physical abuse and childhood neglect– Children whose response style is characterized by high levels of

negative emotion or excessive activity may be especially irritating to parents and care givers, and may evoke maladaptive reactions from parents who are poorly equipped to deal with this type of behavior.

– Limited range of social skills– Consequences of antisocial behavior.

Psychological Factors– Emotionally impoverished-lack of anxiety and fear.– Do not show exaggerated startle response indicative of fear of

aversive stimuli-– Unable to shift attention to consider the possible negative

consequences of their behavior.

Treatment

Treatment relatively un-effective due to inability to form intimate trusting relationships which are essential to any treatment program.

Seldom seek treatment unless forced by legal system.

Dependent Personality Disorder

Criteria– Assume a submissive role in relationships with other

people– Require an extraordinary level of reassurance and support– Cling to others who will take care of them.– Preference for affiliation that reflects motivation to remain

close to people who will provide security and comfort– Fear of criticism and rejection leads to a lack of self

confidence

Etiology

Over-protective authoritarian parents Bowlby’s attachment theory-insecurely

attached babies who have little confidence that attachement figures will be responsive when they need something.

Treatment

No literature on treatment outcome Cognitive therapy predicted to be beneficial

when teaching problem solving abilities, coupled with practice making decisions.

Medication not thought to be helpful for disorder itself, many times prescribed for co-morbid diagnosis such as anxiety and depression.