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January 2015 - Canberra (ACT) Dr. Dion Gee Australasian Psychology Services :

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1 January 2015 - Canberra (ACT) Dr. Dion Gee Australasian Psychology Services :

2 O VERVIEW Personality vs. Personality Disorder Elements of Intra- & Inter-personal Conduct Influences on PD Development Classification of Personality Disorder Categorical: The Mad, the Bad & the Sad Dimensional: Self & Interpersonal Core Features/Traits of the Client Paranoid; Narcissistic; Antisocial Trait Specified: NA, DT, P, A Self-Perpetuating Cycles Client Engagement Traps

3 What is Personality Enduring patterns of perceiving, relating to, and thinking about the environment and oneself, which are exhibited in a wide range of important social and personal contexts.

4 Self (Intrapersonal): Identity: Experiences oneself as unique, with clear boundaries between self and other; stability of self- esteem and accuracy of self-appraisal; capacity for, and ability to, regulate a range of emotional experiences. Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilisation of constructive and prosocial internal standards of behaviour; ability to self-reflect productively. Elements of Personality Functioning

5 Interpersonal (Other): Empathy: Comprehension & appreciation of others experiences and motivations; tolerance of differing perspectives; understanding the effects of one’s own behaviours on others. Intimacy: Depth and duration of connection with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behaviour. Elements of Personality Functioning

6 Defining Personality Disorder Psychological Disorder characterised by: “an enduring pattern of inner experience and behaviour 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” Source: Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5: American Psychiatric Association, 2013, p.645).

7 Influences on PD Development The causes of personality disorder are not fully known; although it is thought that a combination of genetic and environmental influences offer the best explanation. Your genes (neurological and genetic factors): Certain personality traits may be passed on to you by your parents through inherited genes. These traits are sometimes called your temperament. Your environment (intra- and inter-personal): This involves the surroundings you grew up in, events that occurred (e.g., trauma in early childhood, abuse, violence & neglect); relationships with family members (e.g., parenting style) and others (peers influences) can all influence development. Your genes make you vulnerable to developing a personality disorder; whereas a life situation may trigger the actual development.

8 Categorical Classification DSM-5 P ERSONALITY D ISORDERS

9 Main Features (Diagnostic Criteria) A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture. This pattern is manifest in two (or more) of the following areas: Cognition; Affectivity; Interpersonal functioning; Impulse control. B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. ego-syntonic vs. ego-dystonic. D. The pattern is stable and of long duration, and its onset can be traced back to at least adolescence or early adulthood. E. The enduring pattern is not attributable to the physiological effects of a substance or another medical condition (e.g., head trauma, dementia). Source: Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5: American Psychiatric Association, 2013; p.646-7).

10 The Mad, the Bad & the Sad Source: Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5: American Psychiatric Association, 2013). The 10 discrete personality disorders identified within the DSM-5

11 The Odd-Eccentric PDs Paranoid personality disorder Chronic and pervasive mistrust and suspicion of other people that is unwarranted and maladaptive. Schizoid personality disorder Chronic lack of interest in and avoidance of interpersonal relationships, emotional coldness toward others. Schizotypal personality disorder Chronic pattern of inhibited or inappropriate emotion and social behavior, aberrant cognitions, disorganized speech. Relationship to Schizophrenia

12 The Dramatic Emotional PDs

13 The Anxious-Fearful PDs Avoidant personality disorder Pervasive anxiety, a sense of inadequacy, and a fear of being criticized, which leads to the avoidance of social interactions and nervousness. Dependent personality disorder Pervasive selflessness, need to be cared for, fear of rejection, leading to total dependence on and submission to others. Obsessive-compulsive personality disorder Pervasive rigidity in one’s activities and interpersonal relationships, including emotional construction, extreme perfectionism, and anxiety about even minor disruptions in one’s routine.


15 Main Features (Diagnostic Criteria) The essential features of a personality disorder are: A. Moderate or greater impairment in personality (self/interpersonal) functioning. B. One or more pathological personality traits (trait domains or specific trait facets). C. The impairments in personality functioning and the individuals personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations. D. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time, with onset that can be traced back to at least adolescence or early adulthood. E. The impairments in personality functioning and the individual’s personality trait expression are not better explained by another mental disorder. F. The impairments in personality functioning and the individual’s personality trait expression are not solely attributable to the physiological effects of a substance or another medical condition (e.g., head trauma). G. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normal for an individual's developmental stage or socio-cultural environment. Source: Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5: American Psychiatric Association, 2013; p.761).

16 PD Trait-Specified A moderate or greater impairment in personality functioning, manifested by difficulties in two or more of the following: Identity; Self-direction; Empathy; Intimacy. One or more Pathological personality trait domains: 1. Negative Affectivity (vs. Emotional Stability): Frequent and intense experiences of high levels of a wide range of negative emotions and their behavioural and interpersonal manifestations. 2. Detachment (vs. Extraversion): Avoidance of socio-emotional experience, including both withdrawal from interpersonal interactions, as well as restricted affective experience and expression.

17 PD Trait-Specified 3. Antagonism (vs. Agreeableness): Behaviours that put the individual at odds with other people, including an exaggerated sense of self- importance and an expectation of special treatment, as well as a callous antipathy toward others, encompassing an unawareness of others’ needs and feelings, and a readiness to use others for self-enhancement. 4. Disinhibition (vs. conscientiousness): Orientation toward immediate gratification leading to impulsive behaviour driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences. 5. Psychoticism (vs. Lucidity): Exhibiting a wide range of culturally incongruent odd, eccentric, or unusual behaviours and cognitions, including both process (e.g., perception, dissociation) and content (e.g., beliefs).

18 Client-Specific Personality Pathology

19 Borderline Personality Disorder  Labile Mood-Temperament: mismatch between unstable mood and external reality; displaying marked shifts from normality  depression  excitement, or dejection & apathy, with episodes of intense and inappropriate anger, and brief spells of anxiety or euphoria).  Expressively Spasmodic: displays inconsistent energy level with unexpected and impulsive outbursts; abrupt, endogenous shifts in drive state and inhibitory controls and engages in recurrent suicidal or self- harming behaviours).  Interpersonally Paradoxical: whilst needing attention and affection, is unpredictably contrary, manipulative and often elicits rejection; frantically reacts to fears of abandonment and isolation, but often in angry and self-damaging ways.  Uncertain Self-Image: experiences an immature and wavering sense of identity, with underlying feelings of emptiness; seeks to redeem actions and self-presentations with expressions of contrition and self-punitive behaviours).  Split Morphologic Organization: inner structures are sharply segmented and conflicted, with a lack of consistency among them; levels of consciousness often shift and result in rapid movements across boundaries, memories, and affects, often resulting in transient, stress-related psychotic episodes).

20 Paranoid Personality Disorder  Inviolable Self-Image: persistent ideas of self-importance and self-reference; perceives attacks on one's character not apparent to others (innocuous actions/events are derogatory); pride-fully independent & reluctant to confide in others; intense fears of losing identity, status and powers of self-determination.  Irascible Mood-Temperament: cold, sullen, churlish and humourless demeanour; attempts to appear unemotional and objective, but is edgy, envious, jealous, quick to take personal offense and react angrily.  Interpersonally Provocative: bears grudges and is unforgiving of those of the past; displays a quarrelsome, fractious and abrasive attitude with recent acquaintances; precipitates exasperation/anger by testing loyalties and an intrusive and searching preoccupation with hidden motives.  Mistrustful Cognitive Style: unwarrantedly sceptical and cynical of the motives of others; construes innocuous events as signifying hidden or conspiratorial intent; reads hidden meanings into benign matters; magnifies minor difficulties into proofs of duplicity (notably fidelity/trustworthiness of intimate).  Expressively Defensive: vigilantly guarded, alert to anticipate and ward off expected derogation, malice, and deception; is tenacious and resistant to sources of external influence/control.  Projection Mechanism: actively disowns undesirable personal traits and motives - attributing them to others; blind to one's own unattractive behaviours and characteristics, yet is over-alert and hypercritical of similar features in others.

21 Narcissistic Personality Disorder  Rationalization Regulatory Mechanism: is self-deceptive & facile in devising plausible reasons to justify self-centered and socially inconsiderate behaviours; offers alibis to place oneself in the best possible light, despite evident shortcomings and failures.  Contrived Object-Relations: internalized representations are composed of generally illusory and changing memories of past relationships; unacceptable drives and conflicts are readily refashioned, and/or simulated.  Expressively Haughty: acts in an arrogant, pompous & disdainful manner; flouts conventional rules of shared social living, viewing them as naive or inapplicable to oneself; reveals a careless disregard for personal integrity and a self-important indifference to the rights of others).  Admirable Self-Image: is meritorious, special, & unique; deserving of great admiration; acts in a grandiose/self-assured manner, often without commensurate achievements; sense of high self-worth, despite being seen by others as egotistic, inconsiderate, and arrogant.  Interpersonally Exploitive: feels entitled; is unempathic; expects favours without reciprocal responsibilities; shamelessly takes others for granted & uses to enhance self/indulge desires.  Expansive Cognitive Style: undisciplined imagination & exhibits preoccupation with immature & self-glorifying fantasies of success, beauty or love; minimally constrained by objective reality, takes liberties with facts & lies to redeem self-illusions.

22 Antisocial Personality Disorder  Expressively Impulsive: impetuous and irrepressible; acts hastily and spontaneously in a restless, spur-of-the-moment manner; short-sighted, incautious and imprudent, failing to plan ahead or consider alternatives or heed consequences.  Acting-Out Mechanism: inner tension accrued by postponing the expression offensive thoughts and actions go unconstrained; socially unacceptable impulses are discharged in precipitous ways, usually without guilt or remorse.  Interpersonally Irresponsible: is untrustworthy/unreliable; fails to meet/intentionally negating personal obligations of a marital, parental, employment or financial nature; actively intrudes upon/violates the rights of others; transgresses social codes through deceitful or illegal behaviours.  Autonomous Self-Image: unfettered by the restrictions of social customs & constraints of personal loyalties; values the image and enjoys the sense of being free, unencumbered and unconfined by persons, places, obligations or routines.  Deviant Cognitive Style: construes events & relationships according to socially unorthodox beliefs & morals; disdainful of traditional ideals and is contemptuous of conventional values. Adulthood: Criminal behaviour Little adherence to societal norms Little anxiety Conflicts with others Callous/exploitive Lie, cheat, steal Lack of conscience Carless with money

23 Disordered Personality Facets Negative Affectivity Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behaviour. Detachment Suspiciousness: Expectations of (and sensitivity to) signs of interpersonal ill- intent or harm; doubts about loyalty and fidelity of others; feelings of being mistreated, used, and/or persecuted by other. Intimacy Avoidance: Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships. Psychoticism Unusual beliefs and experiences: Beliefs that one has unusual abilities and unusual experiences of reality, including hallucination-like experiences. Antagonism Grandiosity: Believing that one is superior to others and deserves special treatment; self-centeredness; feelings of entitlement. Attention Seeking: Engaging in behaviours designed to attract notice and make oneself the focus of others’ attention.

24 Self-Perpetuating Cycles Situations that promote the anxieties of attachment, expectations of sadistic treatment, or the loss of self-determination result in defensive vigilance, withdrawal, & ultimately in the delusions characteristic of his personality structure:  Countering Separation: While he wishes to gain approval and affection, he is principally concerned with preventing further loss. Unable to quiet there misconstrued fears they often resort to demanding, aggressive. (B)  Countering Attachment: He has learnt to keep a distance from others and remain strong and vigilant; both as a protective stance and as a means of vindication and triumph over possible attackers. To assure security he engages in a variety of measures both to prevent the weakening of his resolve and to generate new powers for controlling others. (P)  Lack of Self-Control: Operating outside objective fact and the boundaries/customs of social living, he takes liberties with rules and reality, prevaricating and fantasising at will. He may lose touch with reality, and think along peculiar & deviant lines. (N)

25 Self-Perpetuating Cycles  Illusion of Competence: Believing that the presumption of superiority will suffice as his proof, he sees little reason to waste effort acquiring the virtue of admiration. Rather than face genuine challenges, he may temporise and boast; retaining the illusion of superiority. An unfounded sense of confidence in perfection inhibits his aptitude development. The strain of this false self-image may see him succumb to depression, paranoid irritabilities and delusions. (N)  Redemption Through Self-Derogation: Attempting to avoid counter-hostility that might bring rejection and abandonment, he must reproach. Hostile and aggressive urges become self-directed and he experiences exaggerated feelings of quilt and worthlessness. (B)  Restructuring Reality: He generally transforms events to suit his self-image and aspirations, with delusions being an extreme form of reality reconstruction. Denial of weakness and malevolence (and its projection onto other) & self-aggrandisement through grandiose fantasies result in a loosening of the reality-fantasy boundary. (P)

26 Self-Perpetuating Cycles  Distrustful Anticipations: With a clear strategy: “I cannot trust others; they will abuse and exploit their power, they will be indifferent to my needs, strip me of all gratifications, and brutalise me if they can.” Only through self-sufficiency and decisiveness can he forestall the indifference & dangers of his environment. (A)  Social Alienation: Thinking of other as naive, simpleminded and untrustworthy leads to the minimal questioning of one’s correctness/beliefs; as others are deemed at fault. Recurrent disagreements bolster a sense of superiority, with a detachment from objective reality making it difficult to grasp why he may be rebuffed or misunderstood. (N)  Discharging Hostility: With a hollow-shelled confidence and pride, his pose of independence is on an insecure footing. He is extremely vulnerable to challenge and his defensive facade is constantly weakened by real & delusional threats. Hostility is used to reassert power and invincibility, counteract threats, & shore up defences. (P)

27 Engagement Strategies/Traps Often complicated by a suspicious and distrustful nature, which guards against revealing emotional and interpersonal difficulties. Aim to resist being intimidated by arrogant and demeaning comments; as weakness is not tolerated in those that he places his trust in. Excessive friendliness and overt sympathies can often connote deceit. Questioning him directly about distorted attitudes/beliefs will intensify distrust, destroy rapport, and unleash a barrage of defensive hostility. Challenging self-confidence and his image of autonomy/strength risks destabilising a fragile equilibrium. Maintain ‘distance’ & resist personal exploration = indigence of perceived deficiencies Avoid situations whereby he seeks to outwit or attempt to assert dominance. Sarcasm, devaluation, & domination is often a ‘test’; reciprocation results in distrust. Limiting setting without invoking an accusatory or attacking stance is invaluable. Patience & equanimity can help establish a spirit of genuine confidence and respect. Avoid implicit requests to side with his opinions that identified problems are largely a result of imperfections and weaknesses of others.

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