What is personality disorder? Empowering you with the language and concepts

Personality We all have one. It makes us unique. It shapes how we understand and interact with the world

3 P’s Pattern of relating to self, other and the world that deviates from cultural norm. Pattern of relating to self, other and the world that deviates from cultural norm % prisoners believed to meet criteria for one or more PD % prisoners believed to meet criteria for one or more PD. 10% of people in the community would meet criteria for PD. 10% of people in the community would meet criteria for PD. A helpful way of thinking about PD relates to the 3 P’s A helpful way of thinking about PD relates to the 3 P’s – happens frequently P ersistent – happens frequently P ervasive – across different circumstances P roblematic – and cause problems for themselves and others

Immune system metaphor Millon (2004) Robust immune system responds constructively & appropriately to our environment. PD = system that interacts with the environment Personality = Psychological equivalent of body’s immune system Rigidity in strategies + Others reactions = Repeated bad one-act play

PD Diagnosis Labelling and the Disease model

Classification into PD types Akin to diagnosing a disease that you either have or don’t have Categories based on “pure” prototype. Assumes each personality disorder is distinct

Diagnostic systems DSM IV-TR ParanoidSchizoidSchizotypalAntisocialBorderlineHistrionicNarcissisticAvoidantDependent Obsessive Compulsive Not Otherwise Specified ICD-10ParanoidSchizoidDissocial Emotionally unstable HistrionicAnankasticAnxiousDependent Other specific PD Unspecified PD Mixed and other PD

DSM Clusters Cluster A Odd / Ecentric Cluster B Dramatic / Erratic Cluster C Anxious / Fearful

Character Assassination Schizoid Schizotypal Borderline Histrionic Antisocial/ Psychopathy

Pros and Cons of Types Facilitates communication by the use familiar language between professionals. It’s best we’ve got at the moment. Enables quick signposting to services Rarely find “pure types” in real life. People are individuals. BPD = 5 of 9 criteria = potentially only 1 symptom overlap. Lack of empathic understanding of the origins and maintenance of the problem which is central to therapy. Stigma facilitates reactions in others which perpetuates the problem (eg. verbal attack driven by paranoid interpretation is met by defensiveness, which further creates suspicion in the individual).

Dimensions of personality The direction to be taken in DSM-V?

Dimensional perspective 1) Personality represented by severity of traits rather than distinct categories. 2) Or, ASPD variations = Normal variation: Adventurer, Independent, Courageous Pathological variation Callous, Lacking conscience Breaks rules Impulsive

‘Normal’ continua of Antisocial Normal variation Adventurer, lives life on the edge, pioneers, risk-takers, courageous and tough. Slight pathological normal variation Does things own way, flirts with legal boundaries, dislikes daily routine, action-oriented, independent thinkers, confrontational and masterful leaders. Cusp No forensic history but only due to being good at covering their tracks, will deceive and exploit by minimising negatives and exaggerating positives but not physically cruel, industrialists, exploit legal technicalities and loopholes for personal gain, “smooth-talking businessman”, “dodgy used-car salesman”.

‘Normal’ continua of Paranoid Normal variation Highly independent, value their freedom, sensitive to issues of power, authority and domination. Cautious and reserved with others and enter relationships only after careful consideration. Touchy, but not intimidated, when given criticism Paranoid “style” Distant from others, places premium on honesty and loyalty. Plays cards closely to chest with acquaintances. Attuned to subtleties and nuances of communication at many levels. Skeptical.

Dimensions of personality Five Factor Model (Costa & McCrae, 1992) - five dimension (primary traits): Five Factor Model (Costa & McCrae, 1992) - five dimension (primary traits): O penness to experience vs tradition/convention a general appreciation for art, emotion, adventure, unusual ideas, imagination, curiosity, and variety of experience C onscientiousness vs negligence tendency to show self-discipline, act dutifully, and aim for achievement. Preference for planned rather than spontaneous behaviour E xtraversion vs introversion characterized by positive emotions A greeableness vs antagonistic tendency to be compassionate and cooperative rather than suspicious and antagonistic towards others O penness to experience vs tradition/convention a general appreciation for art, emotion, adventure, unusual ideas, imagination, curiosity, and variety of experience C onscientiousness vs negligence tendency to show self-discipline, act dutifully, and aim for achievement. Preference for planned rather than spontaneous behaviour E xtraversion vs introversion characterized by positive emotions engagement with the external world enthusiastic, action-oriented individuals A greeableness vs antagonistic tendency to be compassionate and cooperative rather than suspicious and antagonistic towards others N euroticism vs emotional stability emotionally reactive and vulnerable to stress

DAPP (Livesley & Jackson 2009) Cluster labelContributing dimensions Emotional dysregulation Affective labilityAnxiousness Cognitive dysregulationIdentity problems Insecure attachmentOppositionality Submissiveness Dissocial Behaviour Conduct problemsCallousness NarcissismRejection Stimulus seeking Social Avoidance Intimacy problemsLow affiliation Restrictive expression CompulsivenessCompulsivity

Pros and Cons of Dimensions Research gives greater support to the dimensional view of personality Engenders a more compassionate understanding of personality Diagnostic types can be translated into dimensions No consensus about nature and number of dimensions More complex picture of personality = more difficult to comprehend and communicate to other clinicians