Chapter 12 Personality Disorders Chapter 12 Personality Disorders

Personality Disorders: An Overview Enduring and pervasive predispositions Perceiving Relating Thinking Inflexible and maladaptive Distress Impairment Coded on Axis II Distress – individual with disorder may not be distressed, but others may be (i.e., antisocial) Technology Tip: Check out the Mental Help Net's site devoted to personality disorders: http://personalitydisorders.mentalhelp.net/

Personality Disorders 10 specific personality disorders Several under review for DSM-V 3 clusters High comorbidity with Axis I disorders Poorer prognosis Therapist reactions Countertransference Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: Identifying Personality Disorders

Personality Disorders: An Overview Categorical vs. Dimensional Views “Kind” vs. “Degree” DSM is categorical Reifies concepts Less flexible Loss of individual information Sometimes arbitrary Kind – different way of relating compared to healthy individuals Degree – extreme versions of normal personality variations Technology Tip: The following Personality Disorder Foundation site provides useful information about personality disorders (e.g., description, diagnosis, impact, educational resources, treatment). http://counsellingresource.com/distress/personality-disorders/foundation/index.html

Personality Disorders: An Overview Five factor model of personality (“Big Five”) Openness to experience Conscientiousness Extraversion Agreeableness Emotional stability Technology Tip: Visit the Srivastava Lab website on the Big Five, hosted by the University of Oregon: http://darkwing.uoregon.edu/~sanjay/bigfive.html

DSM Personality Disorder Clusters Cluster A Odd or eccentric Paranoid, schizoid, schizotypal Cluster B Dramatic, emotional, erratic Antisocial, borderline, histrionic, narcissistic Cluster C Fearful or anxious Avoidant, dependent, obsessive-compulsive Technology Tip: Visit The International Society for the Study of Personality Disorders (ISSPD) website for more information on personality disorders including research, diagnosis, course, and treatment. http://www.isspd.com/

Personality Disorders: Facts and Statistics Prevalence = 0.5 - 2.5%, may be closer to 10% Outpatient = 2 - 10% Inpatient = 10 – 30% Origins and Course Begin in childhood Chronic course High comorbidity

Personality Disorders: Gender Differences Differences in diagnostic rates Borderline (75% female) Clinician bias Assessment bias Measures Criterion bias Histrionic = extreme “stereotypical female” No “macho” disorder Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: Gender Bias and "Normal" Behavior

Personality Disorders: Gender Differences Figure 12.1 Gender bias in diagnosing personality disorders

Personality Disorders Under Study Individual disorders Sadistic Self-defeating Categories of disorders Depressive Negativistic Passive aggressive Negativistic- expansion of former DSM IIIR Passive aggressive PD and may be a subtype of narcissistic PD.

Cluster A: Paranoid Personality Disorder Clinical Description Mistrust and suspicion Pervasive Unjustified Few meaningful relationships Volatile Tense Sensitive to criticism Technology Tip: Paranoid Personality Disorder This web site (part of internet mental health) is devoted to information pertaining to the diagnosis, etiology, and treatment of paranoid personality disorder. http://www.mentalhealth.com/dis/p20-pe01.html

Cluster A: Paranoid Personality Disorder Causes Possible relationship to schizophrenia Possible role of early experience Trauma Abuse Learning “World is dangerous”

Cluster A: Paranoid Personality Disorder Treatment Unlikely to seek on own Crisis Focus on developing trust Cognitive therapy Assumptions Negative beliefs No empirically-supported treatments

Cluster A: Schizoid Personality Disorder Clinical Description Appear to neither enjoy nor desire relationships Limited range of emotions Appear cold, detached Appear unaffected by praise, criticism Unable or unwilling to express emotion No thought disorder Technology Tip: Schizoid Personality Disorder This web site (part of internet mental health) is devoted to information pertaining to the diagnosis, etiology, and treatment of schizoid personality disorder. http://www.mentalhealth.com/dis/p20-pe02.html Teaching Tip: The film Taxi Driver provides a depiction of features of this disorder.

Cluster A: Schizoid Personality Disorder Causes Limited research Precursor: childhood shyness Possibly related to: Abuse/neglect Autism Dopamine

Cluster A: Schizoid Personality Disorder Treatment Unlikely to seek on own Crisis Focus on relationships Social skills therapy Empathy training Role playing Social network building No empirically-supported treatments Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: Diagnose A Film Character With a Personality Disorder

Cluster A: Schizotypal Personality Disorder Clinical Description Psychotic-like symptoms Magical thinking Ideas of reference Illusions Odd and/or unusual Behavior Appearance Socially isolated Highly suspicious Technology Tip: Schizotypal Personality Disorder This web site (part of internet mental health) is devoted to information pertaining to the diagnosis, etiology, and treatment of schizotypal personality disorder. http://www.mentalhealth.com/dis/p20-pe03.html

Cluster A: Schizotypal Personality Disorder Causes Schizophrenia phenotype? Lack full biological or environmental contributions Preserved frontal lobes Cognitive impairments Left hemisphere? More generalized?

Cluster A: Schizotypal Personality Disorder Treatment Options Treatment of comorbid depression Multidimensional approach Social skill training Antipsychotic medications Community treatment

Cluster B: Antisocial Personality Disorder Clinical Description Noncompliance with social norms “Social Predators” Violate rights of others Irresponsible Impulsive Deceitful Lack a conscience, empathy, and remorse Technology Tip: Antisocial Personality Disorder This web site (part of internet mental health) is devoted to information pertaining to the diagnosis, etiology, and treatment of antisocial personality disorder. http://www.mentalhealth.com/dis/p20-pe04.html Teaching Tip: The films A Clockwork Orange, Fight Club, Apocalypse Now, and American Psycho provide depictions of this disorder.

Cluster B: Antisocial Personality Disorder Nature of psychopathy Glibness/superficial charm Grandiose sense of self-worth Proneness to boredom/need for stimulation Pathological lying Conning/manipulative Lack of remorse Overlap with ASPD, criminality Intelligence Intelligence may separate those who do and do not get in trouble with the law Technology Tip: Visit Dr. Robert Hare’s website for more information on psychopathy: http://www.hare.org/

Cluster B: Antisocial Personality Disorder Figure 12.2 Overlap and lack of overlap among antisocial personality disorder, psychopathy, and criminality.

Cluster B: Antisocial Personality Disorder Figure 12.3 Lifetime course of criminal behavior in psychopaths and nonpsychopaths (based on Hare, McPherson, & Forth, 1988).

Cluster B: Antisocial Personality Disorder Developmental considerations Early histories of behavioral problems Conduct disorder Families history of: Inconsistent parental discipline Variable support Criminality Violence Teaching Tip: Have students participate in the following Instructor Resource Manual Video Activity: The Case of George and His Antisocial Personality

Causes of Antisocial Personality Gene-environment interaction Genetic predisposition Environmental triggers Arousal hypotheses Underarousal Fearlessness Underarousal hypothesis – Cortical arousal is too low Fearlessness hypothesis – Fail to respond to danger cues

Causes of Antisocial Personality Gray’s model of brain functioning Behavioral inhibition system (BIS) Low Reward system (REW) High Fight/flight system (F/F) BIS – slow or stop behavior when threatened with punishment, associated with anxiety and fear, septohippocampal system, involves noradrenergic and serotonergic REW – approach behavior, associated with hope and relief, mesolimbic area, dopaminergic “pleasure pathway” F/F – fight or flight, associated with norepinephrine, adrenaline, lower brain stem pathways (medulla)

Causes of Antisocial Personality Interactive, integrative model Genetic vulnerability Neurotransmitters Environmental factors Family stress Reinforcement of antisocial behaviors Alienation from good role models Poor occupational/social function Neurotransmitters that influence aggressiveness, stress response

Antisocial Personality Disorder Treatment Unlikely to seek on own High recidivism Incarceration Early intervention Parent training Prevention Rewards for pro-social behaviors Skills training Improve social competence

Cluster B: Borderline Personality Disorder Clinical Description Patterns of instability Labile, intense moods Turbulent relationships Impulsivity Fear of abandonment Very poor self-image Self-mutilation Suicidal gestures Technology Tip: Borderline Personality Disorder This web site (part of internet mental health) is devoted to information pertaining to the diagnosis, etiology, and treatment of borderline personality disorder. http://www.mentalhealth.com/dis/p20-pe05.html Teaching Tip: The films Fatal Attraction and The Hand that Rocks the Cradle provide depictions of features of this disorder.

Cluster B: Borderline Personality Disorder Comorbid disorders Depression – 24-74% Suicide – 6% Bipolar – 4-20% Substance abuse – 67% Eating disorders 25% of bulimics have BPD

Cluster B: Borderline Personality Disorder Causes Genetic/biological components Serotonin Frontolimbic circuit Cognitive biases Early childhood experience Neglect Trauma Abuse

Cluster B: Borderline Personality Disorder Treatment Highly likely to seek treatment Antidepressant medications Dialectical behavior therapy Reduce “interfering” behaviors Self-harm Quality of life Outcomes Demonstrated efficacy Cortical activation changes Technology Tip: BPD Central A web site devoted to furthering the understanding of borderline disorder, written with those who live with a BPD patient in mind. http://www.BPDCentral.com/ Technology Tip: Visit Dr. Linehan’s University of Washington website for more information on DBT and BPD: http://faculty.washington.edu/linehan/ Technology Tip: Also visit Dr. Linehan’s other site for more information: http://www.behavioraltech.com/resources/whatisdbt.cfm

Cluster B: Borderline Personality Disorder Figure 12.4 The colored lines show changes in the cortical arousal to upsetting photos in the week before and days following DBT treatment for subjects who responded positively.

Cluster B: Histrionic Personality Disorder Clinical Description Overly dramatic Sensational Sexually provocative Impulsive Attention-seeking Appearance-focused Impressionistic Vague, superficial speech Common diagnosis in females Technology Tip: Histrionic Personality Disorder This web site (part of internet mental health) is devoted to information pertaining to the diagnosis, etiology, and treatment of histrionic personality disorder. http://www.mentalhealth.com/dis/p20-pe06.html

Cluster B: Histrionic Personality Disorder Causes Little research Links with antisocial personality Sex-typed alternative expression?

Cluster B: Histrionic Personality Disorder Treatment Problematic interpersonal behaviors Attention seeking Long-term consequences of behavior Little empirical support

Cluster B: Narcissistic Personality Disorder Clinical Description Exaggerated and unreasonable sense of self-importance Require attention Lack sensitivity and compassion Sensitive to criticism Envious Arrogant Technology Tip: Narcissistic Personality Disorder This web site (part of internet mental health) is devoted to information pertaining to the diagnosis, etiology, and treatment of narcissistic personality disorder. http://www.mentalhealth.com/dis/p20-pe07.html

Cluster B: Narcissistic Personality Disorder Causes Deficits in early childhood learning Altruism Empathy Sociological view Increased individual focus “Me generation” Teaching Tip: The film Magnolia provides a depiction of features of this disorder.

Cluster B: Narcissistic Personality Disorder Treatment focuses on: Grandiosity Lack of empathy Hypersensitivity to evaluation Co-occurring depression Little empirical support

Cluster C: Avoidant Personality Disorder Clinical Description Extreme sensitivity to opinions Avoid most relationships Interpersonally anxious Fearful of rejection Technology Tip: Avoidant Personality Disorder This web site (part of internet mental health) is devoted to information pertaining to the diagnosis, etiology, and treatment of avoidant personality disorder. http://www.mentalhealth.com/dis/p20-pe02.html

Cluster C: Avoidant Personality Disorder Causes Sub-schizophrenia disorder? Difficult temperament Early parental rejection Interpersonal isolation and conflict

Cluster C: Avoidant Personality Disorder Treatment Similar to social phobia Increase social skills Reduce anxiety Importance of therapeutic alliance Moderate empirical support

Cluster C: Dependent Personality Disorder Clinical Description Rely on others for major and minor decisions Unreasonable fear of abandonment Clingy Submissive Timid Passive Feelings of inadequacy Sensitivity to criticism High need for reassurance Technology Tip: Dependent Personality Disorder This web site (part of internet mental health) is devoted to information pertaining to the diagnosis, etiology, and treatment of dependent personality disorder. http://www.mentalhealth.com/dis/p20-pe09.html

Cluster C: Dependent Personality Disorder Causes Little research Early experience Death of a parent Rejection Attachment

Cluster C: Dependent Personality Disorder Treatment Limited empirical support Caution: dependence on therapist Gradual increases in: Independence Personal responsibility Confidence

Cluster C: Obsessive-Compulsive Personality Disorder Clinical Description Fixation on doing things the “right way” Rigid Perfectionistic Orderly Preoccupation with details Poor interpersonal relationships Obsessions and compulsions are rare Technology Tip: Obsessive Compulsive Personality Disorder This web site (part of internet mental health) is devoted to information pertaining to the diagnosis, etiology, and treatment of obsessive-compulsive personality disorder. http://www.mentalhealth.com/dis/p20-pe10.html

Cluster C: Obsessive-Compulsive Personality Disorder Causes Limited research Weak genetic contributions Predisposed to favor structure?

Cluster C: Obsessive-Compulsive Personality Disorder Treatment Similar to OCD Address fears related to the need for orderliness Decrease: Rumination Procrastination Feelings of inadequacy Limited efficacy data

Personality Disorders: Future Directions Completely rethinking personality disorders Dimensional models Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: Student Identification With Personality Disorder Features