Chapter 13 Personality Disorders Ch 13

Personality Disorders refer to long-standing, pervasive and inflexible patterns of behavior –Depart from cultural expectations –Impair social and occupational functioning –Cause emotional distress Personality disorders are coded on Axis II of the DSM –Personality disorders can be a co-morbid condition for an Axis I disorder Personality Disorders Ch 13.1

Personality Disorders: Facts and Statistics Prevalence of Personality Disorders –About 0.5% to 2.5% of the general population –Rates are higher in inpatient and outpatient settings Origins and Course of Personality Disorders –Thought to begin in childhood –Tend to run a chronic course if untreated Co-Morbidity Rates are High Gender Distribution and Gender Bias in Diagnosis –Gender bias exists in the diagnosis of personality disorders –Such bias may be a result of criterion or assessment gender bias

Personality disorders fall into three general clusters: –Persons in cluster A seem odd or eccentric Paranoid, schizoid, schizotypal –Persons in cluster B seem dramatic, emotional or erratic Antisocial, borderline, histrionic, narcissistic –Persons in cluster C appear as anxious or fearful Avoidant, dependent, obsessive-compulsive Personality Disorder Clusters Ch 13.2

Odd/Eccentric Cluster Paranoid personality disorder (PD) involves suspicion of others, hostility, jealousy –No hallucinations and no full-blown delusions are present in paranoid PD Paranoid PD occurs more frequently in men than in women Lifetime prevalence is about 1 percent Ch 13.3

Schizoid personality disorder (PD) involves –Reduced social relations and few friends –Reduced sexual desire and few pleasurable activities –Indifference to praise or criticism –Lonely life style Prevalence of schizoid PD is less than 1 percent and occurs more commonly in men than women Odd/Eccentric Cluster Ch 13.4

Schizotypal personality disorder (PD) involves –An attenuated form of schizophrenia Odd beliefs and magical thinking Recurrent illusions (things not present) Ideas of reference (hidden meaning) Behavior and appearance is eccentric Prevalence of schizotypal PD is about 3 percent and occurs slightly more commonly in men than women Odd/Eccentric Cluster Ch 13.5

Etiology of the Odd/Eccentric Cluster These disorders are linked to schizophrenia and may represent a less severe form of the disorder –Schizophrenia has clear genetic determinants –Family studies reveal that relatives of schizophrenic patients are at increased risk for developing schizotypal PD as well as paranoid PD No clear pattern for schizoid PD Additional similarities for Schizotypal PD –Have cognitive and neuropsychological problems similar to those found in individuals with schizophrenia. –Have enlarged ventricles and less temporal lobe gray matter. Ch 13.6

Borderline personality disorder (PD) involves –Impulsivity (gambling, spending, sexual sprees) –Instability in relationships, mood and self-image –Borderline PD persons are argumentative and difficult to live with Prevalence of Borderline PD is about 1-2 percent and occurs more commonly in women than men Linehan’s diathesis-stress theory –Difficulty controlling emotions (biological diathesis) –Raised in “invalidating” family environment Dramatic/Erratic Cluster Ch 13.7

Figure 13.1 Linehan’s Diathesis-Stress theory: Etiology of borderline personality disorder Emotional dysregulation in child (diathesis) and a failure to validate the child’s feelings by the parents (stress) leads to a vicious cycle. –The emotional dysregulation may be inadvertently reinforced by parents if it becomes one of the only times the child receives parental attention.

>Borderline Personality Disorder >Unstable Relationships –Avoid Abandonment >Poor Self-Image –Mood Swings, Feel Empty >Impulsivity –Substance Abuse, Sex, Suicidality >Unstable Relationships –Avoid Abandonment >Poor Self-Image –Mood Swings, Feel Empty >Impulsivity –Substance Abuse, Sex, Suicidality

>Borderline Personality Disorder >Causes –Runs in Families –Connection With Mood Disorders –Contribution of Early Abuse >Causes –Runs in Families –Connection With Mood Disorders –Contribution of Early Abuse

>Borderline Personality Disorder >Treatment –Few Controlled Studies –Dialectical Behavior Therapy (DBT) –Medications Antidepressants, Mood Stabilizers, Antipsychotics Antidepressants, Mood Stabilizers, Antipsychotics >Treatment –Few Controlled Studies –Dialectical Behavior Therapy (DBT) –Medications Antidepressants, Mood Stabilizers, Antipsychotics Antidepressants, Mood Stabilizers, Antipsychotics

Histrionic personality disorder (PD) involves –People who are overly dramatic and attention seeking –People who exhibit emotional displays but are emotionally shallow –People who are self-centered and overly concerned about physical attractiveness Prevalence of histrionic PD is about 2-3 percent and occurs slightly more commonly in women than men Dramatic/Erratic Cluster Ch 13.8

Narcissistic personality disorder (PD) involves –A grandiose view of the person’s own importance –A strong sense of entitlement –A lack of empathy for others Prevalence of narcissistic PD is less than 1 percent and this disorder co-occurs with borderline PD Dramatic/Erratic Cluster Ch 13.9

Antisocial personality disorder (PD) involves –The presence of conduct disorder before the age of fifteen Conduct disorder includes truancy, lying, theft, arson, running away from home and destruction of property –The continuation of these behaviors into adulthood Prevalence of antisocial PD is about 3% of men and 1 % of women Dramatic/Erratic Cluster Ch 13.10

Etiology of Antisocial PD Family issues may play a role in the development of antisocial PD –Lack of affection –Severe parental rejection –Inconsistent (or no) discipline Twin studies show a greater concordance for antisocial PD in MZ twins relative to DZ twins Adoption studies (e.g., Cadoret et al., 1995) –Adverse adoptive environment may be the stressor triggering the ASPD biological diathesis Psychopaths –Have reduced gray matter in frontal lobes –Perform more poorly on tests of frontal lobe functioning –These findings are supportive of a key role for impulsivity in psychopathy Ch 13.11

Cluster B: Antisocial Personality Disorder Figure 12.2 Barlow/Durand, 3rd. Edition Overlap and lack of overlap among antisocial personality disorder, psychopathy, and criminality

Cluster B: Antisocial Personality Disorder (cont.) Figure 12.3 Barlow/Durand, 3rd. Edition Lifetime course of criminal behavior in psychopaths and non-psychopaths

Fig 13.2 Figure 13.2 Skin-conductance responses of psychopathic and non-psychopathic men. Psychopathic men's response to distress stimuli is evidence of a lack of empathy

>Antisocial Personality Disorder >Neurobiological Influences –Underarousal Hypothesis Low Corical Arousal or “Tuning it Out”? Low Corical Arousal or “Tuning it Out”? –Fearlessness Hypothesis Fail to Show Normal Fear Fail to Avoid Punishment >Neurobiological Influences –Underarousal Hypothesis Low Corical Arousal or “Tuning it Out”? Low Corical Arousal or “Tuning it Out”? –Fearlessness Hypothesis Fail to Show Normal Fear Fail to Avoid Punishment

>Antisocial Personality Disorder >Treatment –Many Do Not Seek Treatment –Poor Prognosis –Focus on Prevention >Treatment –Many Do Not Seek Treatment –Poor Prognosis –Focus on Prevention

Avoidant personality disorder (PD) involves –People who are fearful in social situations –People who are keenly sensitive to criticism, rejection or disapproval –People whose lives and job are restricted by their fear of negative interactions Prevalence of Avoidant PD is about 1 percent and this disorder is co-morbid with dependent PD and borderline PD Anxious/Fearful Cluster Ch 13.12

>Avoidant Personality Disorder >Treatment –Several Well Controlled Studies –Target Anxiety and Social Skills –Treatment Similar to Social Phobia Systematic Desensitization Behavioral Rehearsal >Treatment –Several Well Controlled Studies –Target Anxiety and Social Skills –Treatment Similar to Social Phobia Systematic Desensitization Behavioral Rehearsal

Dependent personality disorder (PD) involves –A lack of self confidence –A lack of a sense of autonomy –A view that others are powerful while they are weak Prevalence of Dependent PD is about 1.5 percent and occurs slightly more commonly in women than men –May be related to insecure “anxious” attachment Anxious/Fearful Cluster Ch 13.13

Obsessive-Compulsive personality disorder (PD) involves a person who –Is a perfectionist, but who does not complete projects –Is a ‘control freak” who must have their own way Prevalence of Obsessive-Compulsive PD is about 1 percent and this disorder is co-morbid with avoidant PD Anxious/Fearful Cluster Ch 13.14

>Dimensional vs. Categorical –Problem of Degree? –Problem of Kind? >DSM-IV –Categorical View –Axis II –Ten Types >Dimensional vs. Categorical –Problem of Degree? –Problem of Kind? >DSM-IV –Categorical View –Axis II –Ten Types

Dimensional Approach to Personality Disorders Five-Factor Model (McRae & Costa, 1990) –Neuroticism –Extroversion/introversion –Openness to experience –Agreeableness/antagonism –Conscientiousness Relationship of PDs to FFM (Widiger & Costa, 1994) Advantages of dimensional model –Handles the comorbidity problem –Makes a link between normal and abnormal personality –Supported by behavior-genetic and statistical techniques

Therapies for Personality Disorders Therapists treating PD patients are concerned about co- morbid Axis I disorders Therapy modalities include: –Antianxiety or antidepressant drugs –Psychodynamic therapy aims to change the person’s understanding of the childhood problems that underlie the PD –Behavioral and cognitive therapy focuses on specific symptoms and issues (e.g. social skills) Overall therapeutic goal: change the “disorder’ into a “style”, except for ASPD (D&N, p.377) –Recent meta-analysis show promising results with CBT for younger psychopaths. Ch 13.15