1. Personality Disorders in DSM-5 Timothy C. Thomason Northern Arizona University

2. Definitions Personality: Enduring patterns of perceiving, relating to, and thinking about the environment and oneself. Personality traits: Prominent aspects of personality that are exhibited in relatively consistent ways across time and across situations. Impairments in personality trait expression may reflect the presence of a personality disorder.

3. Personality Disorder: an enduring pattern of inner experience and behavior 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.

4. General Personality Disorder A. An enduring pattern that deviates from the expectations of the individual’s culture 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 situations. C. The enduring pattern leads to clinically significant distress or impairment. p. 646

5. GPD, cont. D. The pattern is stable and of long duration. E.The pattern is not better explained as a manifestation of another mental disorder. F.The pattern is not attributable to the effects of a substance or another medical condition.

6. Re. GPD, the DSM-5 Notes That: It is often necessary to conduct more than one interview with the individual to make a diagnosis. The characteristics that define a personality disorder may not be considered problematic by the individual (i.e., the traits are often ego- syntonic). Supplementary information from other informants may be helpful.

7. Culture Judgments about personality functioning must take into account the individual’s ethnic, cultural, and social background. It may be necessary to obtain additional information from informants who are familiar with the person’s cultural background.

8. Gender PDs diagnosed more often in males: Antisocial PD PDs diagnosed more often in females: Borderline PD, Histrionic PD, Dependent PD Social stereotypes about typical gender roles and behaviors should not influence the diagnosis of personality disorders.

9. Differential Diagnosis Some personality disorders may have a “spectrum” relationship to other mental disorders. E.g., Schizotypal PD with schizophrenia E.g., Avoidant PD with social anxiety disorder

10. Personality disorders must be distinguished from personality traits that do not reach the threshold for a personality disorder. Personality traits are diagnosed as a personality disorder only when they are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress.

11. Cluster A Personality Disorders Paranoid Schizoid Schizotypal

12. Cluster B Personality Disorders Antisocial Borderline Histrionic Narcissistic

13. Cluster C Personality Disorders Avoidant Dependent Obsessive-Compulsive

14. Other Personality Disorders Personality Change Due to Another Medical Condition E.g. Brain cancer; head trauma; CVA disease; epilepsy, autoimmune conditions, etc. Other Specified Personality Disorder Give the reason the PD does not fit the other criteria (e.g., “mixed personality features”). Unspecified Personality Disorder – E.g., due to insufficient information

15. Paranoid Personality Disorder Distrust Suspiciousness The motives of others are interpreted as malevolent Preoccupied with doubts about the loyalty of friends Reads hidden meanings into benign remarks Etc.

16. Schizoid Personality Disorder Detachment from social relationships Restricted range of expression of emotions Neither desires nor enjoys close relationships Almost always chooses solitary activities Little interest in having sexual relationships Takes pleasure in few activities Emotionally cold and detached

17. Schizotypal Personality Disorder Acute discomfort with close relationships Cognitive or perceptual distortions Eccentricities of behavior Ideas of reference Odd beliefs or magical thinking inconsistent with subcultural norms (e.g., superstitious; belief in telepathy; bizarre fantasies). Odd thinking and speech Etc.

18. Antisocial Personality Disorder Disregard for and violation of the rights of others Repeated acts that are grounds for arrest Deceitfulness, lying, conning others Impulsivity Irritability and aggressiveness (e.g. fights) Reckless disregard for safety of self or others

19. Antisocial P. D., cont. Consistent irresponsibility (e.g. failure to sustain work behavior or pay bills) Lack of remorse (indifferent to having hurt or mistreated another person) The person must be at least 18 years old. There is evidence of conduct disorder with onset before age 15 years.

20. Antisocial P. D., cont. This pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder. Prevalence is up to about 3% in the general population. Prevalence is about 70% among severe samples of males with alcohol use disorders and samples from prisons.

21. Antisocial P. D. Antisocial personality disorder must be distinguished from criminal behavior undertaken for gain that is not accompanied by the personality features characteristic of this disorder.

22. Borderline Personality Disorder Instability of interpersonal relationships, self- image, and affects Marked impulsivity Frantic efforts to avoid abandonment Unstable self-image or sense of self Self-damaging impulsivity (e.g., spending, sex, substance abuse, reckless driving)

23. Borderline P. D., cont. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior Affective instability due to reactivity of mood Chronic feelings of emptiness Inappropriate, intense anger Transient paranoid ideation or severe dissociative symptoms

24. Histrionic Personality Disorder Excessive emotionality and attention seeking Uncomfortable when not the center of attention Inappropriate sexually provocative behavior Shifting and shallow expression of emotions Uses physical appearance to draw attention Shows self-dramatization, theatricality, and exaggerated expression of emotion

25. Narcissistic Personality Disorder Grandiosity in fantasy or behavior Need for admiration Lack of empathy Grandiose sense of self-importance Preoccupied with fantasies of success, power Believes he or she is special and unique Requires excessive admiration Has a sense of entitlement

26. Avoidant Personality Disorder Social inhibition Feelings of inadequacy Hypersensitivity to negative evaluation Fears criticism, disapproval, or rejection Is inhibited in new social situations Views self as socially inept or inferior to others Reluctant to engage in new activities due to fear they may prove embarrassing

27. Dependent Personality Disorder Need to be taken care of Submissive and clinging behavior Fear of separation Has difficulty making everyday decisions without excessive advice and reassurance Needs others to assume responsibility for most major areas of his or her life Goes to excessive lengths to obtain support

28. Obsessive-Compulsive P.D. Preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency Preoccupied with details, rules, and order to the extent that the point of the activity is lost Perfectionistic traits that interfere with task completion

29. O.-C. P. D., cont. Obsessively devoted to work and productivity to the exclusion of leisure activities and friendships Over-conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)

30. DSM-5 Personality Assessments Personality Inventory for DSM-5 - Brief Form 25 items on one page 0 - 1 - 2 - 3 scale (false to true) for each item E.g. “People would describe me as reckless.” Personality Inventory for DSM-5 220 items on six pages Available at www.psychiatry.org/dsm5www.psychiatry.org/dsm5 See “Online Assessment Measures”

31. Alternative DSM-5 Model for Personality Disorders A hybrid of the categorical approach and a new dimensional approach to personality. Personality types, traits, and disorders are on a continuous spectrum (like blood pressure and hypertension). Too much of a useful, adaptive trait may become a problem. The alternative model is in section III (Emerging Measures and Models), p. 761

32. Alternative Model, cont. In the alternative model, personality disorders are characterized by impairments in personality functioning and pathological personality traits. This model includes diagnoses for six personality disorders: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal.

33. General Criteria for P. D. A. Moderate or greater impairment in personality functioning. B.One or more pathological personality traits. C.The impairments are inflexible and pervasive. D.The impairments are stable across time. E.The impairments are not due to another mental disorder, a substance, or another medical condition.

34. Criterion A: Level of Personality Functioning Two elements of personality functioning: Self – Identity (stability of self; accuracy of self-appraisal, capacity for a range of emotions) – Self-direction (pursuit of coherent life goals) Interpersonal – Empathy (appreciating others’ experiences) – Intimacy (depth of connection with others)

35. Criterion B: Pathological Personality Traits Five broad trait domains – Negative affectivity – Detachment – Antagonism – Disinhibition – Psychoticism 25 specific trait facets The B criteria for the six P. D.s comprise subsets of the 25 trait facets.

36. Structure of Criteria for Six P. D.s Proposed diagnostic criteria A. Impairment in personality functioning manifested by difficulties in two or more of: Identity Self direction Empathy intimacy B. Six or more of the following traits: [each disorder has a subset of the 25 trait facets]

37. Example: Antisocial P. D. A. Impairment in personality functioning; two or more of the following: – Identity: egocentrism – Self-direction: goal setting based on personal gratification, failure to conform to lawful behavior – Empathy: lack of concern for others – Intimacy: incapacity for mutually intimate relationships; exploitation of others; use of deceit, coercion, dominance, or intimidation

38. Example of Antisocial P. D., cont. B. Six or more of the following traits: manipulativeness Callousness Deceitfulness Hostility Risk taking Impulsivity Irresponsibility

39. Example of Antisocial P. D., cont. Specify if: With psychopathic features Psychopathy is marked by a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviors. It is characterized by low anxiousness, withdrawal, and attention seeking.

40. Level of Personality Functioning Scale This scale has descriptors for five levels of impairment (from 0 to 5) in the areas of Identity, Self-direction, Empathy, and Intimacy. See DSM-5 pages 775-778.

41. Definitions of DSM-5 Personality Disorder Trait Domains and Facets This scale defines the trait facets within the five trait domains. See DSM-5 pages 779-781.