1. Chapter 12 Personality Disorders
Chapter 12 Personality Disorders

2. 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:

3. 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

4. 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).

5. 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:

6. 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.

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

8. 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

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

10. 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.

11. 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.

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

13. 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

14. 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.
Teaching Tip: The film Taxi Driver provides a depiction of features of this disorder.

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

16. 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

17. 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.

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

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

20. 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.
Teaching Tip: The films A Clockwork Orange, Fight Club, Apocalypse Now, and American Psycho provide depictions of this disorder.

21. 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:

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

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

24. 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

25. 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

26. 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)

27. 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

28. 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

29. 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.
Teaching Tip: The films Fatal Attraction and The Hand that Rocks the Cradle provide depictions of features of this disorder.

30. 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

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

32. 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.
Technology Tip: Visit Dr. Linehan’s University of Washington website for more information on DBT and BPD:
Technology Tip: Also visit Dr. Linehan’s other site for more information:

33. 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.

34. 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.

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

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

37. 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.

38. 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.

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

40. 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.

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

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

43. 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.

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

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

46. 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.

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

48. 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

49. 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