PERSONALITYDISORDERS

PERSONALITY FEATURES VERSUS DISORDER

CATEGORICAL VERSUS DIMENSIONAL APPROACHES

OVERVIEW OF MAJOR DISORDERSCato Grønnerød

PSY2600

DEFINITIONS

Personality• “The enduring patterns of thinking, feeling and

reacting that define a person”

Personality Disorder• “An enduring pattern of inner experience and

behavior that deviates markedly from the expectations of the individual’s culture” (APA, 2000)

• Must fit both the general and the specific criteria for DSM diagnosis

DEFINITIONS

Personality Disorder• Pattern of deviation must be evident in two or more of

the following domains• Cognition• Emotional responses• Interpersonal functioning• Impulse control

• Pattern must be inflexible and pervasive across a broad range of personal and social situations

DEFINITIONS

Personality Disorder• Must be a source of clinically significant distress or

impairment in social, occupational or other important areas of functioning

• Must be stable and of long duration, with an onset that can be traced back to at least adolescence or early adulthood

Clinical constructs used to• understand, describe and communicate about• the complex phenomena that result when• the personality system is not functioning optimally

WAYS OF UNDERSTANDING

Categorical Classification• DSM-IV – Axis II Disorders• Cluster A: odd or eccentric behaviour

• Paranoid, schizoid, schizotypal personalities

• Cluster B: erratic, emotional and dramatic• Antisocial, borderline (unstable), histrionic and narcissistic

personalities

• Cluster C: anxiety and fearfulness• Avoidant, dependent and obsessive-compulsive

personalities

WAYS OF UNDERSTANDING

Categorical Classification• ICD-10 – F60: Specific Personality Disorders• PDM, MCMI-III: Sadistic, Masochistic, Depressive,

Passive-Aggressive

Dimensional Classification• Personality disorders are normal traits amplified to the

extreme• E.g. Five-Factor Model of Personality: neuroticism,

extraversion, openness to experience, agreeableness and conscientiousness

• Psychodynamic Diagnostic Manual (PDM)

NeuroticismVery Low

Very Extraverted

Extraversion

Openness

Agreeableness

Conscientiousness

Very Introverted

Very Low

Very Low

Very Low

Very High

Very High

Very High

Very High

WAYS OF UNDERSTANDING

AETIOLOGY

Genetic predisposition• Varies among PDs

Childhood experience• Attachment experience• Traumatic events• Family factors and dysfunction

Sociocultural and political forces• Variations between nations• More Antisocial PD in the US• Presentation of symptoms may vary

PREVALENCE Varies according to gender, social factors and type Approx. 10-14% overall Most prevalent

• Obsessive Compulsive, Avoidant, Paranoid

Least prevalent• Narcissistic, Borderline, Dependent

Most visible• Borderline, Antisocial

Assumption of stability over time, but some more than others• e.g. schizotypal > borderline

CLUSTER A: PARANOID

Pervasive distrust and suspicion of others Argumentative, tense and humourless Become preoccupied with their distrust in

others, causing relational problems Attributional style: blames other for

everything that is wrong

CLUSTER A: PARANOID

Normal trait: Suspicious, sceptical

Comorbid: anxiety, psychosis, mood disorder

CLUSTER A: SCHIZOID

Social detachment/indifference Limited emotional experience and

expression Strong fantasy life Takes pleasure in few activities Appears indifferent to praise or criticism Modest genetic link to autism

CLUSTER A: SCHIZOID

Normal trait: Retiring, introvert Subclinical: asocial

CLUSTER A: SCHIZOTYPAL

Cognitive and perceptual distortions• Derealisation and depersonalization• Suspicion, magical thinking, illusions

Eccentric behaviour Discomfort with close relationships Not serious enough to warrant a

schizophrenia diagnosis Genetically related to schizophrenia

CLUSTER A: SCHIZOTYPAL

Normal trait: Eccentric Extreme: Schizophrenia?

CLUSTER B: NARCISSISTIC

Grandiosity, inflated sense of self-importance

Need for attention, lack of empathy Fragile, unstable self image

CLUSTER B: NARCISSISTIC

Normal trait: Confident Subclinical: Egoistic Examples: Capote, American Beauty

CLUSTER B: ANTISOCIAL

Disregard for and violation of (the rights of) others

Includes sociopaths and psychopaths Emotional detachment Antisocial life style Charming and even charismatic

CLUSTER B: ANTISOCIAL

Normal trait: Nonconforming Subclinical: Grandiose, conning Examples:Reservoir Dogs, Silence of the

Lamb, Wall Street

CLUSTER B: BORDERLINE

Instability of interpersonal relationships, self-image, emotions, and control over impulses

Frantic efforts to avoid real or imagined abandonment

“Borrowing” identity from others High comorbidity with other disorders

CLUSTER B: BORDERLINE

Normal trait: Capricious (NO: lunefull) Extreme: biploar? Example: Fatal Attraction

CLUSTER B: HISTRIONIC/DRAMATIZING

Excessive emotionality and attention-seeking

Superficial charm, viewed as shallow Demanding, inconsiderate and egocentric in

relationships Some overlap with Antisocial PD Less severe form of Borderline PD?

CLUSTER B: HISTRIONIC/DRAMATIZING

Normal trait: Sociable Subclinical: affect ridden (NO: affektert) Example: Being Julia

CLUSTER C: AVOIDANT

Social withdrawal Feelings of inadequacy, low self-esteem Hypersensitive to criticism, disapproval or

rejection Overlap with social phobia Normal trait: shy Subclinical: withdrawn

CLUSTER C: DEPENDENT

Excessive need to be taken care of Clinging and submissive behaviour Relies on others for important decisions Will often tolerate abuse Subtypes

• Attachment/abandonment• Dependency/incompetence

Normal trait: cooperative Subclinical: attached

CLUSTER C: OBSESSIVE COMPULSIVE

Preoccupation with orderliness, perfection and control at the expense of flexibility

Sticks to plans and rules to an extent that the original purpose of the activity is lost

Demands perfection from themselves and others

Very little overlap with OCD Normal trait: conscientious Subclinical: restricted

TREATMENT

Traditionally PDs considered very difficult to treat because of their pervasive, entrenched nature

Psychoanalysis/psychodynamic therapy• Esp. Borderline, Histrionic, Dependent, Narcissistic,

etc.

Cognitive Behavioural Therapy Medication

ANTISOCIAL PERSONALITY DISORDER (APD)

More studied than any other personality disorder

Origins usually traced back to earlier periods in development (Conduct Disorder),• Can not be diagnosed until late adolescence (DSM

criteria)

Has the distinction between ASPD and criminality been blurred?• Not all psychopaths are criminals, and not all serious

offenders are psychopaths

ANTISOCIAL PERSONALITY DISORDER (APD)

Psychopathy includes• ”Shallow, deceitful, unreliable and incapable of learning

from emotional experience”• Seemingly lacking in basic emotions: shame, guilt,

anxiety, remorse (conscience).

Increasing age can bring a change (lessening) in overt antisocial behaviors• Less obvious impulsivity, recklessness, social deviance• Some argue that the behaviors merely go

”underground”

APD: CAUSES Biological Factors

• Seems to be a genetic loading, esp. father-son, but outcome strongly determined by environment (adoption studies)

Temperament and family environment interaction• Parenting (punitive, inconsistent, low warmth), peers,

school

Behavioral and social reinforcers• Learned behavior resistant to change, modeling,

consequence ”trap”, peer support

APD: BORN BAD? Psychological factors

• Inability to anticipate punishment• Lack of anxiety regarding punishment/negative

consequences

Consequent participation in risk-taking, self-promoting behaviour with reduced ability to interpret (or pay attention to) nonverbal cues• Esp. fear, distress, anger, anxiety

Some people ”born bad”?• GSR, emotional responsiveness, empathy studies

APD: TREATMENT

Seldom seek treatment Often coerced into treatment by the legal

system• Participation does not always equate with success

Difficulty building a therapeutic relationship Very high recurrance of behaviour Limited success with behavioural

techniques

BORDERLINE PERSONALITY DISORDER (BPD)

Often present due to other complaints• E.g. somatic, self-harm, anxiety, depression, abuse

history; large degree of comorbidity

Initially conceptualized as the ”borderline” between neurosis and schizophrenia

Very poor sense of/integration of self leads to uncertainty about personal values, identity, worth and choices• = erratic, impulsive and self-damaging behavior

BPD: COGNITIVE/BEHAVIOURAL FEATURES Fear abandonment and crave relationships Incapable of maintaining these due to unrealistic

expectations and lack of self-cohesion Subject to chronic feelings of depression,

worthlessness, ’emptiness’ leading to self-harm and self-deprecating behavior• E.g. sexual activity, substance abuse, eating

Demonstrate dissociation during intense distress Splitting

• Tend to see people and events as either all good or all bad, and can shift rapidly between these.

BPD: CAUSES

Biological/genetic• Seems to run in families and may be associated with

genes that contribute to anxiety, frontal lobe dysfunction

Object Relations• The internalisation of early caregiving relationships

• E.g. inconsistency = insecurity & ego confusion leads to ego defence such as splitting

Diathesis-stress• Vulnerability thresholds overwhelmed e.g. by abuse

and trauma

BPD: TREATMENT

Perceived as very difficult clients Therapeutic relationship is key but

threatening to person with BPD• Attrition is high, and therapy is made very challenging

Psychoanalysis uses the transference relationship to interpret and integrate• Ego-supportive therapy