personality disorders uofl

7/30/2019 Personality Disorders UofL

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Personality Disorders

The Concept of Personality:

- individuals have personality traits (consistent ways of

thinking, perceiving and relating to others)

- traits may be genetic (temperament) or learned, but are stable

across adulthood

- traits result in consistent behavior patterns

Abnormal Personality Traits

- inflexible patterns

- maladaptive behavior- marked distress or dissatisfaction


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DSM Criteria:

-enduring pattern of inner experience and behavior that deviates markedly

from the expectations of the individuals culture

- manifest in 2 or more areas:

cognition (ways of perceiving either self or others)

affectivity (how emotion is felt or expressed)interpersonal (relationships with others)

impulse control

-pattern is inflexible and pervasive across a broad range of personal and

social situations

- leads to clinically significant distress or impairment in social,

occupational, or other important areas of functioning

-pattern is stable and of long duration and its onset can be traced back at

least to adolescence or early adulthood

- not due to other mental disorders, substance abuse, or medical condition


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Personality Disorder Clusters:

10 Specified Disorders

Cluster A: Odd-Eccentric Personality Disorders

characterized by odd ways of thinking or social

withdrawal, but no impairment in reality testing.

Cluster B: Dramatic-Emotional Disorders

characterized by lability of emotion, harmful behavior to

self/others, impulsivity, shallow/manipulative/unfeeling

conduct

Cluster C: Anxious-Fearful Disorders

characterized by fearfulness/anxiety, primarily related to

interpersonal relationships.


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Cluster A Disorders

Schizoid PD (4 or more characteristics)

neither desires nor enjoys close relationships

almost always chooses solitary activities

little, if any, interest in sexual experiences with otherstakes pleasure in few, if any, activities

lacks close friends or confidants other than relatives

appears indifferent to praise/criticism

shows emotional coldness, detachment, flat affect


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Cluster A Disorders

Schizotypal PD (5 or more characteristics)

ideas of reference

odd beliefs, magical thinking that influences behavior and

inconsistent with subcultural norms

unusual perceptual experiences

odd thinking and speech

suspiciousness or paranoid ideation

inappropriate or constricted affectodd, eccentric or peculiar behavior

lack of close friends or confidants, other than relatives

excessive social anxiety that does not diminish with

familiarity, tends to be paranoid rather than negative about self


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Cluster A Disorders

Paranoid PD (4 or more characteristics)

Suspects, without evidence, others are exploiting, harming or

deceiving them.

Preoccupied with unjustified doubts about loyalty or trustworthiness

of othersreluctant to confide due to unwarranted fear that info will be

maliciously used against them

reads hidden demeaning/threatening meanings into benign remarks or

events

persistently bears grudges

quick to react angrily, counterattack to perceived attacks

recurrent suspicions, without justification, about fidelity of partners


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Cluster B Disorders

Antisocial PD (3 or more characteristics, past age 18)

failure to conform to social norms/law (repeatedly

performing acts that are grounds for arrest)

deceitfulness (repeated lying, use of aliases, conning

others for personal profit/pleasure)

impulsivity or failure to plan ahead

irritability and aggressiveness (repeated fights/assaults)

consistent irresponsibility (failure to sustain consistentwork behavior or honor financial obligations)

lack of remorse (indifferent or rationalizes having hurt,

mistreated, or stolen from others)


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Cluster B Disorders

Borderline PD (5 or more characteristics)

frantic efforts to avoid real/imagined abandonment

pattern of unstable/intense interpersonal relationships

(alternating idealization and devaluation)

identity disturbance (markedly persistent unstable self-image or sense

of self)

impulsivity (at least 2 areas: spending, sex, SA, reckless driving,

binge eating)

recurrent suicidal behavior, gestures or threats, self-mutilating

behavior

affective instability due to marked reactivity of mood

chronic feelings of emptiness

inappropriate, intense anger or difficulty controlling anger

transient, stress-related paranoid ideation/dissociative sxs


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Cluster B Disorders

Histrionic PD (5 or more characteristics)

uncomfortable in situation in which not center of attention

inappropriately sexually seductive or provocative behavior

rapidly shifting/shallow expression of emotion

uses physical appearance to draw attention to self

excessively impressionistic style of speech lacking in detail

self-dramatizing, theatrical, exaggerated emotional expression

suggestible (easily influenced by others/circumstances)

considers relationships more intimate than actually are


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Cluster B Disorders

Narcissistic PD (5 or more characteristics)

grandiose sense of self-importance

preoccupied with fantasies of success, power, brilliance, beauty or

ideal love

belief in specialness only understood by other special, high-statuspeople/institutions.

requires excessive admiration

sense of entitlement

interpersonally exploitative

lacks empathy

often envious of others, believes others envy them

shows arrogant, haughty behaviors/attitudes


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Cluster C Disorders

Avoidant PD (4 or more characteristics)

avoids interpersonal contact due to fears of criticism, disapproval or

rejection

unwilling to get involved with others unless certain of being liked

restrained in intimate relationship due to fear of being shamed orridiculed

preoccupied with being criticized or rejected in social situations

inhibited in new interpersonal situations due to feelings of inadequacy

views self as socially inept, unappealing or inferior to others

unusually reluctant to take risks or try new things due to fear of

embarrassment.


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Cluster C Disorders

Dependent PD (5 or more characteristics)

difficulty making decisions without advice or reassurance

needs others to assume responsibility for most major areas of their life

difficulty expressing disagreement with others due to fear of loss of

support or approval

difficulty initiating projects or doing things by themselves

goes to excessive lengths to obtain nurturance and support from

others

feels uncomfortable or helpless when alone due to exaggerated fears

of being unable to care for themselves

urgently seeks another relationship when close relationships end

unrealistically preoccupied with fears of being left to care for

themselves


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Cluster C Disorders

Obsessive-Compulsive PD (4 or more characteristics)

preoccupied with details, rules, lists, order, organization, or schedules

losing major point of activity

shows perfectionism that interferes with task completion

excessively devoted to work/productivity to exclusion ofleisure/friendships

overconscientious, scrupulous and inflexible about morality, ethics or

values

unable to discard worn-out or worthless objects

reluctant to delegate tasks or work with others, unless others submit

to their way of doing things

miserly spending style (hoarding money against future catastrophes)

rigidity and stubbornness


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Critical Issues with DSM PD diagnoses

1) Categorical system of a dimensional construct

PDs are extreme variants of normal personality styles

2) Overlap in criteria

multiple combinations of sxs to meet dx criteria

meeting more than one criteria set

having some, but not all, criteria (PD-NOS)

3) Poor diagnostic reliability, imprecise/vague sx descriptions

4) Potential for bias in diagnostic process.5) Gender bias in diagnoses


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Proposed Diagnostic Changes in DSM5

1) Dimensional ratings of general personality functioning

Self-Functioning: identity and self-direction

Interpersonal-Functioning: empathy and intimacy

2) 6 Personality Disorder Types

Borderline: - affect; disinhibition, antagonism

Antisocial: antagonism; disinhibition

Schizotypal: psychoticism; detachment; - affect

Avoidant: detachment; - affectNarcissistic: - affect; detachment; antagonism

Obsessive-Compulsive: - affect; disinhibition


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Proposed Diagnostic Changes in DSM5

3) Trait Specifications (Facet dimensions)

Negative Affectivity (anxiousness, lability, hostility,

perseveration [fixated mood], restricted affect, separation

insecurity, submissiveness)

Detachment (anhedonia, depressivity, intimacy avoidance,

suspiciousness, withdrawal)

Antagonism (attention-seeking, callousness, deceitfulness,

grandiosity, manipulativeness)

Disinhibition (distractibility, impulsivity, irresponsibility,

perfectionism, risk-taking)

Psychoticism (eccentricity, perceptual dysregulation, unusual

beliefs and experiences)


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Antisocial PD (3 or more characteristics, past age 18)

failure to conform to social norms/law (repeatedly

performing acts that are grounds for arrest)

deceitfulness (repeated lying, use of aliases, conning

others for personal profit/pleasure)

impulsivity or failure to plan ahead

irritability and aggressiveness (repeated fights/assaults)

consistent irresponsibility (failure to sustain consistent

work behavior or honor financial obligations)

lack of remorse (indifferent or rationalizes having hurt,

mistreated, or stolen from others)


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Psychopathy= alternative diagnostic perspective

Cluster of personality traits characterized by:

superficial charm

pathological lying

egocentricity

lack of remorse

callousness to the suffering of others

Cleckley (1941) Mask of Sanity

David Hare (1991) Psychopathy Checklist-Revised (PCL-R)(1993) Without Conscience


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Epidemiology of Psychopathy2-3 % of general population

4.5% of males compared to 0.8% of females

5x more prevalent in lower SES


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PCL-R items fall into two distinct factors:

Aggressive Narcissism (Core Psychopathy Characteristics)Glib/superficial charm Grandiosity

Pathological lying Cunning/manipulativeness

Lack of remorse/guilt Shallow affect

Lack of empathy PromiscuityFailure to accept responsibility for actions

Socially Deviant Lifestyle (Antisocial Characteristics)

Parasitic lifestyle Impulsivity

Prone to boredom Early behavioral problemsIrresponsibility Juvenile delinquency


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Antisocial PD, Psychopathy and Criminal Behavior

Not all criminals Psychopaths, not all Psychopaths criminalsDSM=50-80% of forensic setting evaluations

PCL-R= 15-30%

Successful Psychopaths (non-criminals) tend to be:

higher IQ

higher SES

higher Emotional Intelligence

although their emotional experience is abnormal,

they have more information about emotions


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Psychopathic Criminals

more likely to be career criminals may diminish with age3x more likely to commit violence during crimes

Less likely to be emotionally aroused prior to crime

More likely to commit instrumentalviolence during crime

violence aimed at obtaining goals, establishing status,

maintain perceived safety

More likely to re-offend after release from prison

Serial Killers: psychopathy + sexual sadism

target particular types of victims

plan murders carefully

use close contact weapons

maintain contact with victims after killing


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Antisocial Criminals

if violent during crime, tends to be reactive violence:based on perception of threat to violent person:

low threat = freeze response

moderate threat = escape response

high threat = attack response

APD more prone to perceive threat as high and attacking

when actual threat is low and more successful response

would be escape


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Etiological Models of Antisocial PD

A maladaptive developmental pathway that begins inchildhood.

Conduct D/O strongest predictor of Adult APD

Greater likelihood of Adult APD when

greater variety of delinquent behavior in childhood

MacDonald Triad (1963) = 3 childhood behaviors that predict

Adult Psychopathy:

Bed-wetting

Abuse of animals

Pyromania


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Etiology of Psychopathy

Genetic inheritance56% heritability in twin/adoption studies

molecular studies have not identified gene anomalies

Neurocircuitry Abnormalities

underactivation of frontal lobes

underactivation of limbic system, particularly amygdala


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Etiological Models of Psychopathy

Dysfunctional Fear Hypothesis (Lykken 1957)abnormal fear response in psychopathy

Passive Avoidance Learning Hypothesis (Gray 1990)

impaired Behavioral Inhibition System (BIS)

increased anxiety when punishment cues present

lack of anxiety leads to failure to learn to stop behavior to

avoid punishment


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Etiological Models of Psychopathy

Impaired Emotional Processing Hypothesis (Patrick 1991)

impaired fear/anxiety capacity leads to

lack of attention to emotional signals in others

resulting in inability to feel empathy for others

Violence Inhibition Failure Hypothesis (Gray 1994)

lack of anxiety in response to others distress leads to

failure to learn to inhibit violence toward others

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