the personality disorders troubling, mysterious, untreatable?
TRANSCRIPT
The Personality Disorders
Troubling, mysterious, untreatable?
Over-arching characteristics
• The 3 P’s
• Pervasive – their problems cut across settings• Persistent – difficulties don’t go away or wax
and wane, last for decades• Pathological – behaviors are destructive and
maladaptive
More characteristics
• Tremendous problems with relationships hot and then ice-cold don’t last long few, if any, friends
• Identity issues – don’t form a stable, positive sense of self
Worse yet
• Lots of them• Notoriously hard to treat• Great burden on society crime family issues general chaos
Classification – DSM5
• Recognizes 10 types divided into three clusters
• Odd/eccentric – Schizoid, Schizotypal, Paranoid
• Erratic/emotional/dramatic – Histrionic, Antisocial, Borderline, Narcissistic
• Fearful/anxious – Avoidant, Obsessive-compulsive, Dependent
Comorbidity
• Many have other disorders – 50%!• The presence of a pd has a great influence on
symptoms, social functioning and treatment options
• More severe symptoms• More frequent in treatment settings
Reliability
• Since DSMIII commenced listing specific behavioral criteria, interrater reliability has greatly improved, typically >.8
• At least if structured interviews are used• Exception – schizotypal • Gender expectations
Self reports as basis?
• Huge reliability concern• By definition, pd involves an unstable self-view• Can they accurately describe their behaviors?• Another perspective is crucial, though rarely
obtained
An alternative DSM5 model
• Described in appendix to DSM5• Reduces disorders• Heavy reliance on the Big 5 personality traits• Provides more detail• Stability • Better predictions• Aids research
Odd/Eccentric Cluster
• Characterized by weird, bizarre behaviors
• Somewhat similar to schiz, but less severe
• Paranoid• Schizoid• Schizotypal• Lots of comorbidity between disorders
Paranoid
• Suspicion • Great effect on all types of relationships• Expectation of betrayal• Attend to and exaggerate threats & ill will• Hostility
• Not as severe or as profound as Schiz – lack hallucinations & full-blown delusions
Schizoid
• Don’t want or maintain relationships• Lifeless, bland• Little joy or fun• No interest in sex• Indifferent to other people, no warm feelings
for others
Schizotypal – “Schiz lite”
• Strange, unusual thoughts and behaviors• Magical thinking – think they can read minds• Ideas of reference – everything is about them• Illusions – strange, impossible sensory
perceptions• Strange appearance• Flat or out of place affect• Paranoia• Limited social contacts
Cause?
• Highly heritable • Beyond that, much uncertainty
• Schizotypal – high genetic overlap w/ schiz• Also share same cognitive and neuro
functioning issues w/ Schiz, just milder• Find enlarged ventricles and decreased grey
matter like schiz
Dramatic/erratic • Extremely variable behavior• Excessive, unrealistic self-esteem• Emotional outbursts• Rule-breaking• Antisocial – no care or concern for others• Histrionic – drama kings and queens• Borderline – rollercoaster relations, fragile self
image • Narcissistic – I’m perfect, you’re snot
Antisocial vs. Psychopathy
• Related but distinct
• Antisocial w/in DSM, Psychopathy not
• Both involve flagrant disregard for rules/ laws
Antisocial
• Long-standing pattern of behavior flouting the rights of others
• Aggressive, impulsive, callous• DSM5 requires Conduct Disorder diagnosis• All sorts of nasty behaviors – fighting, stealing,
lying, never planning ahead, impulsivity, failing to repay debts, temper outbursts
• No remorse
Demographics
• More men than women• Some seem to outgrow• More severe among young• ¾ comorbid• Substance abuse most common• ¾ of convicted felons meet criteria
Psychopathy
• Came before antisocial • Cleckly (1976)’s classic – The Mask of Sanity• Focused on thoughts and feelings (or lack of)• Lack emotions, good or bad• No sense of shame• Any exhibited emotion just an act• No plan, just acting on whim or impulse
Differences in DSM 5
• DSM 5 requires onset before 15, many psychopaths didn’t
• Antisocial often (80%) score low on Psychopathy Checklist
Causes
• Lots of research and theories• Two limitations though, 1) findings include both psychopaths and
antisocials = despite differences in diagnoses 2) samples drawn from convicts., some
escape criminal penalties
Genetic factors
• Follows biological children of APDs and substance abuse
• Heritability estimates range from 40-50%• More aggression, more heritability• More thorough (reliable) studies, higher
heritability• These run parallel with substance abuse• But very difficult to disentangle genetic, familial
& behavioral influences
Social factors
• Initial socialization from family key to building respect for others
• Parenting red flags - high negativity, low warmth, inconsistency
• Especially crucial if there is genetic risk• Also, poverty and exposure to violence predict
even w/out genetic risk
Nothing scares them
• Seem unable to profit from experience, even punishment
• Don’t fear arrest, prison, social stigma• The opposite of anxiety disorders, don’t
develop conditioned fear responses• Amygdala doesn’t get activated by stimuli
which should trigger CRs• CC fail
Can’t resist
• Impulsivity predicts• If they are pursuing something they want,
they don’t respond to consequences• However, if they are forced to pause before
responding, they do show learning
They just don’t feel others pain
• Focus on lack of empathy – being able to walk in another’s shoes
• Can’t even recognize other’s fear• Don’t respond to victimization scenes• Lack of arousal of ventromedial prefrontal
cortex in brain-imaging studies
Borderline
• Wild, inconsistent relationships• Rollercoaster moods• Rapidly changing, searingly hot to freezing
cold• Typical behaviors – promiscuity, gambling,
over-spending, substance abuse
Who am I?
• Fail to develop a clear and coherent sense of self
• Basic aspects of identity can change instantaneously
• Career plans, hobbies, values, loyalties can shift from one moment to the next
• Correspondingly, great fear of abandonment, rejection, emptiness
Self-harm, even suicide
• Many engage in self-destructive behaviors• 2/3’s engage in self-mutilation at some point
• 15% attempt and 7.5 % succeed in taking life
• But these tendencies tend to decrease as they mature
Duration, comorbidity• Thankfully, many lose the diagnosis over 10-15
years, most by 40
• Many suffer from: 1) other pds 2) mood disorders 3) substance abuse• More conditions, longer duration
The many causes of Borderline
• Neurobiological factors high, 60% heritability lower serotonin function hyper amygdala reactivity explains erratic
emotions poor function of prefrontal cortex explains
impulsivity also poor control of amygdala
Social factors – child abuse
• Compared to other pds, Borderlines show more parental separation, verbal and emotional abuse
• Similar to Dissociative Identity Disorder• On a continuum DID?
Diathesis- Stress model
• If you have genetic difficulties in controlling your emotions (diathesis) and are raised in an invalidating environment (stress), you are likely to develop Borderline
• Invaladating – no one pays attention to you or credits your expression of emotion
• Abuse is even worse
Dynamics of DS
• Interactive effect• Some children are difficult and demanding
from the start• Children punish or ignore emotional outbursts• Child suppresses emotions• Child boils over, drawing attention
(reinforcement)• Ongoing and escalating
Histrionic
• Excessive need for attention • Overly dramatic behavior• Provocative dress• Seductive, theatrical behavior• Emotional volatility• Easily persuaded• Strange, shallow language• Exaggerated intimacy in relationships
Cause
• Psychodynamic theory poses a father’s seductive behavior as cause for daughter’s actions
• Parents ambivalent views towards sex cause child to approach but then withdraw
• unverified
Narcissistic
• Grandiose, unjustified opinion of achievements and talents
• Demand attention and admiration• So special, only the truly gifted can
understand them• Entitled, exploitative• Arrogant, envious• No empathy
Causes of Narcissisitic
• Often comorbid with Borderline• Two distinct theories• Self-psychology – studies find parental
coldness & excessive praise• Parents set this up by exaggerating child’s
abilities to bolster their own self-esteem• Child feels shame with any failure
Social-cognitive model
• Two basic premises 1)Narcissists desperately seek to prove their
specialness due to precarious self-esteem, and
2) dealings with other people serve to bolster self-esteem, not warmth or fun
Support for social-cognitive model
• In controlled settings, they exaggerate attractiveness and achievement
• They falsely attribute success to special abilities rather than good fortune
• Hyper sensitive to feedback because they need constant praise
• Thirst to prove their specialness, rather than get close to people alienates others
The Anxious/Fearful Cluster
• Preoccupied and functionally impaired by worry and distress
• Avoidant – so terrified of social humiliation, they keep away from others
• Dependent – need someone else for everything
• Obsessive-Compulsive – rigid, inflexible, demanding perfection
Avoidant
• Afraid of criticism, rejection and negativity, so they avoid social contact
• Especially jobs or situations which will expose them to such
• Very restrained face-to-face• Deep seated conviction that they are
worthless and incompetent
Social Anxiety, & other connections
• Often found together• On a continuum, with Avoidant just more
severe?• Plenty of overlap w/ symptoms• Both similar to taijin kyofusho• Often found with MDD (80%!), borderline, and
schizotypal pds• And, of course, alcohol abuse
Cause?
• No one knows• Victims don’t want to discuss it• Fair heritability - ~30%• Maybe, through childhood modeling, they
associated any social contact with humiliation and ridicule
Dependent
• Desperate need for someone to take care of them and make decisions for them
• No self-confidence• Grave fear of being alone• Willing to sacrifice anything for support• When one “guardian” leaves, another must be
found
Other aspects
• DSM might be wrong in requiring helpless passivity – can work to keep relationships
• Found more frequently in eastern cultures like India and Japan where some passivity is expected
• Found w/ many of PDs, mood and anxiety mds• Bulimia also
Cause of Dependent?
• Parenting – authoritarian style – which prevents self efficacy, might be responsible
• Also, maybe it arises from an attachment failure, infant didn’t get enough affection and attention
Obsessive-Compulsive
• Wrapped up completely in details, rules, schedules, etc. to the point of impairing performance
• Trouble with decisions and time-management• No fun, all work• “Control freaks”• Troubled relationships• Inflexible morally
Distinguishing from OCD
• Not prey to obsessions and compulsions• Can appear together • But more likely found with Avoidant
Obsessive – compulsive cause?
• Not much research• Twin studies produced differing heritability
estimates• Some genetic overlap with OCD found• Especially with traits like Perfectionism
Treatment for PD
• Many get into treatment itself for other conditions like mood disorders or substance abuse
• Treaters should always consider since presence of pd predicts more difficult treatment
General Treatments
• Surprisingly pds respond to treatment, with a 52% recovery rate within 15 months
• But lack of control group limits optimism• Typically, several hours a day of
psychotherapy, and attention to social and occupational skills
• Sometimes in groups, other times solo• Can run for months
Specific Treatments
• Schizotypal – treated similarly to schiz with resperodone, effectively manages strange thinking
• Avoidant – mix of antidepress and cognitive behavioral therapy. Social skills training can help with fear of criticism. Similar, but more severe than social anxiety d.
Effective cure for psychopathy?
• Meta-analysis (42 studies) suggests there is hope
• Psychoanalytic therapy helps w/ relationships, experiencing remorse/empathy, reducing lying, holding a job, and completing probation
• Cognitive-Behavioral helped also• Therapy must be intense – 4x weekly• But are they just playing us?
Treating Borderline
• Very difficult to treat• Relationship issues rear up in treatment• Rollercoaster course 1)BDPs idealize then despise therapists 2) demand trust, then lie 3) demand extra, but give nothing 4) plus, great feat of suicide • Therapists need great support & feedback
Do meds help?
• Tried to calm moods and impulsivity• Some success re anger and depression• Lithium helps with irritability and suicide
• Much more research is necessary
Dialectical Behavior Therapy
• Linehan pioneered approach combining empathy/acceptance w/ Cog/Behav strategies
• Cog/Behav techniques: 1) problem solving, 2) emotion-regulation, and 3) social skills training• Clients are pushed towards self-acceptance
tempered with a more reasonable world-view
4 Stages of Dialectical Behav Therapy
• 1) take on dangerous, impulsive behaviors to gain control
• 2) learning to handle emotional upsets• 3) improving relationships & self-esteem• 4) promote connectedness and happiness• Follow-up studies revealed improvement vs.
controls but ongoing problems with happiness