chapter 12 personality disorders. personality disorders: an overview enduring and pervasive...
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Chapter 12
Personality Disorders
Personality Disorders: An Overview
Enduring and pervasive predispositions Perceiving Relating Thinking
Inflexible and maladaptive Distress Impairment
Coded on Axis II
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
Personality Disorders: An Overview
Categorical vs. Dimensional Views “Kind” vs. “Degree”
DSM is categorical Reifies concepts Less flexible Loss of individual information Sometimes arbitrary
Personality Disorders: An Overview
Five factor model of personality (“Big Five”) Openness to experience Conscientiousness Extraversion Agreeableness Emotional stability
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
Personality Disorders: Facts and Statistics
Prevalence = 0.5 - 2.5%, may be closer to 10% Outpatient = 2 - 10% Inpatient = 10 – 30%
Origins and Course Begin in childhood Chronic course High comorbidity
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
Personality Disorders: Gender Differences
Personality Disorders Under Study
Individual disorders Sadistic Self-defeating
Categories of disorders Depressive Negativistic
Passive aggressive
Cluster A: Paranoid Personality Disorder
Clinical Description Mistrust and suspicion
Pervasive Unjustified
Few meaningful relationships Volatile Tense Sensitive to criticism
Cluster A: Paranoid Personality Disorder
Causes Possible relationship to schizophrenia Possible role of early experience
Trauma Abuse Learning
“World is dangerous”
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
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
Cluster A: Schizoid Personality Disorder
Causes Limited research Precursor: childhood shyness
Possibly related to: Abuse/neglect Autism Dopamine
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
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
Cluster A: Schizotypal Personality Disorder
Causes Schizophrenia phenotype?
Lack full biological or environmental contributions
Preserved frontal lobes
Cognitive impairments Left hemisphere? More generalized?
Cluster A: Schizotypal Personality Disorder
Treatment Options Treatment of comorbid depression Multidimensional approach
Social skill training Antipsychotic medications Community treatment
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
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
Cluster B: Antisocial Personality Disorder
Cluster B: Antisocial Personality Disorder
Cluster B: Antisocial Personality Disorder
Developmental considerations Early histories of behavioral problems
Conduct disorder
Families history of: Inconsistent parental discipline Variable support Criminality Violence
Causes of Antisocial Personality
Gene-environment interaction Genetic predisposition Environmental triggers
Arousal hypotheses Underarousal Fearlessness
Causes of Antisocial Personality
Gray’s model of brain functioning Behavioral inhibition system (BIS)
Low Reward system (REW)
High Fight/flight system (F/F)
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
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
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
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
Cluster B: Borderline Personality Disorder
Causes Genetic/biological components
Serotonin Frontolimbic circuit
Cognitive biases
Early childhood experience Neglect Trauma Abuse
Cluster B: Borderline Personality Disorder
Treatment Highly likely to seek treatment Antidepressant medications Dialectical behavior therapy
Reduce “interfering” behaviors Self-harm Treatment Quality of life
Outcomes Demonstrated efficacy Cortical activation changes
Cluster B: Borderline Personality Disorder
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
Cluster B: Histrionic Personality Disorder
Causes Little research Links with antisocial personality
Sex-typed alternative expression?
Cluster B: Histrionic Personality Disorder
Treatment Problematic interpersonal behaviors
Attention seeking Long-term consequences of behavior
Little empirical support
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
Cluster B: Narcissistic Personality Disorder
Causes Deficits in early childhood learning
Altruism Empathy
Sociological view Increased individual focus “Me generation”
Cluster B: Narcissistic Personality Disorder
Treatment focuses on: Grandiosity Lack of empathy Hypersensitivity to evaluation Co-occurring depression
Little empirical support
Cluster C: Avoidant Personality Disorder
Clinical Description Extreme sensitivity to opinions Avoid most relationships Interpersonally anxious Fearful of rejection
Cluster C: Avoidant Personality Disorder
Causes Sub-schizophrenia disorder?
Difficult temperament Early parental rejection
Interpersonal isolation and conflict
Cluster C: Avoidant Personality Disorder
Treatment Similar to social phobia Increase social skills Reduce anxiety Importance of therapeutic alliance
Moderate empirical support
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
Cluster C: Dependent Personality Disorder
Causes Little research Early experience
Death of a parent Rejection Attachment
Cluster C: Dependent Personality Disorder
Treatment Limited empirical support
Caution: dependence on therapist
Gradual increases in: Independence Personal responsibility Confidence
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
Cluster C: Obsessive-Compulsive Personality Disorder
Causes Limited research Weak genetic contributions
Predisposed to favor structure?
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
Personality Disorders: Future Directions
Completely rethinking personality disorders Dimensional models