Personality Disorders 101Mike Pett MSW;RSW

Advanced Practice Clinician

Complex Mental Illness Program

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Objectives for the Presentation

-Common Pathways of Offending for SMI population

-Personality Disorders Defined

-Cluster B personality disorders:

Borderline, Narcissistic, and Anti-social/Psychopathic

-Treatment of Personality Disorders

-Question Period

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Conventional Path to Offending: Part 1.

Biological: TemperamentFamily history

Cognitive ability

Psychological:Antisocial attitudes

Social:Poor parent-child rel’nsSocial learning of antisocial behaviour

Conduct

Disorder

ASPD/Psychopat

hy

Substance Use

Andrews & Bonta 2006

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Proximal motivations (the “weather”)

Conventional Path to Offending: Part 2

Peterson et al. 2010

High Risk Individual

Instrumental

Reactive

Motives: material gain, sexual, power, jealousy,

revenge

Motives: anger, intoxication, perceived threat, emotional

stressor

Disadvantaged

Motives: minor crimes for food, shelter

Substances

Motives: obtain drugs of abuse

+ Paths to Offending in SMI

Positive Symptoms

Serious Mental Illness

Disorganization

High Risk Individual

(ASPD)Instrumental

Reactive

Disadvantaged

Substances

SMI vs. Gen Pop:

•Higher rate of Conduct dis.

•Higher rate of ASPD

•Higher rate of substance

•Higher rate of poverty

The direction of these relationships is unclear

The proportion of each motivation is unclear

+ The False Dichotomy

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Personality Disorders 101

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Personality Disorder Clusters

Cluster A (“mad”)SchizoidSchizotypalParanoid

Cluster B (“bad”)BorderlineAntisocialNarcissisticHistrionic

Cluster C (“sad”)

Obsessive-Compulsive

Avoidant

Dependent

+ Activity: Personalities ‘R Us

Corporate Structure:

President: ?

Vice President: ?

Personnel: ?

Advertising: ?

Legal Department: ?

Research: ?

Customer Service: ?

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Personalities ‘R Us Corporate Structure

President: Narcissist

Vice President: Paranoid

Personnel: Borderline

Middle Management:

Advertising: Histrionic

Research: Schizo-typal

Legal Department: Anti-social

Customer Service: Passive-Aggressive

+ Borderline Personality Disorder

Recorded on Axis II of the DSM-IV

Defined by the DSM-IV:

“an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment”

Not the result of:

Cultural and social expectations

Another mental disorder

A substance or general medical condition

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Borderline Personality Disorder: What is it?

DSM-IV:

“ A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.”

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Borderline Personality Disorder: DSM-IV Criteria

Five or more of the following:

Frantic efforts to avoid real or imagined abandonment A pattern of unstable and intense interpersonal

relationships characterized by alternating between extremes of idealization and devaluation

Identity disturbance: markedly and persistently unstable self-image or sense of self

Impulsivity in at least two areas that are potentially self-damaging

Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior

Affective instability due to a marked reactivity of mood Chronic feelings of emptiness Inappropriate, intense anger or difficulty controlling

anger Transient, stress-related paranoid ideation or severe

dissociative symptoms

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Borderline Personality Disorder: Instability & Impulsivity

Instability of: Mood Self-image and identity– overdetermined by the

environment Interpersonal relationships

Marked impulsivity (5 S’s):

1. Spending

2. Sex

3. Substance use

4. Speeding (reckless driving)

5. Satiety (binge eating)

(6.) Suicidal/self-harm behavior (has its own criterion)

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Borderline Personality Disorder: Demographics & Course

Female > Male (3:1) 2% of community samples ; 15-25% of clinical

populations; 13-56% of hospitalized substance abusers

Completed suicide in ~8-10% (particularly high if comorbid substance use)

High rates of functional deficits, mental health utilization costs

Rocky course during first decade of treatment (high drop out rates); but many improve by second decade of treatment

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Borderline Personality Disorder: Etiology

Environmental:Invalidating Caregivers

Biological:Emotional

Vulnerability

Emotional Dysregulation

Most researched is Marsha Linehan’s biosocial theory

• High sensitivity/reactivity to emotional stimuli

• Slow return to baseline

• Indiscriminately rejects internal emotional experiences

• Punishes emotional expressions and intermittently reinforces emotional escalation

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Anti-social Personality Disorder vs. Psychopathic Personality Disorder

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“All psychopathic personalities are anti-social but not all anti-social personalities are psychopathic”

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Derived from Greek

psych (soul, breath hence mind)

pathos (to suffer)

A constellation of affective, interpersonal, and behavioral characteristics that include grandiosity, a callous disregard for others, a lack of empathy, and highly impulsive and irresponsible behavior

Differentiation from Sociopathy and Antisocial Personality Disorder

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– Superficial charm & good “intelligence”– Absence of delusions / irrational

thinking– Absence of “nervousness”– Unreliability– Untruthfulness and insincerity– Lack of remorse or shame– Inadequately motivated antisocial

behavior– Poor judgment / failure to learn by

experience

– Pathologic egocentricity / incapacity for love– General poverty in major affective reactions– Specific loss of insight– Unresponsiveness in general interpersonal

relations– Fantastic and uninviting behavior with drink

& sometimes without– Suicide rarely carried out– Sex life impersonal, trivial, and poorly

integrated– Failure to follow any life plan

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Operationalized the construct of psychopathy in the PCL and PCL-R instruments

Factor 1: Interpersonal and affective characteristics

Factor 2: Impulsive and antisocial behaviors

Prevalence of psychopathy:

~ 1% of general population

~ 20-25% of prison population

Robust predictor of violent and non-violent criminal behaviors in adult male offenders (e.g., Harris, Rice, & Cormier, 1991; Hemphill, Hare, & Wong, 1998; Salekin, Rogers, & Sewell, 1996)

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PsychopathyPsychopathy

Factor 1Factor 1Arrogant & Deceitful Arrogant & Deceitful Interpersonal StyleInterpersonal Style

Factor 4Factor 4Antisocial BehaviorAntisocial Behavior

Factor 2Factor 2Deficient AffectiveDeficient Affective

ExperienceExperience

Factor 3Factor 3Impulsive & IrresponsibleImpulsive & Irresponsible

Behavioral StyleBehavioral Style

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1. Glibness / Superficial Charm

Insincere and shallow interactional style

Charming, phony, or superficial

2. Grandiose Sense of Self-Worth

Inflated view of abilities and self-worth

Can appear domineering, opinionated, and arrogant

4. Pathological Lying

Deceitful, lying “just for kicks”

5. Conning/Manipulative

Uses deception to cheat, exploit, or manipulate others

Misrepresentation for personal gain

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6. Lack of Remorse or Guilt

Lack of concern for the consequences of their actions on others

7. Shallow Affect

Unable to experience a normal range and depth of emotion

“Play acting” emotions

8. Callous/Lack of Empathy

Disregard for the feelings, rights, and welfare of others

Cynical and selfish

16. Failure to Accept Responsibility for Own Actions

Usually have excuses for behaviors that hurt others

Rationalize or minimize past transgressions

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8. Need for Stimulation / Proneness to Boredom

Chronic and excessive need for novel and exciting stimulation; exciting and risky activities; “on the go”

9. Parasitic Lifestyle

Exploitation of others for basic needs and obligations

13. Lack of Realistic, Long-Term Goals

Inability or unwillingness to formulate plans and commitments; living “day to day” and changing plans frequently

+ Factor 3-cont

14. Impulsivity

Behaviors are unpremeditated and lacking in reflection; doing things on the spur of the moment; opportunistic15. Irresponsibility

Habitual failure to honor obligations and commitments to others

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10. Poor Behavioral Controls

12. Early Behavioral Problems

18. Juvenile Delinquency

19. Revocation of Conditional Release

20. Criminal Versatility

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11. Promiscuous Sexual Behavior

17. Many Short-Term Marital Relationships

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Best Practices for Treatment of Borderline and Anti-social personality disorder

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Dialectical Behaviour Therapy for Borderline Personality Disorder (Linehan, 2007)

Mindfulness

Interpersonal effectiveness

Distress Tolerance

Emotion Regulation

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Best Practices for Psychopathy and Anti-social Personality Disorder

“Nothing Works”

vs.

“What Works”?

+ Watch Dexter!

+ “Most Best” Menu of Treatment Strategies Substance Use Treatment

Pharmacological treatments for impulse control/cravings.

I.M. medication for chronic non-adherence.

Anger Management.

Assertive outreach

Crisis intervention

Critical time intervention

Volunteerism

+ Most Best Treatment Options.

CTO’s, probation, bail orders as leverage points to motivate recovery.

Drug Treatment Court/Mental Health Diversion in cases of precontemplation/low motivation in terms of mental health and addiction treatment.

Community placement should be in safe, pro-social neighborhoods where exposure to criminal activities and substance use is limited.

Re-training/Re-schooling

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Questions and Comments