Personality DisordersPersonality Disorders

Coded on Axis IICoded on Axis II

Defined as: 1) Long-standing, 2) Defined as: 1) Long-standing, 2) pervasive, and 3) inflexible patterns of pervasive, and 3) inflexible patterns of behavior and inner experience that behavior and inner experience that deviate from the expectations of a deviate from the expectations of a persons culture and that impair social persons culture and that impair social and occupational functioning.and occupational functioning.

Personality is influenced by bio-Personality is influenced by bio-psychosocial developmentpsychosocial development

Personality Disorder: Clinical Personality Disorder: Clinical Features Features

DSM-IV’S five criteriaDSM-IV’S five criteria Enduring pattern of inner experience and Enduring pattern of inner experience and

behavior that deviates markedly from the behavior that deviates markedly from the expectations of the individuals cultureexpectations of the individuals culture

Onset can be traced to adolescent or early Onset can be traced to adolescent or early adult stagesadult stages

Inflexible and pervasive pattern across a Inflexible and pervasive pattern across a broad range of personal and social broad range of personal and social situations.situations.

Must be manifest in at least two of the Must be manifest in at least two of the following: cognitive, affective, following: cognitive, affective, interpersonal, and impulse control.interpersonal, and impulse control.

Distress/Impairment in important areas of Distress/Impairment in important areas of functioningfunctioning

Personality Disorders (cont)Personality Disorders (cont) All are conscious upon entering a crowed All are conscious upon entering a crowed

room but this does not equate with room but this does not equate with paranoid levels.paranoid levels.

A personality disorder is defined by the A personality disorder is defined by the extremesextremes of several traits and by the rather of several traits and by the rather inflexible and maladaptive way these traits inflexible and maladaptive way these traits are expressed.are expressed.

The personality each of us develops over The personality each of us develops over the years reflects a persistent means of the years reflects a persistent means of dealing with life’s challenges, a certain style dealing with life’s challenges, a certain style of relating to other people (overly of relating to other people (overly dependent, shy, aggressive, appearance)dependent, shy, aggressive, appearance)

Clinical Features of Personality Clinical Features of Personality DisordersDisorders

Difficulties in diagnosing personality disordersDifficulties in diagnosing personality disorders Categories are not as sharply definedCategories are not as sharply defined Categories are not mutually exclusiveCategories are not mutually exclusive Characteristics that define them are all dimensionalCharacteristics that define them are all dimensional

Reliability has been poor in the past but has Reliability has been poor in the past but has improved due to:improved due to:

Publication of specific diagnostic criteria from Publication of specific diagnostic criteria from DSM-III to current editionsDSM-III to current editions

Development of structured interviewsDevelopment of structured interviews

Reliability (Zanarini, 2000)Reliability (Zanarini, 2000)

ParanoidParanoid BorderlineBorderline HistrionicHistrionic NarcissisticNarcissistic AntisocialAntisocial DependentDependent ObsessiveObsessive SchizotypalSchizotypal

Inter-raterInter-raterTest-RetestTest-Retest .86.86 .57.57 .90.90 .56.56 .83.83 .40.40 .88.88 .32.32 .97.97 .84.84 .87.87 .15.15 .85.85 .52.52 .91.91 .11.11

Personality Disorder Personality Disorder (Clusters)(Clusters)

Cluster A= individuals are odd or Cluster A= individuals are odd or eccentriceccentric (paranoid, schizoid, and schizotypal)(paranoid, schizoid, and schizotypal)

Cluster B= individuals are dramatic, Cluster B= individuals are dramatic, emotional or erraticemotional or erratic (antisocial, borderline, histrionic, & (antisocial, borderline, histrionic, &

narcissistic) narcissistic) Cluster C= individuals are anxious or Cluster C= individuals are anxious or

fearfulfearful (avoidant, dependent, obsessive-comp)(avoidant, dependent, obsessive-comp)

Cluster A Personality Cluster A Personality DisordersDisorders

Odd/Eccentric ClusterOdd/Eccentric Cluster

Paranoid (five)Paranoid (five)

Pervasive suspiciousness of being harmed, Pervasive suspiciousness of being harmed, deceived or exploiteddeceived or exploited

Unwarranted doubts about loyalty of friends Unwarranted doubts about loyalty of friends or associatesor associates

Reluctance to confide in others due to aboveReluctance to confide in others due to above

Hidden meaning read into innocuous actionsHidden meaning read into innocuous actions

Grudges for perceive wrongsGrudges for perceive wrongs

Angry reactions to perceived attacks on Angry reactions to perceived attacks on character or reputationcharacter or reputation

Schizoid (four)Schizoid (four) Lack of desire or enjoyment of close Lack of desire or enjoyment of close

relationshipsrelationships Almost exclusive preference for Almost exclusive preference for

solitudesolitude Little interest in sex with othersLittle interest in sex with others Few if any pleasuresFew if any pleasures Lack of friendsLack of friends Indifference to praise or criticismIndifference to praise or criticism Flat affect, emotional detachmentFlat affect, emotional detachment

Schizotypal (five)Schizotypal (five) Ideas of referenceIdeas of reference Peculiar beliefs or magical thinking Peculiar beliefs or magical thinking

(belief in extrasensory perception)(belief in extrasensory perception) Unusual perceptions (distorted body Unusual perceptions (distorted body

belief)belief) Peculiar patterns of speechPeculiar patterns of speech Extreme suspiciousness, paranoiaExtreme suspiciousness, paranoia Inappropriate affectInappropriate affect Odd behavior or appearanceOdd behavior or appearance Lack of close friendsLack of close friends

Etiology of Cluster AEtiology of Cluster A Possible genetic links (eg.. Possible genetic links (eg..

Schizophrenic similarities)Schizophrenic similarities) Deficits in neuropsychological Deficits in neuropsychological

functioningfunctioning Enlarged ventricles and less temporal Enlarged ventricles and less temporal

lobe gray matter in schizotypal lobe gray matter in schizotypal personalitypersonality

Cluster B Personality Cluster B Personality DisordersDisorders

Dramatic/Erratic ClusterDramatic/Erratic Cluster

Histrionic Personality (five)Histrionic Personality (five) Strong need to be the center of attentionStrong need to be the center of attention Inappropriately sexually seductive bxInappropriately sexually seductive bx Rapidly shifting expression of emotionsRapidly shifting expression of emotions Use of physical appearance to draw Use of physical appearance to draw

attention to selfattention to self Speech excessively impressionistic, Speech excessively impressionistic,

passionately held opinions lacking detailpassionately held opinions lacking detail Exaggerated theatrical emotional expressionExaggerated theatrical emotional expression Overly suggestibleOverly suggestible Misreads relationships as being more Misreads relationships as being more

intimate than they really areintimate than they really are

Histrionic Personality: Histrionic Personality: EtiologyEtiology

Little research with Little research with Freudian ExplanationFreudian Explanation

Thought to be raised in families Thought to be raised in families where emotionality and where emotionality and seductiveness were encouraged by seductiveness were encouraged by parental seductiveness.parental seductiveness.

Parents talk about sex as something Parents talk about sex as something dirty yet behave as though it is dirty yet behave as though it is exciting and desirable.exciting and desirable.

Narcissistic Personality Narcissistic Personality (five)(five)

Grandiose view of one’s Grandiose view of one’s importance, arroganceimportance, arrogance

Preoccupation with one’s success, Preoccupation with one’s success, brilliance, beautybrilliance, beauty

Extreme need for admirationExtreme need for admiration Strong sense of entitlementStrong sense of entitlement Tendency to exploit othersTendency to exploit others Envy of othersEnvy of others

Narcissistic: EtiologyNarcissistic: Etiology

Parents do not respond with approval Parents do not respond with approval to their children’s displays of to their children’s displays of competency; the child is not valued for competency; the child is not valued for his own self worth but is valued as a his own self worth but is valued as a means to foster the parents self-means to foster the parents self-esteem (Kohut & Wolf, 1978)esteem (Kohut & Wolf, 1978)

Antisocial PersonalityAntisocial Personality Pervasive disregard for the rights of Pervasive disregard for the rights of

others since the age of 15 and at others since the age of 15 and at least three of the following least three of the following characteristicscharacteristics Repeated law breakingRepeated law breaking Deceitfulness, lyingDeceitfulness, lying ImpulsivityImpulsivity Irritableness and aggressivenessIrritableness and aggressiveness Reckless disregard for other and own Reckless disregard for other and own

safetysafety Irresponsibility (employment or financial)Irresponsibility (employment or financial) Lack of remorseLack of remorse

Antisocial Personality:Antisocial Personality:Clinical PictureClinical Picture

Inadequate conscience developmentInadequate conscience development Accept ethical values on at a verbal level.Accept ethical values on at a verbal level.

Irresponsible and impulsive behaviorIrresponsible and impulsive behavior Take rather than earn. Pleasure seekers.Take rather than earn. Pleasure seekers.

Rejection of authorityRejection of authority Ability to Impress and ExploitAbility to Impress and Exploit

Charming and likableCharming and likable Appear sincere when caughtAppear sincere when caught

Antisocial: Etiology I.Antisocial: Etiology I. Genetics (modest heritability)Genetics (modest heritability)

Deficient Deficient Behavioral Inhibition SystemBehavioral Inhibition System Inhibits behavioral responses to cues Inhibits behavioral responses to cues

signaling punishmentsignaling punishment Overactive Overactive Behavioral Activation SystemBehavioral Activation System

Activates behavior in response to Activates behavior in response to rewardsrewards

Emotion DeficitsEmotion Deficits Inability to profit from experience Inability to profit from experience Respond less anxiously to fear-eliciting Respond less anxiously to fear-eliciting

stimuli (thus little deterrent effect)stimuli (thus little deterrent effect)

Antisocial: Etiology II.Antisocial: Etiology II. Role of the familyRole of the family

Parental loss, parental rejection, Parental loss, parental rejection, inconsistent or no disciplineinconsistent or no discipline

Antisocial fatherAntisocial father

ImpulsivityImpulsivity Lacking in impulse control due to the Lacking in impulse control due to the

above reasonsabove reasons

A Developmental PerspectiveA Developmental Perspective

Antisocial Personality vs Antisocial Personality vs PsychopathyPsychopathy

Both focus onBoth focus on behavioral behavioral and and affective affective dimensions but in psychopathy the dimensions but in psychopathy the focus is on the affective dimension focus is on the affective dimension while in antisocial personality disorder while in antisocial personality disorder the focus is more behavioralthe focus is more behavioral

Note that some theorists and argue Note that some theorists and argue that there is no difference between that there is no difference between the two.the two.

Borderline Personality (five)Borderline Personality (five) Frantic efforts to avoid abandonment Frantic efforts to avoid abandonment

(real or imagined)(real or imagined) Instability and extreme intensity in Instability and extreme intensity in

interpersonal relations (idealize & revile)interpersonal relations (idealize & revile) Unstable sense of selfUnstable sense of self Impulsive bx, including reckless Impulsive bx, including reckless

spending and sexual promiscuityspending and sexual promiscuity Recurrent suicidal and self-mutilating bxRecurrent suicidal and self-mutilating bx Extreme emotional labilityExtreme emotional lability Chronic feelings of emptinessChronic feelings of emptiness

Borderline Personality: EtiologyBorderline Personality: Etiology Runs in families (genetic)Runs in families (genetic) High in neuroticism (heritable trait)High in neuroticism (heritable trait) Impaired frontal lobe functioningImpaired frontal lobe functioning Object relations theoryObject relations theory

Splitting and TraumaSplitting and Trauma Separation from family in childhoodSeparation from family in childhood Low family support and high conflictLow family support and high conflict Emotional dysregulation (child trait) raised Emotional dysregulation (child trait) raised

by invalidating parentsby invalidating parents

Treatment of Borderline Treatment of Borderline PersonalityPersonality

Dialectical Behavior Therapy (DBT) GoalsDialectical Behavior Therapy (DBT) Goals Decrease suicidal behaviorDecrease suicidal behavior Decrease therapy interrupting behaviors (lying)Decrease therapy interrupting behaviors (lying) Decrease escapist behaviors (substance use)Decrease escapist behaviors (substance use) Increase behavioral skills for emotional Increase behavioral skills for emotional

regulation, interpersonal relations, and regulation, interpersonal relations, and tolerance for distresstolerance for distress

Treatment Requires Consistency Treatment Requires Consistency (emotional etc…) on the Part of the (emotional etc…) on the Part of the Therapist.Therapist.

Cluster C Personality Cluster C Personality DisordersDisorders

Anxious Fearful ClusterAnxious Fearful Cluster

Avoidant Personality (four)Avoidant Personality (four) Avoidance of interpersonal contacts Avoidance of interpersonal contacts

due to fears of criticism or rejectiondue to fears of criticism or rejection Unwillingness to get involved with Unwillingness to get involved with

others unless certain of being likedothers unless certain of being liked Restraint in intimate relationships for Restraint in intimate relationships for

fear of being shamed or ridiculedfear of being shamed or ridiculed Preoccupied about being criticized or Preoccupied about being criticized or

rejectreject Feelings of inadequacy or inferiorityFeelings of inadequacy or inferiority Extreme reluctance to try new things Extreme reluctance to try new things

for fear of being embarrassedfor fear of being embarrassed

Dependent Personality (five)Dependent Personality (five)

Difficulty making decisions without Difficulty making decisions without others excessive advice and others excessive advice and reassurance reassurance

Need for others to take responsibility Need for others to take responsibility for most major areas of lifefor most major areas of life

Difficulty disagreeing with others for Difficulty disagreeing with others for fear of losing supportfear of losing support

Difficulty doing things on own Difficulty doing things on own because of lack of confidencebecause of lack of confidence

Dependent Personality (cont)Dependent Personality (cont)

Doing unpleasant things as a way of Doing unpleasant things as a way of getting others approvalgetting others approval

Feelings of helplessness when aloneFeelings of helplessness when alone Urgently seeking a new relationship Urgently seeking a new relationship

when one endswhen one ends Preoccupation with fears of taking care Preoccupation with fears of taking care

of oneselfof oneself

Obsessive Compulsive (four)Obsessive Compulsive (four) Preoccupation with rules or details to the Preoccupation with rules or details to the

extent that the major point of an activity is extent that the major point of an activity is lostlost

Extreme perfectionism to the degree that Extreme perfectionism to the degree that projects are seldom completedprojects are seldom completed

Excessive devotion to work to the exclusion Excessive devotion to work to the exclusion of leisure and friendshipsof leisure and friendships

Inflexible about moralsInflexible about morals Difficulty discarding worthless itemsDifficulty discarding worthless items Reluctance to delegate unless others Reluctance to delegate unless others

conform to one’s standardsconform to one’s standards Miserliness and Rigidity and StubbornnessMiserliness and Rigidity and Stubbornness

Cluster C: EtiologyCluster C: Etiology

Speculation focuses on parent-child Speculation focuses on parent-child relationships and attachmentrelationships and attachment Dependent personality= Dependent personality=

overprotective parenting that overprotective parenting that prevents feelings of self efficacyprevents feelings of self efficacy

Secure baseSecure base Parents model fears which are Parents model fears which are

transmitted to childtransmitted to child

Therapy for Personality Therapy for Personality DisordersDisorders

Object Relations TreatmentObject Relations Treatment Dialectical Behavioral Therapy Dialectical Behavioral Therapy

(borderline)(borderline) Modulate and control their extreme Modulate and control their extreme

emotionality and behaviorsemotionality and behaviors Tolerate feelings of distressTolerate feelings of distress Trust thoughts and emotionsTrust thoughts and emotions

Cognitive Behavioral TreatmentCognitive Behavioral Treatment Psychosocial Treatments are Used in Psychosocial Treatments are Used in

GeneralGeneral

Treatments and Outcomes Treatments and Outcomes (cont)(cont)

Treating other cluster A and B Treating other cluster A and B disorders besides borderline and disorders besides borderline and antisocialantisocial

Not much research indicating any Not much research indicating any promising treatments.promising treatments.

Treating cluster C disordersTreating cluster C disorders Some indication that medication helps with Some indication that medication helps with

avoidant personality disorderavoidant personality disorder

Efficacy studiesEfficacy studies What does the research show? (see What does the research show? (see

above)above)