6. Personality disorders

Question 1

Personalities

Answer 1

Personality refers to enduring patterns of thinking and behaviour that define the person and distinguish him/her from others. A person’s characteristic manner of thinking, feeling, behaving and
relating to others that has been evident since young adulthood and
is evident throughout almost everyday of adult life

Question 2

What are personalities patterns of?

Answer 2

– expressing emotion

– thinking about ourselves and other people – i.e. our representations

Question 3

What does personality facilitate?

Answer 3

Personality usually facilitates interactions with others – but patterns of behavior and emotion can bring the person into conflict with others

Question 4

Abnormal/dysfunctional personality

Answer 4

• Dysfunctional personality marked by rigidity/inflexibility, narrow range of responses
• Impacting on identity and self direction and interpersonal relationships (empathy and intimacy)
– May bring a person into conflict with others; exacerbate conflict
– Impede connectedness
– Undermine problem resolution

Question 5

Healthy or adaptive personality

Answer 5

Healthy or adaptive personality marked by flexibility, variety in responses & capacity to adapt

Question 6

Reliability of personality disorders

Answer 6

The personality disorders as diagnostic categories tend to lack reliability
– Limited evidence that they are discrete conditions
– Substantial overlap/comorbidity
– Gender bias

Question 7

Descriptive categories of personality disorders

Answer 7

Categories are descriptive – they do not provide any insight into the aetiology of disorder

Question 8

Criticisms of personality disorders

Answer 8

• categories are descriptive• Considerable heterogeneity within categories
• Many are ego-syntonic

Question 9

General criteria for PD

Answer 9

• An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture.
• Manifested in two (or more) of the following areas:
1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response).
3. Interpersonal functioning.
4. Impulse control.

Question 10

Three clsuters of personality disorders

Answer 10

– Cluster A – social detachment, eccentric/odd
– Cluster B – emotional, erratic, dramatic
– Cluster C – anxious, fearful

Also included are:
– Personality change due to another medical condition
– Other specified personality disorder
– Unspecified personality disorder

Question 11

The 10 PDS organised by cluster

Answer 11

• Cluster A
– Schizoid Personality Disorder
– Schizotypal Personality Disorder
– Paranoid Personality Disorder
• Cluster B
– Borderline Personality Disorder
– Histrionic Personality Disorder
– Narcissistic Personality Disorder
– Antisocial Personality Disorder
• Cluster C
– Avoidant Personality Disorder
– Obsessive Compulsive Personality Disorder
– Dependent Personality Disorder

Question 12

Paranoid Personality Disorder: Diagnostic Criteria

Answer 12

A A pervasive distrust and suspiciousness of others such that their motives are interpreted as
malevolent

1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or
   her.
2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or
   associates.
3. Is reluctant to confide in others because of unwarranted fear that the information will be
   used maliciously against him or her.
4. Reads hidden demeaning or threatening meanings into benign remarks or events.
5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
6. Perceives attacks on his or her character or reputation that are not apparent to others and
   is quick to react angrily or to counterattack.
7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual
   partner.
   B Does not occur exclusively during the course of schizophrenia, a bipolar disorder or
   depressive disorder with psychotic features, or another psychotic disorder and is not
   attributable to the physiological effects of another medical condition.

Question 13

Schizoid Personality Disorder: Diagnostic Criteria

Answer 13

A A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings

1. Neither desires nor enjoys close relationships, including being part of a
   family.
2. Almost always chooses solitary activities.
3. Has little, if any, interest in having sexual experiences with another
   person.
4. Takes pleasure in few, if any, activities.
5. Lacks close friends or confidants other than first-degree relatives.
6. Appears indifferent to the praise or criticism of others.
7. Shows emotional coldness, detachment, or flattened affectivity.
   B Does not occur exclusively during the course of schizophrenia, a bipolar
   disorder or depressive disorder with psychotic features, another psychotic
   disorder, or autism spectrum disorder and is not attributable to the physiological
   effects of another medical condition.

Question 14

Schizotypal Personality Disorder: Diagnostic Criteria

Answer 14

A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior

1. ideas of reference (excluding delusions of reference)
2. odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms
   (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense“
3. unusual perceptual experiences, including bodily illusions
4. odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or
   stereotyped)
5. suspiciousness or paranoid ideation
6. inappropriate or constricted affect
7. behavior or appearance that is odd, eccentric, or peculiar
8. lack of close friends or confidants other than first-degree relatives
9. excessive social anxiety that does not diminish with familiarity and tends to be associated with
   paranoid fears rather than negative judgments about self
   B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or
   depressive disorder with psychotic features, another psychotic disorder, or autism spectrum
   disorder.

Question 15

PD distinguished from psychosis

Answer 15

Psychosis (i.e. Schizophrenia) is characterised by a number of other symptoms which may include paranoia, ideas of reference, social withdrawal
– Positive symptoms: hallucinations and delusions
– Negative symptoms of reduced affectivity, poverty of thought, avolition, amotivation, anhedonia
– Disorganised thinking, speech and behaviour

Question 16

Antisocial Personality Disorder:

Diagnostic Criteria

Answer 16

A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years

1. failure to conform to social norms with respect to lawful behaviors as indicated by
   repeatedly performing acts that are grounds for arrest
2. deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal
   profit or pleasure
3. impulsivity or failure to plan ahead
4. irritability and aggressiveness, as indicated by repeated physical fights or assaults
5. reckless disregard for safety of self or others
6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work
   behavior or honor financial obligations
7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated,
   or stolen from another
   B. The individual is at least age 18 years.
   C. There is evidence of Conduct Disorder with onset before age 15 years.
   D. The occurrence of antisocial behavior is not exclusively during the course of
   Schizophrenia or a Manic Episode.

Question 17

Psychopathy distinguished from antisocial behaviour

Answer 17

• Cleckley (1976) distinguished between 2 groups of symptoms, which Hare (1998) argues differentiate between psychopathy and
antisocial behaviour
• Psychopathy is argued to consist of both emotional/interpersonal traits and social deviance – see below
• The diagnostic criteria for ASPD capture mainly the “Social Deviance” factor

Question 18

Borderline Personality Disorder

Answer 18

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

1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or selfmutilating
   behavior covered in Criterion 5.
2. a pattern of unstable and intense interpersonal relationships characterized by alternating
   between extremes of idealization and devaluation
3. identity disturbance: markedly and persistently unstable self-image or sense of self
4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,
   substance abuse, reckless driving, binge eating). Note: Do not include suicidal or selfmutilating
   behavior covered in Criterion 5.
5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
   irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
7. chronic feelings of emptiness
8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of
   temper, constant anger, recurrent physical fights)
9. transient, stress-related paranoid ideation or severe dissociative symptoms

Question 19

Histrionic Personality Disorder

Answer 19

A. A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts,

1. is uncomfortable in situations in which he or she is not the center of
   attention
2. interaction with others is often characterized by inappropriate sexually
   seductive or provocative behavior
3. displays rapidly shifting and shallow expression of emotions
4. consistently uses physical appearance to draw attention to self
5. has a style of speech that is excessively impressionistic and lacking in
   detail
6. shows self-dramatization, theatricality, and exaggerated expression of
   emotion
7. is suggestible, i.e., easily influenced by others or circumstances
8. considers relationships to be more intimate than they actually are

Question 20

Narcissistic Personality Disorder

Answer 20

A. A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts

1. has a grandiose sense of self-importance (e.g., exaggerates achievements and
   talents, expects to be recognized as superior without commensurate achievements)
2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal
   love
3. believes that he or she is “special” and unique and can only be understood by, or
   should associate with, other special or high-status people (or institutions)
4. requires excessive admiration
5. has a sense of entitlement, i.e., unreasonable expectations of especially favorable
   treatment or automatic compliance with his or her expectations
6. is interpersonally exploitative, i.e., takes advantage of others to achieve his or her
   own ends
7. lacks empathy: is unwilling to recognize or identify with the feelings and needs of
   others
8. is often envious of others or believes that others are envious of him or her
9. shows arrogant, haughty behaviors or attitudes

Question 21

Avoidant Personality Disorder

Answer 21

A. A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation,
beginning by early adulthood and present in a variety of contexts

1. avoids occupational activities that involve significant interpersonal contact,
   because of fears of criticism, disapproval, or rejection
2. is unwilling to get involved with people unless certain of being liked
3. shows restraint within intimate relationships because of the fear of being
   shamed or ridiculed
4. is preoccupied with being criticized or rejected in social situations
5. is inhibited in new interpersonal situations because of feelings of
   inadequacy
6. views self as socially inept, personally unappealing, or inferior to others
7. is unusually reluctant to take personal risks or to engage in any new
   activities because they may prove embarrassing

Question 22

Avoidant personality disorder distinguished from social anxiety

Answer 22

• Some argue there is no difference between Social Anxiety and AvPD
• Others argue that AvPD is characterised by more pervasive and diffuse avoidance

Question 23

Why is AvPD characterised by more pervasive and diffuse avoidance?

Answer 23

– Persons with SAD tend to avoid particular situations/activities that may involve scrutiny – may have friends/close relationships but avoid ‘performance’ situations
– Tend to be comfortable with persons whom they are close to/familiar
– Persons with AvPD tend to be concerned about intimate/close relationships more generally
– Closeness/intimacy and relationships may be avoided

Question 24

Dependent Personality Disorder

Answer 24

A. A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts

1. has difficulty making everyday decisions without an excessive amount of advice and
   reassurance from others
2. needs others to assume responsibility for most major areas of his or her life
3. has difficulty expressing disagreement with others because of fear of loss of support
   or approval. Note: Do not include realistic fears of retribution.
4. has difficulty initiating projects or doing things on his or her own (because of a lack
   of self-confidence in judgment or abilities rather than a lack of motivation or energy)
5. goes to excessive lengths to obtain nurturance and support from others, to the point
   of volunteering to do things that are unpleasant
6. feels uncomfortable or helpless when alone because of exaggerated fears of being
   unable to care for himself or herself
7. urgently seeks another relationship as a source of care and support when a close
   relationship ends
8. is unrealistically preoccupied with fears of being left to take care of himself or herself

Question 25

Obsessive Compulsive PD

Answer 25

A. A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency 1. is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost 2. shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met) 3. is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity) 4. is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification) 5. is unable to discard worn-out or worthless objects even when they have no sentimental value 6. is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things 7. adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes 8. shows rigidity and stubbornness

Question 26

Obsessive Compulsive PD comarpred to OCD

Answer 26

* Rigidity/rule bound behaviours are prescribed to because of the belief that they are the best person to control things * Often do not describe subjective feelings of anxiety * Having control does not relieve distress/anxiety as in OCD * OCPD is typically ego-syntonic, whereas OCD is usually ego-dystonic

Question 27

Other Specified Personality Disorder

Answer 27

``` – General criteria are met but criteria for a single diagnostic class are not met – Clinician specifies a particular reason that person does not meet criteria for a specific PD (e.g. mixed personality features) ```

Question 28

Unspecified Personality Disorder

Answer 28

– General criteria for a PD are met but do not fully meet criteria for a specific PD – Insufficient specific information available to make a definitive diagnosis OR – Clinician does not specify the reason criteria are met for a specific PD

Question 29

Personality Change | Due to Another Medical Condition

Answer 29

A. A persistent personality disturbance that represents a change from the individual’s previous characteristic personality pattern. B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition. Specify whether: – Labile type: If the predominant feature is affective lability. – Disinhibited type: If the predominant feature is poor impulse control as evidenced by sexual indiscretions, etc. – Aggressive type: If the predominant feature is aggressive behavior. – Apathetic type: If the predominant feature is marked apathy and indifference. – Paranoid type: If the predominant feature is suspiciousness or paranoid ideation. – Other type/combined/unspecified

Question 30

prevalence of PD

Answer 30

• Lifetime prevalence of PD ~ 10% • Harder to identify the rates for specific PD due to reliability issues and comorbidity • Best prevalence data is for antisocial PD – overall lifetime prevalence (men and women combined) = 3% • OCPD and AvPD seem to affect 3-4% • The prevalence rates for other PDs tends to be lower (about 1-2%), except for NPD which affects >1% • BUT comorbidity is a significant issue

Question 31

Heterogeneity of PD

Answer 31

Extreme heterogeneity among patients considered to have the same disorder -there are many different ways to exhibit each disorder

Question 32

Comorbidity of PD

Answer 32

* People may exhibit characteristics from across disorders * People many meet criteria for multiple PDs, as well as other disorders - excessive cooccurrence among disorders - at least 50% of people with PD, meet the criteria for some other PD – similar symptoms are used to describe more than one disorder * 75% of people with a PD will also meet criteria for other mental disorders (e.g. depression, anxiety etc) * Arbitrary diagnostic thresholds between normal and pathologic personality functions * Inadequate coverage of personality psychopathology, evident in the common diagnosis of other Specified or Unspecified PDs (Previously PD Not Otherwise Specified)

Question 33

Cloninger (2000) criticism of PD

Answer 33

“Our current official classification of personality disorders is fundamentally flawed by its assumption that personality disorder is composed of multiple discrete categorical disorders. The current list of clusters and categories are highly redundant and overlapping. Systematic diagnosis of so many categories is not feasible in clinical practice and unjustifiable in psychometric research. The predictive power of categorical diagnosis is weak and inconsistent”

Question 34

Gender differences in PD generally

Answer 34

Overall prevalence of PD about equal in men and women | Gender differences for other PD are more contentious

Question 35

Gender differences in antisocial PD

Answer 35

Antisocial PD is unquestionably much more common in men with rates of approx. 5% reported for men and 2% for women

Question 36

gender differences in BPD and DPD

Answer 36

BPD and DPD may be more prevalent in women than in men – but evidence is not strong

Question 37

Gender differences in paranoid and OCPD

Answer 37

Some speculation that paranoid and OCPDs are more common among men

Question 38

Gender Bias in PD diagnosis?

Answer 38

The definitions of some PDs are based on sex role stereotypes and are therefore are inherently sexist – The dependent type might be viewed as a reflection of typically feminine traits – unassertive, putting needs of others first – Is DSM “arbitrarily” labeling these traits as maladaptive? • Potentially, also clinicians may be biased in the way they diagnose their clients - more likely to diagnose a woman with borderline than a man, even if they display the same symptoms

Question 39

Course of PD

Answer 39

* Long term course by definition | * Present from adolescence/early adulthood and persistent

Question 40

Outcome of PD

Answer 40

Disruptive to relationships, work, sense of self

Question 41

Cause of PD

Answer 41

* No single cause/pathway – multifactorial aetiology * Recall equifinality and multifinality * Theoretical models can help to understand the motivations for particular behaviours

Question 42

Development and Childhood maltreatment as a cause of PD

Answer 42

Childhood maltreatment increases the risk for the development of any of the personality disorders • This link is particularly strong for Cluster B • A number of theories attempt to explain this link – attachment theory, mentalisation, object relations, cognitive, schema based, affect regulation • All suggest developmental capacities are affected in some way (probably multiple ways) leading to impairments see in PDs

Question 43

Adolescent girls and BPD

Answer 43

Adolescent girls with BPD report – a lack of supervision – frequent witness of domestic violence – being subjected to inappropriate behavior by their parents and other adults – verbal, physical, and sexual abuse (Helgeland & Torgersen, 2004; Pally, 2002).

Question 44

Childhood trauma and BPD

Answer 44

– Disrupts the attachment relationship – basic security, expectation that others are reliable and available – Impacts the developing self and process of separation-individuation – Undermines the development of affect regulation – experiences of co-regulation are necessary for development of self-regulation – Undermines capacity for mentalisation

Question 45

Linehan’s Diathesis-Stress | Theory

Answer 45

– Individuals with BPD have difficulty regulating their emotions (Possible biological diathesis) – Family invalidates or discounts emotional experiences and expression – Leads to further difficulty organising and regulating affect – Corresponds to the symptoms of BPD

Question 46

Treatment of BPD

Answer 46

* Psychotherapy is the main treatment | * Often long term

Question 47

Types of psychotherapy treatment

Answer 47

``` – Dialectical Behaviour Therapy – Schema Therapy – Interpersonal Therapy – Psychodynamic psychotherapies – Mentalisation Based Therapy ```

Question 48

Dialectical Behaviour therapy

Answer 48

* Emphasis on increasing tolerance of strong affective states – building resources to soothe intensity and, * Therapist’s stable presence, acceptance of the patient and challenging behaviours

Question 49

Medications used to treat BPD

Answer 49

– antidepressants (to treat depressive symptoms, anxiety) – Antipsychotics (work as a sedative to regulate lability in moods/transient psychotic thinking) – Lithium/mood stabilisers (to target emotional lability

Question 50

The relationship between Schizophrenia and PD - Schizotypal PD

Answer 50

* First degree relatives of patients diagnosed with Schizophrenia are more likely to meet criteria for Schizotypal PD * Has lead to the postulate that Schizotypal PD is genetically related to Schizophrenia

Question 51

Treatment of Schizotupal PD

Answer 51

* Limited treatment seeking and high rates of premature termination * Low doses of antipsychotic medications have been shown to be effective in some instances * Limited evidence for psychotherapy * Treatment often focuses on other comorbid issues – e.g. depression or substance abuse/dependence

Question 52

Kohut’s Self-Psychology Model to explain the aetiology of NPD

Answer 52

– Characteristics mask low self-esteem, feelings of worthlessness – The presentational self – In childhood, narcissism valued as a means to increase parent’s own self-esteem – People with high levels of narcissism often report cold parents who overemphasized child’s achievement/performane – May have been dismissing or mocking/devaluing of vulnerability, emotion and distress

Question 53

Social cognitive model to explain the aetiology of NPD

Answer 53

– Narcissist has low self esteem – Sense of self depends on achieving – Interpersonal relationships are a way to bolster self esteem rather than increase closeness to others – Cognitive biases that maintain narcissism

Question 54

Treatment of NPD

Answer 54

• Psychotherapy is main treatment • Low rates of treatment seeking due to difficulty acknowledging weakness/vulnerability • Treatment complicated by difficulty with interpersonal relationships • Often short term – present during a depressive episode/crisis, cease treatment following crisis • May be cyclical engagement • Psychodynamic psychotherapies focus on increasing willingness to acknowledge vulnerability and understanding the impact of defenses on relationships

Question 55

Genetics and ASPD

Answer 55

• offspring of convicted criminals raised by adoptive families show higher rates of arrests and antisocial personality disorder than controls • concordance rates for criminality are 55% for MZ twins and 13% for DZ twins – The genetic risk for APD, conduct disorder, and substance abuse are related – BUT, genetics interact with environment

Question 56

Family environment as a cause of ASPD

Answer 56

``` – Lack of warmth, negativity, and parental inconsistency – Poverty – Inconsistent discipline and poor parental monitoring – Exposure to violence – Marital conflict – Drug abuse – Criminal activity Argued to predict increased risk of ASPD ```

Question 57

Underarousal hypotheses as a cause of ASPD

Answer 57

– Low levels of anxiety and fear – Lower physiological response to frightening or disgusting stimuli – longitudinal study found that future criminals had lower skin conductance activity, lower heart rate, and more slow-frequency brain wave activity – Higher levels of impulsivity – Lower responsiveness to conditioning/punishment

Question 58

Treatment of ASPD

Answer 58

• Rarely seek treatment • May be referred via the legal system • Treatment tends to be time limited and focused on reducing recidivism OR targeting substance abuse/dependence • Some evidence that targeted interventions are effective in changing specific behaviours, but general character/personality remains unchanged

Question 59

The DSM 5 dimensional model of PD

Answer 59

personality disorders are characterized by impairments in personality functioning and presence of pathological personality traits. Impairment in personality functioning evaluated on a continuum in terms of disturbance in both self and interpersonal functioning

Question 60

Self functioning in DSM5 dimensional model

Answer 60

Self functioning involves identity and self-direction

Question 61

Interpersonal functioning in DSM 5 dimensional model

Answer 61

Interpersonal functioning involves empathy and intimacy

Question 62

General criteria fro PD

Answer 62

A. Moderate or greater impairment in personality (self/interpersonal) functioning. B. One or more pathological personality traits. C. The impairments in personality functioning and the individual’s personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations. D. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time, with onsets that can be traced back to at least adolescence or early adulthood.

Question 63

Identity in self functioning in DSM 5 criterion A

Answer 63

1. Identity: Experience of oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a range of emotional experience.

Question 64

self-direction in self functioning in DSM 5 criterion A

Answer 64

2. Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behavior; ability to self-reflect productively.

Question 65

Empathy in interpersonal functioning in DSM 5

Answer 65

1. Empathy: Comprehension and appreciation of others’ experiences and motivations; tolerance of differing perspectives; understanding the effects of own behavior on others.

Question 66

Intimacy in interpersional function in DSM 5

Answer 66

2. Intimacy: Depth and duration of connection with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior.

Question 67

Pathological Personality Traits in criterion B if DSM 5

Answer 67

• One or more pathological personality traits • Pathological personality traits are organized into five broad domains (similar to the Five factor Model, but trait labels emphasise maladaptive nature): – Negative Affectivity – Detachment – Antagonism – Disinhibition – Psychoticism • Within the five broad trait domains are 25 specific trait facets and how they may be associated with current categories of PD