1
Q
What is the DSM-5 general definition of personality disorders?
A
- “A personality disorder is 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 in early adulthood, is stable over time, and leads to impairment.” DSM-5 (APA, 2013, p.645)
- DSM-5 published in 2013 (potentially outdated) and nothing changed in personality disorders since then
2
Q
What is the DSM-5 general diagnostic criteria for personality disorders?
A
- The pattern of inner experience is manifested via two or more of: (1) cognitions, (2) affectivity, (3) interpersonal functioning and (4) impulse control
- Is inflexible and pervasive across personal and social contexts
- Leads to clinically significant distress or impairment in social, occupational, or other areas
- Is stable and can be traced back to adolescence or earlier
- Is not better accounted for by another mental disorder
- Is not due to physiological effects of substance or general medical condition such as traumatic brain injury
3
Q
What is a useful mnemonic for personality disorders?
A
PIMS:
- Persisting
- Inflexible
- Maladaptive
- Significant impairment or distress
4
Q
What is the categorical classification of personality disorders (one side of the debate)?
A
o Presence or absence of a PD (often measured by number of symptoms)
o PDs are qualitatively distinct from each other, and from normal personality (big 5 traits)
o No assumptions are made about the underlying dimensions or structure of PDs
5
Q
What is the dimensional classification of personality disorders (other side of the debate)?
A
o Personality manifests on continuous dimensions of traits
o PDs are quantitively distinct from normal personality
o PDs manifest as extreme and maladaptive levels of personality traits
6
Q
Which classification system does the DSM-5 use currently?
A
DSM-5-TR (March, 2022) still contains categorical classification system, but this has been much debated as to whether it’s the right approach
7
Q
What is the DSM-5 categorical classification of PDs?
A
- Based on descriptive similarities, not empirical work
- Cluster A (“eccentric, odd”) = paranoid, schizoid, schizotypal
- Cluster B (“erratic, emotional) = antisocial, borderline, histrionic, narcissistic
- Cluster C (“fearful, anxious”) = avoidant, dependent, obsessive-compulsive
8
Q
What are the other two categories (separate to clusters A, B or C) in the DSM-5?
A
- Personality change is due to another physiological or medical condition
- Other specified PD or unspecified PD:
o Individual meets the general diagnostic criteria for PDs but does not meet the full criteria for any one of the 10 PDs e.g. shows 3 not 4 symptoms of one PD or may be because DSM gets updated and PDs removed/changed
o Insufficient evidence for the clinician to make diagnosis of one PD
9
Q
What is paranoid personality disorder (A)?
A
- Paranoid PD = distrust and suspicion of others across contexts and without basis. Seek to be independent and in control of situation
- Must show 4 or more:
o Suspects others of harming, plotting or deceiving
o Doubts trustworthiness of friends
o Suspects infidelity in relationships
o Reluctant to confide in others
o Reads hidden meaning into remarks
o Bears grudges and does not forgive
o Perceives attacks and reacts quickly with anger
10
Q
What is schizoid personality disorder (A)?
A
- Schizoid PD = detachment from relationships and restricted emotional expression. Lack of interest in relationships
- Must show 4 or more:
o Does not seek or enjoy relationships
o Little interest in sexual relationships
o Prefers solitary activities
o Enjoys very few activities (which other people would find joy in)
o Lacks close confidants
o Indifference to praise or criticism
o Emotional coldness, detachment and flattened affect
11
Q
What is schizotypal personality disorder (A)?
A
- Schizotypal PD = pervasive discomfort with relationships (from social anxiety). Eccentric behaviour and cognitive or perceptual distortions. Believe their thoughts can will things to happen, and have distinctive/unique speech patterns
- Must show 5 or more:
o Odd beliefs, outside norms
o Odd thinking and speech patterns
o Perceptual illusions
o Odd or incorrect interpretations of events
o Peculiar behaviour
o Suspicious or paranoid
o Lack of confidants
o Social anxiety that does not lessen with familiarity with others
o Inappropriate or constricted affect
12
Q
What is antisocial personality disorder (B)?
A
- Antisocial PD = persuasive disregard of the rights and welfare of others since or before 15 years of age (often diagnosed with conduct disorder before age 15)
- Must show 3 or more:
o Lack of conformity to social norms
o Lying, deceiving others for profit or pleasure
o Impulsivity
o Irresponsibility and failure to maintain obligations
o Irritability and aggressiveness
o Reckless disregard for safety of self and others
o Lack of remorse
13
Q
What is borderline personality disorder (B)?
A
- Borderline PD = pervasive and instability of inter-personal relationships, self-image, and affect. Marked impulsivity and heightened sensitivity to abandonment
- Must show 5 or more:
o Frantic efforts to avoid abandonment (real or imagined)
o Extreme idealization and devaluation in relationships
o Identity disturbance
o Impulsivity in at least two areas – sex, spending, drinking
o Recurrent suicidal gestures and/or self-harm
o Persistent feelings of emptiness
o (Short lived) reactivity in mood
o Inappropriate anger
o Transient, stress-related paranoia or severe dissociative symptoms
14
Q
What is histrionic personality disorder (B)?
A
- Histrionic PD = persuasive and excessive emotionality and attention seeking behaviours. Lively/dramatic and initially charming
- Must show 5 or more:
o Uncomfortable if not centre of attention
o Interactions often inappropriately sexual or provocative
o Rapidly shifting and shallow emotional expression
o Gains attention through physical appearance
o Speech is impressionistic and lacking in detail
o Self-dramatization, theatrical expression of emotion
o Suggestable
o Considers relationships more intimate than they are
15
Q
What is narcissistic personality disorder (B)?
A
- Narcissistic PD = grandiosity, need for admiration and lack of empathy. Inflated sense of own importance which they believe should be endorsed by other people. Often actually have a fragile sense of self-esteem (compensating for)
- Must show 5 or more:
o Grandiosity (without commensurate achievements)
o Preoccupied with fantasies of power or success
o Requires excessive admiration
o So gifted, few people can understand them
o Arrogance
o Sense of entitlement
o Interpersonally exploitative
o Lacks empathy
o Envious of others and believes others envy them
16
Q
What is avoidant personality disorder (C)?
A
- Avoidant PD = persuasive social inhibition, inadequacy, and hypersensitivity to negative evaluation
- Must show 4 or more:
o Avoids interpersonal contact due to fear of rejection or disapproval
o Only involved with people where certain to be liked
o Restraint in relationship to avoid ridicule
o Preoccupation with social rejection
o Reluctant to take socials due to fear of failure or embarrassment
o Views self as socially inept
17
Q
What is dependent personality disorder (C)?
A
- Dependent PD = persuasive need to be taken care of. Submissive and clingy behaviour. Argued comes from feeling of inadequacy and can’t take care of selves
- Must show 5 or more:
o Difficulty making everyday decisions without advice or reassurance
o Needs other to take responsibility
o Difficulty expressing disagreement due to fear of loss
o Difficulty initiating projects
o Goes to great lengths to gain support and nurturance
o Uncomfortable when alone
o Immediately seeks new relationship when one ends
o Preoccupied with fears of being left to care for oneself
18
Q
What is obsessive-compulsive personality disorder (C)?
A
- Obsessive-Compulsive PD = pervasive pre-occupation with order, perfection and control at the cost of flexibility – stubborn, rigid, striving for perfection
- Must show 4 or more:
o Preoccupied with details, rules, lists
o Perfectionism hinders completion
o Devoted to work at expense of leisure and relationships
o Inflexible about morals/ethics
o Rigidity and stubbornness
o Reluctant to delegate unless others follow exact instructions
o Unable to discard items (even with no value)
o Misery form of spending on self and others
19
Q
What are some challenges with the categorical approach according to Hopwood et al.’s (2018) commentary?
A
- ‘The time has come for dimensional personality disorder diagnosis’:
- No evidence supporting presence of 10 discrete PD categories (clusters descriptive)
- Diagnostic comorbidity between 10 PD categories (if diagnosed with one PD, likely to be diagnosed with at least 1-2 more)
- Within-disorder heterogeneity (don’t have to show same 4/7 symptoms – same diagnosis but potentially different symptoms between people)
- Few validated interventions for the 10 distinct PD categories
- Categorical approach lacks evidence base when compared to trait approach
20
Q
How did Marinangeli et al. (2000) provide evidence for comorbidity in PD classification?
A
- Examined the issue of comorbidity in PD classification using secondary data set
- 156 participants (90 women) voluntarily admitted to a psychiatric ward
- Semi-structured clinical interview (SCID-II) for PD classification based on DSM-3 criteria
- 26.3% didn’t have PD, 18.6% did
- 10% had a diagnosis of 4 personality disorders, indicating they are not as distinct as they appear
- E.g. all with borderline PD also had other PD except schizoid
21
Q
What is the FFM?
A
- Model for normal/adaptive personality traits which takes a dimensional approach
- Psychoticism also considered a dimensional personality trait (Eysenck, 1952)
22
Q
What were Samuel and Widiger’s (2008) aims and methods?
A
- Conducted a large meta-analysis to investigate relationship between FFM traits and PDs
- To be included, studies had to measure all 30 facets of the FFM and all 10 DSM categorical personality disorders
- In total, 16 studies were included, comprising 18 independent samples and 3207 participants
23
Q
What were Samuel and Widiger’s (2008) results?
A
- There are relationships between PDs and 5 personality traits (with the exception of openness) – normal traits shouldn’t correlate with PDs
- Normal personality traits could be used to understand PDs but not openness at the trait level
- E.g. cluster A (struggle trusting) correlated with neuroticism and low extraversion
- E.g. cluster B – antisocial correlated with low agreeableness and low conscientiousness
- E.g. cluster C – obsessive-compulsive only correlated with conscientiousness
- Relationships which make sense, but there are issues e.g. all of these PDs are fairly highly correlated with neuroticism i.e. doesn’t differentiate between them
24
Q
What is the dimensional approach to PDs with 5 traits?
A
- Widiger and Simonsen (2005)
o Reviewed 18 proposals that could update DSM-3 with a dimensional approach to PD classification
o Differences in 18 approaches but proposals can be integrated into a hierarchical structure of maladaptive personality traits - Theoretically proposed 5 broad traits:
o Extraversion (active, talkative) – Introversion (withdrawn, inhibited)
o Antagonism (suspicious, deceptive) – Compliance (cooperative, trusting, empathetic)
o Constraint (disciplined, rules, rigid) – Impulsivity
o Negative Affect – Emotional Stability
o Unconventionality – Closed to Experience
25
How did Krueger et al. (2021) empirically validate a dimensional approach for use in DSM-5?
- Measure maladaptive traits dimensionally (like normal traits)
- PID/5
- Detachment = absence of E
- Disinhibition = absence of C
- Antagonism = absence of A
- Negative affect = presence of N
- Psychoticism = no clear consensus (presence of O?)
- Facets for each in notes
26
What is a hybrid approach to diagnosing PDs (Skodol et al., 2015)?
- DSM-5 Section 3 Alternative Model of Personality Disorders (AMPD) (diagram in notes)
- Step 2 = dimensional traits
- Step 3 = categorical PDs
- Criteria A (step 1) = Maladaptive Personality Functioning assessed from 0 (no impairment) to 5 (extreme impairment). Level of personality functioning scale
- Criteria B (step 2) = Maladaptive Personality Content
- Took 6/10 PDs and said if showing this PD, you would show this profile of maladaptive traits (looking at facet levels)
27
How may the AMPD be applied to the classification of borderline PD?
- Moderate impairment in at least two areas of identity, self-direction, empathy, and intimacy
- Experience of 4+ of these 7 facets of maladaptive traits:
- Emotional liability, anxiousness, separation insecurity, or depressively (Negative Affectivity)
- Impulsivity and risk taking (Disinhibition)
- Hostility (Antagonism)
- At least one of these 3 facets must be present for diagnosis
- Alternative approach clinicians can use, but main approach remains categorical
28
How did Samuel et al. (2013) show that neuroticism and borderline PD share a structure?
- Archival data of a clinical sample of 370 participants receiving treatment for substance abuse
- PD diagnoses in sample – antisocial (58%), borderline (33%) and avoidant (18%)
- Self-report measures of normal traits (FFM) and a clinical interview (via DSM-4) for PDs
- Fairly high amounts diagnosed with anti-social and borderline PDs
- They selected the FFM items from neuroticism trait most characteristic of borderline PD
- Looked at relationship between neuroticism and borderline PD
- Used IRT analysis (latent structure of traits) – are there shared similarities?
- Put in items in Borderline diagnostic criteria and items from neuroticism personality questionnaire
- If alpha levels approaching or over 1, loading on same trait/concept
- All items had high alpha levels – loading on same latent trait
- Maybe neuroticism and borderline share a structure
29
What is the relationship between DSM-5 Alternative Model and FFM?
- Watson et al. (2013) examined correlations between Big Five Inventory (FFM), SNAP-2 (Psychoticism) and PID-5 (DSM-5)
- Relationships as we would expect them e.g. negative affectivity and neuroticism, disinhibition and conscientiousness (negative), psychoticism and peculiarity, antagonism and agreeableness (negative) – indicates there is an underlying structure which applies to PDs as well
- Still no relationship with openness to maladaptive personality
- Detachment = same strength/magnitude of relationship for neuroticism and extraversion
30
What did Suzuki et al. (2017) find about how similar traits are in FFM and DSM-5 Alternative Model in relationships to key outcomes?
- Administered PID-5 (DSM-5) and NEO PI-R (FFM) and measured life satisfaction, social adjustment and key behaviours (academic grades, drinking habits)
- Calculate statistical profile of similarity – how significantly explaining same relationship
- Higher scores = higher similarity
- In all except openness, there is high level of similarity
- Indicated PDs might be best represented on a dimensional level and extreme versions of maladaptive personality traits
31
What did Suzuki et al. (2017) find about the temporal stability of the DSM-5 alternative model?
- Suzuki et al. (2017): do FFM traits and DSM-5 Alternative Model traits show similar temporal consistency?
- High test-retest reliability for FFM domains but also found same pattern for maladaptive traits (PIDS-5 domains)
- Perhaps not qualitatively different
32
What did Ahmed et al. (2013) find about the clinical utility of dimensional classification?
- Ahmed et al. (2013) compared taxonic vs. dimensional classification of schizotypal PD (cluster A) on key outcomes
- Two large and national samples from UK and US
- Participants completed the structured clinical interview for DSM-IV
- Dimensional scale done on severity of impairment
- Categorical relationships are lower
- All apart from SCAN are significantly different and in favour of dimensional
33
What did Anderson et al. (2014) find about the clinical utility of dimensional classification?
- Anderson et al. (2014) compared taxonic vs. dimensional classification of borderline PD (cluster B) on key outcomes, including self-harm, antisocial, and risky sexual behaviours
- Clinical sample – 167 newly admitted US patients to a psychiatric ward
- University sample – 399 students in the US
- Administered PID-5 for maladaptive traits (DSM-5) and BPD section of DSM-4 Axis II personality questionnaire (SCID-II-PQ) in both samples
- In both samples, categorical (taxonic) and dimensional maladaptive traits were correlated with key outcomes
- In both samples, the dimensional maladaptive trait model tended to perform better than the categorical model
- Section 2 = categorical, section 3 = dimensional
- When already dimensional and add categorical, only improved in one case
- When already categorical and add dimensional, improved in all cases
- Clinical utility/greater precision with dimensional approach
34
What are the advantages of the DSM-5 Alternative Personality Trait Model (Krueger & Makron, 2014)?
- Empirical model that extends knowledge of FFM into maladaptive personality traits
- It predicts clinical outcomes above and beyond categorical classification
- More in accordance with the complexity of syndromes observed in clinical practice
- Finer analyses can be made of the patient characteristics
35
Decks in class (8)
# Cards
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Lecture 1 - Introduction to Trait Approaches to Personality31
-
Lecture 2 - Eysenck's and Gray's Models of Personality61
-
Lecture 3 - Five Factor Models of Personality32
-
Lecture 4 - Intelligence31
-
Lecture 5 - Narrative Identity37
-
Lecture 6 - Personality Disorders35
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Lecture 7 - Wealth, Happiness and Health45
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Lecture 8 - Personality and Wellbeing40
