Conceptualizing Personality Disorders
Inflexible patterns of maladaptive behaviour that become generalized and trait like over time and lead to distress of impairment.
Impact individuals with disorder and cause distress for other people
DSM - 5 Personality Disorder
Criterion A: Behaviour must be manifested in at least two of the following areas: cognition, emotions, interpersonal functioning, or impulse control
Criterion B: Behaviour is rigid and consisten
Criterion C: Behaviour should lead to clinically significant distress
Criterion D: Onset in adolescence or earlier
Criterion E: Behaviour cannot be accounted for by another mental disorder
Criterion F: Behavioural patterns are not the result of substance use or another medical condition
Clusters of Personality Disorder
Cluster A: Odd and eccentric disorders (paranoid, schizoid, and schizotypal)
Cluster B: Dramatic, Emotional, or Erratic Disorder
Cluster C: Anxious, Fearful disorders (avoidant, dependent, and obsessive compulsive)
Diagnostic Issues
Low reliability of their diagnosis, poor etiology, weak treatment efficacy.
John Livesey (Canadian Researcher) and colleagues argue that they are better viewed as constellations of traits which lie across a continuum
Gender and Cultural Issues; Reliability of Diagnosis; Comorbidity and Diagnostic Overlap
Gender and Cultural Issues (PD)
Ensure clients functioning does not simply reflect normative responding in client’s culture.
Clinicians may misdiagnose if they do not take adequate precautions to determine whether certain attitudes and behaviours are appropriate for distinct cultures or societal subgroups.
Sx role stereotypes may influence the clinicans determination of the presence of personality disorders (ex. clinicians have ben shown to be reluctant to diagnose males with histrionic personality disorder and are unlikely to consider females as having ASPD)
Reliability of Diagnosis (PD)
Early field trials with DSM - II revealed that poor reliability for the personality disorders, suggesting clinicians often fail to agree on a particular diagnosis for a specific patient, however likely that most personality disorders can be reliably diagnosed given enough information and effort
Sometimes consequences of missed PD diagnosis can be devastating
Comorbidity (PD)
Used to describe the co occurence of two or more different diagnoses for one person
Overlap
Similarity of symptoms in two or more different disorders.
Diagnostic criteria should be distinct, but for some PD switch the criteria remain sufficiently vague or require such significant inference by the clinician that overlap seems likely
Cluster A: Odd and Eccentric Disorders
Schizoid Personality Disorder; Schizotypal Personality Disorder; Antisocial Personality Disorder; Borderline Personality Disorder; Histrionic Personality Disorder; Narcissistic Personality Disorder; Avoidant Personality Disorder; Dependent Personality Disorder; Obsessive Compulsive Personality Disorder
Schizoid Personality Disorder
Comes across as being detached, aloof, or self absorbed. Rarely experience intense emotions and may be puzzled by passions of others. Tend to spend time alone and can appear cold and indifferent towards others. Avoid social activities and do not seek or desire sexual relations
Schizotypal Personality Disorder
Pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour.
Major presenting features of individuals with schizotypal personality disorders are eccentricity of thought and behaviour. Many are extremely superstitious and have thoughts that a permeated by odd beliefs. Individuals with this condition may engage in magical thinking and believe in paranormal phenomena (telepathy); it is not uncommon for these individuals to see these skills in themselves
Some similarities with schizphrenia
Antisocial Personality Disorder
Pattern of disregard for, and violation of, the rights of others.
Criminal lifestyle - Not all patients with ASPD commit crimes, although most of them who are diagnosed by clinicians have a criminal record.
Essential feature of ASPD is a pervasive pattern of disregard for and violation of the rights of others that begin in childhood or early adolescence and continues into adulthood. The increasing indices of the disorder introduced since DSM-II has raised concerns regarding the relation of the diagnostic criteria to clinical conceptions of the related construct of psychpathy
DSM-5 Criteria of ASPD/APD
Three or more symptoms must be present
1) Nonconformity
2) Callousness
3) Deceitfulness
4) Irresponsibility
5) Impulsivity
6) Aggressiveness
6) Recklessness
Etiology of ASPD
Initially, social and family factors were highlighted. View was that parental behaviours can influence the development of antisocial functioning, leading to application of family systems approaches to treatment which empirically determined risk factors are targeted within a family centred model of service delivery.
Multisystemic therapy approach has produced promising outcome data and has further encouraged idea that disruptive families are causal factors in disorder.
Moffits work on developmental trajectories indicate that a minority of youth become involved in rule breaking and delinquent behaviour at an early age and is sustained through lifespan in one form or another. Research also suggests importance of familial/parental factors and genetic features as risk factors for developing ASPD.
Neuropsychological markers that in combination with specific environmental circumstances, interact to make children vulnerable to developing an antisocial lifestyle and personality
ASPD Treatment
Responsivity Factor - treatment must be responsive (or matched) to a particular patients needs and interpersonal style
Includes a focus on som ecombination of aggressive and antisocial attitudes and beliefs, impulsivity or poor self regulation, social skills, anger, assertiveness, substance abuse, empathy, problem solve and moral reasoning.
Pharmacotherapy also works however side effects of long term drug use and problems of noncompliance hade been noted in forensic patients
Short term use of antipsychotic, anti anxiety and sedative medication is not uncommon, symptom alleviation is rarely sustained and patients are typically provided with no new skills to improve their ability to deal with future situations
Borderline Personality Disorder
Pattern of instability in interpersonal relationships, self image, and affects, and marked impulsivity.
Can be characterized by instability across various domains of personal functioning
Specific Features of BPD
a) Fluctuations in and difficulty regulating emotions
b) Unstable sense of one’s identity
c) Instability in social relationships
d) Impulsive behaviour
Not uncommon to engage in non suicide self injury
Unable to tolerate being alone and can become desperate about relationships - ex. may go to extreme lengths to avoid being alone
NSSI (Non Suicidal Self - Injury)
One diagnostic criterion for BPD. Engagement in suicidal ideation or suicidal behaviour, including suicide attempts. Rates of NSSI among those meeting criteria for BPD can be as high as 70% especially in adolescent populations.
BPD Etiology
Evidence strongly implicates disruptions in family or origin and childhood abuse and neglect as very significant factors in development of borderline personality disorder.
Murray suggested an association between minimal brain dysfunction on perceptual processes may interfere with effective parent - child relationships and these effects may continue to disrupt relationships throughout the lifespan
Recent study examined brains of individuals with BPD and revealed that these individuals have significantly reduced right hippocampal volumes compared to healthy participants
BPD Treatment
Dialectical Behaviour Therapy - developed by Marsha Linehan. Attracted major international attention
One of the main features is the acceptance by the therapist of the patients maladaptive and at times self destructive behaviours.
Several standard behavioural procedures are used, sucha s exposure treatment for internal and external cues that evoke distress, skills training, contingency management and cognitive restructuring
Histrionic Personality Disorder
Pattern of grandiosity, need for admiration and lack of empathy.
Can sometimes be “life of the party” - attention seeking behaviours tend to characterize people with this disorder.
Overly dramatic in emotional displays, self centred, constantly attempting to be centre of attention.
May dress provocatively and be overly sexualin inappropiate contexts such as a job interview
Flamboyant displays of those with HPD are intended to make others focus on them, as they are unable to tolerate being ignored
Narcissistic Personality Disorder
Consider themselves to have unique and outstanding abilities
Exaggerated sense of self importance - egocentricity s staple charcteristic
Preoccupied with their own interests and desires that they typically have difficulty feeling any concern for others
Easily hurt by any perception that their greatness is not being recognized
Characteristics include grandiosity, egocentricity, elevated sense of self importance
Avoidant Personality Disorder
Pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
Avoidant personality disorder is characterized by a pervasive pattern of avoiding interpersonal contacts and an extreme sensitivity to criticism and disapproval.
Avoid intimacy with others, although clearly desire affection - as a result, they frequently experience terrible loneliness
Fundamental fear is social rejection
Dependent Personality Disorder
Pattern of submissive and clinging behaviour related to an excessive need to be taken care of.
Afraid to rely on themselves to make decisions
Seek advice and direction from others, need constant reassurance, seek out relationships in which they can adopt a submissive role
Desperately need other people to assume responsibility onto others for important aspects of their lives
Unable to function independently and typically ask their spouse or partner to decide what job they should seek or what clothes to purchase
