what is it that PD lacks from normal personalities?
Normal personalities are stable over time but also v flexible i.e. we know what ti inhibit during certain times
- It is this flexibility that people with PD often lack
- Enduring, rigid pattern of inner experiences and outward behaviour that impairs their sense of self-worth, emphatic abilities, intimacy issues
Is it over diagnosed?
- shown to be overdiagnosed in ED
- Biases in what actually diagnosed with
- Easy to attach the label “borderline” to virtually any client who is extremely difficult to deal with
- Symptoms overlap massively - bound to fit the “criteria” for one PD
DSM 4 + 5 both still use categorical approach - what are the clusters?
a) Odd and eccentric behaviour (Paranoid PD;suspicious// Schizotypal PD; magical thinking, isolation// Schizoid PD; emotionless + avoid social relationships)
b) Dramatic, emotional or erratic (antisocial PD//BPD//Histronic//Narcissistic PD)
c) Anxious or fearful (avoidant PD// dependent PD//obsessive compulsive PD; need order,control,strict code)
Validity of DSM5 categories?
- the symptoms normally overlap so much clinicians have trouble distinguishing the two = resulting in a lot of disagreement between clinicians
- should be seen as the degree of dysfunction NOT Y/N
Schizotypal PD
- mentioned twice in the DSM 5
- once under SZ disorders + once under PD
- surely this should give rise to dimensional approach?
- often comorbid with MDD too
antisocial PD and psychopathy?
However, the definition for antisocial personality disorder also differs from the definition for psychopathy in important ways.
- But the two are now independent diagnoses
- Psychopathy has antisocial elements to it
- Lack of fear response and anxiety in psychopathy + show more attention seeking
BPD
WHAT (4)
- Instability including ,mood shifts, unstable self-image + impulsivity
- Swing in and out of very depressive/anxious states that can last for short periods or long periods/ anger prone
- Impulsivity puts them @ risk; suicide is extremely common in BPD
- Easily become furious when their expectations are broken BUT remain very attached in relationships//have fears about abandonment
Causes of BPD
NOTE: THE BIOSOCIAL THEORY OF BPD IS THE SAME FOR ED:
- if parents don’t teach their children how to respond accurately to their feelings or needs (internal cues) they may never learn to id emotions
- **large number of people with ED have an BPD
- difficulty in identifying emotions as an adult
ALEXITHYMIA = The very heightened emotions they express outwardly are unidentifiable inwardly and they often cannot identify the emotions of those they are unintentionally hurting
when self-injury or drug abuse is involved it is often misconstrued as an intended suicide attempt; however, its purpose is to regulate unbearable emotional states.
BPD Should this disorder be treated as a form of PTSD?
- Similarities (2) + differences (3)
- People have said that they have defining differences while also being similar. They also normally occur together; BPD diagnosis common in PTSD + vice versa
Main differences:
(1) Frantic efforts to avoid real or imagined abandonment (i.e. PTSD don’t fear abandonment)
(2) Markedly and persistently unstable self-image or sense of self
(3) Impulsiveness
Avoidant PD vs SAD?
many people who are diagnosed with one are diagnosed with the other
BUT
THE KEY DIFFERENCE BETWEEN THE TWO = PEOPLE WITH SAD PRIMARILY FEAR SOCIAL CIRCUMSTANCES w unknown people
AVOIDANT PD FEAR SOCIAL RELATIONSHIPS//a fear of emotional intimacy and rejection. Often have history of neglect
VRET good for both tho **
But others suggest that the two should be combined.
OCD vs OCPD
- OCD + OCPD are related. Share a number of factors BUT those with OCPD are more likely to struggle with MDD, GAD and substance use disorder than from OCD. There is NOT a consistent link between the two
DIFFS
1) OCD = true obsessions; OPCD = not got uncontrollable thoughts or behs that have to do over and over
2) OCD = distressed + seek help // OCPD = usually not seek help because they don’t see anything they are doing is particularly abnormal or irrational and behs have purpose
3) OCD = fluctuates like anxiety// OCPD = inflexible (PD)
Multicultural Factors: Research Neglect
a) problem
b) implications
- for a diagnosis of PD = a person must deviate from the norms of their culture
BUT THE PROBLEM IS -> so little multicultural research has actually been done
BPD implication:
- 75% of BPD diagnoses are women
a) diagnostic bias?
b) Or that women are exposed to more trauma as children (recall this disorder normally stems from childhood experiences; violence,trauma, sexual abuse) (prereq to BPD)
c) Should it be treated as PTSD? (No)
d) BPD the female psychopathy? Share similar aetiological pathways in women - *Psychopathy is a condition characterized by deficits in emotional processing, interpersonal relationships, and self-regulation.
- **IN WOMEN the symptoms of BPD and psychopathy overlap
- ***frantic efforts to avoid abandonment & wavering between devaluation and idealization =
- implusivity/aggression etc on one hand (F2)
- F1 (callousness/ emotional restriction/disengagement) occurs on the other
> has several implications for the “antisocial/psychopathic” and “borderline” personality types in the proposed DSM-5.
- Some features of BPD are perfectly acceptable traits and behaviours in some cultures?
a) i.e. in Puerto Rico = men are expected to show intense emotions – why Hispanics most likely to develop BPD?
Diagnosing personality disorders - problems with the current way (5)
1) Some of the criteria that is used to diagnose the DSM 5 PD cannot be observed directly - must ask them why they do what they do (Schizoid PD) - relies on clinician
2) profs differ widely in their judgements ( even some think that it is wrong to make personality traits into disorders regardless) — for example, there are 256 ways that five out of nine criteria for the diagnosis of borderline personality disorder can be configured, and two patients could receive this diagnosis but share only one criterion.
3) PDs are very similar to each other + people can meet the criteria for multiple PDs
4) Different personalities can qualify for the same DSM PD
5) the categorical approach conveys the impression that the disorder is either present or it is not, rather than that a symptom and trait pattern can vary along a gradient of severity
Big 5 + PD
Super traits =Neuroticism, extroversion, openness to experiences, agreeableness, conscientiousness
SUGGESTION = Best way to describe people with PD is being high or low or in between on the supertraits and drop PD categories
EG avoidant PD = would be described as having high degree of neuroticism, medium agreeableness + consciententiousness, with low extraversion and openness
Evidence for the use of big 5 and PD?
this is being looked @ a lot and might be in the next ICD
Advantages of the FFM of personality disorder include the provision of precise, individualized descriptions of the personality structure, the inclusion of homogeneous trait constructs that will have more specific treatment implications, and the inclusion of normal, adaptive personality traits that will provide a richer and more appreciative description of each patient.
DSM 5 & alternative dimensional approach for PD
what?
“personality disorder- trait specified” - hybrid model; retains the 6 subtypes + if dont fit those you get this
- This diagnosis can now be utilized as more than just a “rule‐out” diagnosis – it indicates that a patient does meet the general criteria for a personality disorder, does not qualify for any of the six designated personality disorders,
- traits that impair functioning = diagnosis of PD
- should list the problematic traits + rate their severity of impairment caused by them
- 5 groups of problematic traits & if anyone is impaired by one of these traits they receive personality disorder- trait specified
- each ‘trait’ is made up of subtraits; E.G. “negative affectivity” – person has to score on anxiousness, submissiveness, depressivity etc + adjust the diagnosis to fit it
Problem with DSM 5 & alternative dimensional approach for BPD
Problem with this method of diagnosis: allow clinicians to diagnose with PD to an enormous range of personality patterns
DBT for BPD
DBT encourages clients to accept their painful emotions while acknowledging that they are unhealthy and need help.
It teaches patients specific coping skills, such as mindfulness (observing their own thoughts and feelings non-judgmentally), tolerating distress and mastering negative emotions and group social skills
- The only empirically supported treatment for BPD
- The components work together to teach behavioral skills that target common symptoms of BPD, including:
- unstable sense of self
- chaotic relationships
- fear of abandonment
- emotional lability,
- impulsivity
cbt vs dbt bpd
DBT is simply a modified form of CBT that uses traditional cognitive-behavioral techniques, but also implements other skills like mindfulness, acceptance, and tolerating distress.
BUT in CBT
CBT focuses on cognitie restructuring + behavioral changes, like reducing self-defeating behaviors and learning how to respond to problems in a healthy, adaptive manner.
need to learn how to identify and tolerate emotions (mindfulness/DT) before trying to restructure the thoughts that these emotions lead to*
adaptive aspects of traits?
i.e. if they’re truly ‘disorders’ why havent they been weeded out via evolution?
E.G. Psychopathy:
successful traits - CEOs
a) competitive behaviours = important in some environments (jobs/urban)
b) Frequency – dependent selection theory: if in an environment which is for cooperation – more the psyhcopaths get. The less psychopaths the better.
c) Life-history strategy – more rsiky sexual encounters = more offspring
(Highly resilient BUT due to riskiness have a lower life expectancy)
To what extent is it ok for us to say someone has a disordered personality?
YES:
- psychopaths produce a lot of offspring (life-history strategy) = BUT don’t care about their offspring & leave them
- highly resilient but have high risk taking personality = reduced life expectancy
NO –> yes:
- psychopaths can be successful people - i.e. CEOs & not all psychopaths are killers as the media portrays them BUT these are more likely to commit fraud as a CEO.
- Narcissism - who says that high SE is bad? BUT leads to social isolation so is bad
labelling & PD
1) Less likely to recognise or encounter PD = more stigma
2) Dangerousness and uncontrollability = negative perceptions = dangerousness is seen in SZ/psychopathy but in depression its less cos theres less dangerousness associated
3) Media mediates it = portrayed as “evil” E.G psychopaths seen as “killers” in cinema but recorded greater attention as strongly stigmatised as mental illness – seen as more dangerous – more stigma
psychopathy = What is the distinguishing factor between one committing crimes OR one being successful?
- SES (high vs low) relates to:
- Learning how to get what want; i.e. driven or targeting
- Executive functioning
