Personality Disorders

1) Inflexible and maladaptive traits 2) Treatment3) Distressing4) Early onset and long-lasting 5) Ego-syntonic 6) Pervasive

Personality Disorders (PDs)

CognitionInterpersonal functioning Impulse controlAffectivity

Areas affected by PD

Categories ◦ Medical Model◦ DSM

Dimensions◦Psychology◦Circumplex◦The Big Five

Conceptualization

Cluster A – odd or eccentricCluster B – dramatic or erraticCluster C – anxious or inhibited

PD NOS

Types of DSM-IV PDs

0

30

60

90

120

150

180

210

240

270

300

330

0 11 SDFPAR

AVD

HIS

DEPSZD

ANT

NAR

Assured-Dominance

Unassured-Submissive

Warm-Agreeable

Cold-Hearted

Gregarious-Extraverted

Unassuming-Ingenuous

Aloof-Introverted

Arrogant-Calculating

0

30

60

90

120

150

180

210

240

270

300

330

0 0.20.2 0.40.4 0.60.6

Assured-Dominance

Unassured-Submissive

Warm-Agreeable

Cold-Hearted

Gregarious-Extraverted

Unassuming- Ingenuous

Aloof-Introverted

Arrogant-Calculating

HISNAR

ANT

SAD

PAR

BDL

SZD

AVD

SDF

DPR

DEP

coined by Lew Goldberg 1980s

Costa & McCrae – 1980 to 1990s◦ NEO, NEO-PI, NEO-PIR◦ Five-Factor Model

Openness to Experience Conscientiousness Extraversion Agreeableness Neuroticism

The Big Five

N E O A CSZD LAVD H LDEP HHST HNAR H HANT L LCOM hSZT H L LBDL N L LPAR H L

See commentary below slide to understand letters and numbers

straightforwardness

deliberation

Distrust SuspiciousMotives interpreted as malevolent

.5 to 2.5%

More common in males

Paranoid PD

Unjustified distrust

Appear tense, “Ready to Pounce”

Very sensitive to criticism

Excessive need for autonomy

Jealous, argumentative, counter attacking, unforgiving

Paranoid PD

Cause◦Mistaken beliefs?◦Roots in upbringing?

Treatment◦Nothing know to work

Paranoid PD

◦ Other personality disorders borderline, schizotypal

◦ Schizophrenia paranoid and undifferentiated

◦ Delusional Disorders Persecutory

◦ Substance-related amphetamines, marijuana abuse, steroids

Other variations of paranoia

Detachment from social relationshipsRestricted range of emotions

less than 1%

More common in males

Schizoid PD

Aloof, cold, indifferent

Asexual, social deficiencies

Observers of life

Negative symptoms

Schizoid PD

Causes

Family upbringing

Deficiencies of dopamine?◦ Low levels correlated with detachment/aloofness

Schizoid PD

Schizophrenia Disorganized, undifferentiated

Developmental disorders autism

Other personality disorders schizotypal, paranoid

Schizoid PD Differential Diagnosis

Discomfort in close relationships Cognitive or perceptual distortionsEccentricities of behavior

3 to 5%

More common in males

May later develop schizophrenia

Schizotypal PD

Odd or bizarre

Ideas of reference or magical thinking “Clairvoyant or telepathic”

Unusual perceptual experiences Sensing the presence of the dead

Paranoia, hypersensitivity to criticism

Schizotypal

Causes?

Genetics seem to play a role

Exposure to influenza virus increases chances

Damage to left hemisphere

Schizotypal

30 to 50% also have major depressive disorder

Low dose antipsychotics (Haldol) Problem with side effects – stop taking meds

Social skills training

Schizotypal

Antisocial PD

Callous and remorseless

Negligent and reckless

3% males, 1% females

Dissipates after age 40

Irresponsible, impulsive, deceitful

Social predators, ruthless

Lacking in conscience, selfish

Violating social norms, no guilt or regret

Violation the rights of others

Antisocial PD

Lying and cheating

Substance abuse (83% )

Long-term outcome is poor

boys twice as likely to die from unnatural causes

Antisocial PD

comes by many names

Moral insanity Egopathy Sociopathy Dissocial PD Psychopathy

Antisocial PD

Conceptualization

Hervey Cleckley – Mask of Sanity Described 16 characteristics of psychopaths

Robert Hare UBC Professor Forensic Psychologist PCL-R

Antisocial PD

Hare’s Model 1. glibness / superficial charm 2. grandiose sense of self-worth 3. need for stimulation / proneness to boredom

4. pathological lying 5. conning / manipulative 6. lack of remorse 7. shallow affect 8. callous / lack of empathy 9. parasitic lifestyle 10. poor behavior controls

11. promiscuous sexual behavior 12. early behavior problems

13. lack of realistic long-term goals

14. impulsivity 15. irresponsibility

16. failure to accept responsibility

17. many short-term marital relationships

18. juvenile delinquency

19. revocation of conditional [e.g., from prison]

20. criminal versatility

PCL-R

F1 = Callousness, selfish, remorelessF2 = Antisocial Behavior, socially deviant

PCL-R Data Collection

A) Interview Schedule (90-120 minutes)◦ Interview with participant◦ Lots of history, school, work, goals, drug use, sexual behavior◦ Observer interpersonal style

B) Collateral Information (60 minutes)◦ Based on file information◦ To evaluate the credibility of information in “A”◦ Part B can be used alone

PCL-R 3 point scale

◦ 0 = does not apply◦ 1= applies to some extent◦ 2 = applies to individual

Cutoffs◦ Normal – Score of 5◦ Psychopath – Score of 30 or greater

Hit Rate – 85% A good predictor of recidivism

DSM Focus on observable behavior

Hare Focus on personality traits and observable behavior

Overlap between the models, but not the same Both overlap with criminality

PCL-R versus DSM

Antisocial put less effort into psychotherapy

Antisocial more likely to repeat criminal offenses

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Psychopaths are more planful and selfish in action

Criminals versus Antisocials

Causes

Childhood origin – conduct disorder Risk increase if also ADHD

Lower IQ

Genetics Gene-environment interaction

Antisocial PD

Causes

Cortical underarousal (Quay, 1965) Excessive theta waves when awake Cortical immaturity

Fearless hypothesis (Lykken, 1957) Higher threshold for experiencing fear

MAOA defects

Antisocial PD

Treatment

Rarely seek treatment Very manipulative Incarceration works…

Parenting training

Antisocial PD

Borderline PD

Unstable Relationships, Identity, Mood

Impulsivity

1 to 3%

75% of cases female

Symptoms gradually improve in 40s

6% die by suicide 

Poor self-image Empty, “chaos junkies” At risk of killing themselves

Lack control over emotions Self-damaging (tension releasing) Impulsivity (at the core according to Links)

Mood disorders, substance abuse, bulimia

Borderline PD

Spousal abusers Set high standards then punish for not meeting standard

Tends to improve in 30s and 40s Poor prognosis

Borderline PD

Causes Genetic link with mood disorders

Information processing problems (memory bias)

70%+ report history of childhood sexual abuse

May be a disguised form of PTSD for some cases

Borderline PD

Theory – Marsha Linehan

Highly Emotional Vulnerability

Poor Emotional Regulation

Emotional Dysfunction (biological)

Invalidation(environment)

Emotional Instability

Theory

Emotional Instability

Interpersonal Behavioral

SelfCognitive

Treatment

Drug – Lithium, Tricyclics, SSRIs, MAOIs

Dialectical Behavior Therapy (DBT) Some evidence it works

Borderline PD

Attention-seekingExcessive emotionality

2%

Equal between males and females?

Histrionic PD

Exaggerated emotions

Vain, self-centered, excessive need to be attended to

Seductive, more style than substance

Impulsive? – data does not support this perspective

Counterphobic attitude

Histrionic PD

Co-morbidity, Differential diagnosis

HPD

Cluster BPDsAnxiety

somatoform

HysteroidDysphoria(atypical depression)

dysthymiaMania

SubstanceAbuse

Male version

Two outcomes for males◦ A) effeminate identity – celibate

Very dominant mother, submissive father

◦ B) hypermasculine – promiscuous, Mr. GQ Very submissive mother, no father present

Problems in future relationships

Causes

Hysteria – “the wandering uterus”

Impressionistic cognitive style

Temperament differences

An association with ASPD (2/3rds of histrionics)

Histrionic PD

Admiration neededGrandiosityEmpathy is lacking

Less than 1%

More common in males

Narcissistic PD

Unreasonable sense of self-importance Preoccupied with themselves Lack sensitivity and compassion for others

Need to be admired Expect special treatment

Envious and arrogant Prone to depression

Narcissistic PD

Cause?

Profound inferiority Compensatory mechanism

“Nobel Prize complex”

Lack of parental modeling (i.e., Agreeableness) Stunted growth

“The Culture of Narcissism” – Me Generation

Narcissistic PD

Hypersensitivity InadequacySocial Inhibition

Less than 1%

Equal number of males and females

Avoidant PD

Coined by Millon

Low self-esteem, trouble trusting

Unworthy, unlikable

Undermine successes, lack belief in themselves

Schizoid-----Avoidant-----Dependent

Avoidant PD

Temperament

Behavioral Inhibition –heritable temperament factor involving tendency to avoid the unfamiliar

Rejecting and critical parents

Tend to internalize the “critical voice”

Remarkably similar to Social Phobia

Avoidant PD

Dependent PD

Need to be taken care of Submissive and clinging behavior Fears of separation

2%

Equal between males and females?

Needy Expression of disagreement is limited Excessive need for nurturance Decision making is difficult Self-Motivation is lacking

Preoccupied with being left alone Urgently seeks a relationship when one ends Self-confidence is lacking Helpless when alone

Dependent PD

Dpendent PD

self-doubt, tends to belittle self low self-confidence, faith in others high need for reassurance rarely lives alone work below level of ability continually seek advice seek protection and dominance from others avoid positions of responsibility

Factor Analytic View Livesley, Schroeder, and Jackson (1990)

two orthogonal factors

attachment was defined as needing someone

dependence was defined as the excessive need for advice, encouragement, etc.

Co-morbidity

DPD

ANX*

PDs

MOOD

BDL, HPD

Eating*

Somatization*

• = significant co-morbidity• Bornstein (1995)

Major DepDysthymia

PhobiasAgoraphobia

Substance

PerfectionismOrderlinessControl

Not Flexible, Open or Efficient

4%, more males

Compulsive Personality Disorder

Compulsive PD

Difficult to interview (loads of details – boring to listen to)Tend to control interviewLots of “news” little “weather”Detached, devoid of emotion

Compulsive PD

Misses the forest for the trees Humourless, lacking spontaneity Goal is to accomplish work Fixated on details Rigid and inflexible Hoards money Few Leisure activities, can’t relax

OCD versus OCPD Behaviors Intrusive Thoughts Uncomfortable Specific - cleaning Negative Reinforcement Anxious Drugs work AVD, DEP

Traits No Intrusive Thoughts Comfortable General - perfection Positive Reinforcement Not Anxious Drugs don’t work “None”

A residual categoryA dab of this and a dab of thatMost commonly diagnosed PD

PD NOS

Sadistic and Self-defeating (DSM-III-R, 1987)

Depressive and Negativistic (DSM-IV, 1994)

All are PD NOS

Provisional Categories

Depressive

Somber, pessimistic, fatalistic, brooding Valueless, guilty, impotent Worthy of criticism and contempt

New scale, not a lot of validity Gloomy, passive, quiet, pessimistic Down, hard to please, defeatist Difficulty expressing anger High scores could be due to major depression or

dysthymia

Depressive

Sadistic

Hostile, abrasive, cruel, dogmatic Explosive, intimidating, dominating opinionated and close-minded

Dominating, mean, cruel, aggressive Top Dog persona Publicly “ok” – successful Private “monster” Type A personalities

Sadistic

Negativistic

Resentful, skeptical, discontented Resisting, inefficient Angry, moody, irritable, sullen

Negativistic (Passive-aggressive)

Twisted, conflicted personalities Irritable, hostile, negativistic complaining, disgruntled feel unappreciated, pout disillusioned Vacillate from compliance to oppositional Not official, PD NOS predictor of loss of control over emotions Indicator of serious psychiatric illness

Masochistic

effacing, servile, blameful Defeatist, self-condemning

Self-defeating PD

Self-sacrificing, deserve to suffer Martyr-like, endures abuse Look for victimization Not a well-validated scale

Case Study…