Personality Disorders

Personality is the totality of emotional and behavioral traits apparent in a person’sordinary life that is usually stable and predictable.

Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and the self that are exhibited in a wide range of contexts.

A personality disorder

deviant from cultural standards

rigidly pervasive

onset in adolescence or early adulthood

stable over time,

lead to unhappiness and impairment

maladaptive behavior in at least two:1.Affect 2. Cognition 3. Impulse control4. Interpersonal functioning

Prevalence

9% of US population

Cluster A:

odd and eccentric

more common in biological relatives of client with schizophrenia

Types Paranoid - distrust and suspiciousness Schizoid - detachment from social relationships Schizotypal -acute discomfort in close relationships,

cognitive or perceptual distortions, and eccentric behavior

Cluster B:

dramatic, emotional, erratic, defenses of dissociation, acting out, denial, and splitting

Types Antisocial - distrust of other and violations of their rights,

often co-morbid with substance use disorders Borderline - instability in interpersonal relationships, self-

image, affect, and impulse control, often co-morbid with mood disorders

Histrionic - excessive emotionality and attention-seeking, often co-morbid with somatization

Narcissistic - grandiosity, a need for admiration, and a lack of empathy

Cluster C:

These persons are anxious or fearful, and tend to utilize the defenses of isolation,passive aggression, and somatization

Types Avoidant - social inhibition, feelings of inadequacy, and

hypersensitivity to negative evaluation Dependent - submissive and clinging behavior related to

an excessive need to be taken care of Obsessive-compulsive - preoccupation with

orderliness, perfectionism, and control

Diagnostic Considerations

low inter-rater reliability with personality disorders

require a longitudinal versus a time-limited assessment approach

Psychological testing can be helpful

+Coding

principal diagnosis if focus on PD

should rarely be applied to children and adolescents because personality patterns are evolving during and don’t reach a state of constancy until late adolescence/young adulthood. - Symptoms should be present for a full yr in adolescence in order to diagnose

+ Borderline Personality Disorder

a pattern of instability in interpersonal relationships, self-image, and affect, featuring impulsive behavior

Characterized by extremely unstable affect, mood, object relations, and self-image

frantic efforts to avoid abandonment failed to successfully negotiate task of separating from primary caregivers

while maintaining an internalized sense of being cared for

often in crisis due to their intense feelings of anger, emptiness, and hopelessness that occur when stressed

Other features include anxiety, transient psychotic symptoms, suicidal or self-mutilating behaviors, and substance abuse.

Core features: highly variable mood and impulsive behavior

+Prevalence of BPD

5.9%

most common personality disorder found in clinical settings

In clinical samples, most frequent in females but in population, males and females have equal rates

+Assessment

Determine through a social history whether the client’s presenting problems result from patterns of interaction with others

Assess for recent stressors; determine whether isolated situation or part of a general pattern

Is the client’s presenting problem an outcome of conflicted interactions with significant others? If so, is this an isolated situation, or part of a general pattern?

Does the client maintain positive relationships with some significant others (such as friends, family, and co-workers), or are most relationships conflicted?

Influence of any substances that may account for the symptoms of anxiety and depression.

Medical condition

For older adolescents and young adults, determine whether relatively less severe identity concerns are related to a developmental phase

The client’s manipulative behavior must be related to a desire for nurturance rather than a desire for power, profit, or personal gain

+Assessment

Is the client under the influence of any substances that might account for the symptoms of anxiety and depression?

Is there evidence of a history of hypomanic or manic episodes? Of depressive episodes?

If the client is an older adolescent or young adult, are identity concerns related to a developmental phase?

If the client displays manipulative behaviors toward others, including the social worker, are they related to a desire to elicit nurturance or for power or personal gain?

What cultural conditions may be affecting the client’s relationship-seeking behavior?

What environmental conditions may be affecting the client’s relationship-seeking behavior?

+Co-Morbidity

mood disorders, substance related disorders, eating disorders (notably bulimia), PTSD and other anxiety disorders, dissociative identity disorder, and attention deficit hyperactivity disorder

Symptoms of depression characteristic of BPD - emptiness, self-condemnation, abandonment fears, hopelessness, self-destructiveness, and repeated suicidal gestures

mood swings that resemble bipolar disorder (the interpersonal conflicts are a differentiating factor)

+ Suicidality and Self-Mutilation

55% of inpatients have histories of suicide attempts, although suicide rate is 5-10%

Reasons for self-mutilation: express anger, punish oneself, generate normal feelings when experiencing depersonalization, or distract oneself from painful feelings

+Risk and Protective Factors

37.1% genetic and 62.9% environmental influences

Psychodynamic formulationSeparation-individuation phase fixation – can’t distinguish between self and

others

have failed to successfully negotiate the delicate task of separating from primary caregivers while maintaining an internalized sense of being cared for.

Trauma in the social environment in childhood

+Course

Variableone-third recover ten years after initial diagnosisLow SES do worsea “natural course” recovery rate of 3.7% per yearclients receiving intervention recover at a rate seven

times that of persons who do not receive intervention 25% recovery rate per year for clients receiving

intervention.

Substance use -risk

+Intervention

40-60% drop out prematurely

Components: establishing and maintaining a therapeutic framework

and alliance responding to crises and monitoring the client’s safety providing education about the disorder consistent supportive or insight-oriented therapy coordinating intervention provided by other providers

+Indications for partial or brief inpatient hospitalization Dangerous, impulsive behavior that can’t be managed in an

outpatient setting

Non-adherence with outpatient intervention and a deteriorating clinical picture

Complex comorbidity that requires intensive clinical assessment of response to intervention

Symptoms of sufficient severity to interfere with functioning, work, or family life that are unresponsive to outpatient intervention

Transient psychotic episodes associated with loss of impulse control or impaired judgment

+Contract for services

timing and frequency of sessions,

plans for crises management,

after-hours availability (if any)

expectations about scheduling, attendance, and payment.

+ Dialetical behavior therapy

CBT and social learning, mindfulness

assumes core difficulty of clients is affective instability

"dialectical" intervention needs to address both biological and environmental aspects of the disorder/self-acceptance and change

intensive, one-year outpatient intervention that combines weekly individual sessions with weekly skills-training groups

purpose of group– to teach adaptive coping skills in the areas of emotional regulation, distress tolerance, interpersonal effectiveness, and identity confusion, and to correct maladaptive cognitions.

+Modality of DBT

individual therapy, a formal skills-training group, a therapist consultation team, some form of coaching (usually by telephone), and a treatment length of at least six months for outpatient clients and two months for inpatient clients.

+ Psychodynamic Intervention

draws from three major theoretical perspectives: ego psychology object relations self-psychology

+ Exploratory-supportive continuum of interventions

Supportive strengthening of defenses, development of self-esteem, validation of feelings, internalization of the therapeutic relationship creation of a greater capacity to cope with disturbing feelings

Exploratory make unconscious patterns more consciously available increase affect tolerance, build a capacity to delay impulsive action provide insight into relationship problems develop reflective functioning toward a greater appreciation of internal motivation in

the self and others

+Difficulty Prescribing Medication

disorder’s symptom heterogeneitydiagnostic unreliabilitypresence of comorbid disorders, and the

potential for self-destructiveness.

+Types of medication

SSRI’s – mood and impulsive symptoms Small, positive effects

For symptoms in cognitive dimension (suspiciousness, illusions, depersonalization, or transient hallucinations), antipsychotics

Review of antidepressant, anti-anxiety, antipsychotic, anticonvulsants, and lithium medications, either modest or no symptom relief

+Critique

DSM doesn’t mention how long symptoms have to last

May meet the criteria in 126 different ways

Division between clinical disorders and personality disorders questionable High co-morbidity Psychodynamic vs. atheoretical Recovery rates

+Critique for personality disorders

Personality disorders appear to describe the total person, rather than a particular aspect of the person or the result of person-in-environment processes

+Who in case studies might show Axis II