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Chapter 18: Disorders of Personality

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Title: Chapter 18: Disorders of Personality


1
Chapter 18 Disorders of Personality
  • Psy 260
  • Katherine Aumer-Ryan

Slides created by Leslie G. Eaton State
University of New York College at Cortland
2
People are Different
Every individual thinks, feels and acts in
distinctive ways. The entire field of
personality psychology is an effort to specify
how and explain why. It is good that people are
different. Life would certainly be boring and
lose much of its meaning if everyone thought,
felt, and acted the same way.
3
Personality Disorders
But it is also true that the variations in
individual personality that we celebrate
sometimes go too far. For some people, aspects
of their personality become so extreme as to
cause problems for them or for others who must
deal with them.
4
The Diagnostic and Statistical Manual
(DSM)Development
  • In 1952 the American Psychiatric Association
    imposed some order on psychological disorders by
    publishing the first edition of the Diagnostic
    and Statistical Manual (DSM), which included a
    list and description of what were seen as the
    major disorders of personality.
  • The most recent edition, the DSM-IV-TR was
    published in 2000.
  • It is considered the standard reference on
    psychological disorder for medical professionals.
  • Disorders are classified and described based on
    behavioral symptoms the DSM specifies how many
    problematic behaviors are required to make a
    diagnosis, and in some cases how long the
    behavioral symptom needs to be present.

5
Purposes of the DSM
  • The DSM serves two major purposes.
  • It represents an effort to make psychological
    diagnosis more objective.
  • It provides a common vocabulary for behaviors and
    disorders to be used by medical professionals and
    researchers so that they may communicate with one
    another to make progress toward better
    understanding and treatment of psychological
    disorders.
  • It allows multiple medical professionals, all
    working with the same patient, the ability to
    reach a mutual understanding so that a treatment
    regime can be developed.
  • The DSM is used for insurance billing purposes.
  • Each disorder has a code which is written on
    insurance billing forms when a patient receives
    some kind of treatment.
  • So if psychological treatment is going to be paid
    forwhich is the same as saying, if it is to be
    offered at allcategories of psychological
    disorders must be specified.

6
Organization of the DSM
  • The DSM is criticized on many grounds, but lack
    of comprehensiveness is not among them
  • It contains 943 pages of labels and numerical
    codes for just about everything that could
    conceivably go wrong with a person,
    psychologically speaking.
  • The book is organized around five basic groups or
    axes.
  • Axis I includes severe psychopathologies (e.g.,
    schizophrenia)illnesses that can, in some cases,
    require hospitalization.
  • The personality disorders are included as Axis
    II.
  • Axis III lists physical conditions that might be
    related to the patients mental health, which can
    range from injuries and poisoning to brain
    diseases that impair mental functioning such as
    Alzheimers.
  • Axis IV includes stressors in the patients
    social life such as unemployment, bereavement, or
    a recent divorce.
  • Axis V is used to assess the patients current
    ability to function self-sufficiently, including
    whether he or she can hold a job or maintain a
    relationship.
  • A complete evaluation of a psychiatric patient
    includes a consideration of behaviors and other
    pertinent conditions (physiological and
    environmental) that are included on all five
    axes.
  • Taken as a whole, the DSM-IV describes an amazing
    variety of patterns of thought, feeling, and
    behavior.
  • The DSM can be found in the reference section of
    most college libraries, and it is fascinating to
    thumb through it.

7
Defining Personality Disorders
  • Personality disorders have five general
    characteristics that will be discussed, one at a
    time.
  • Unusually Extreme
  • Problematic
  • Social
  • Stable
  • Ego-Syntonic

8
Unusually Extreme
  • A personality disorder, by definition, is the
    expression of an unusually extreme degree of one
    or more attributes of personality.
  • It is important that the variation not only be
    extreme, but also unusual, especially considering
    the individuals cultural context.

9
Problematic Behavioral Patterns
  • The unusually extreme behavioral pattern causes
    major problems for the person or for others.
  • A personality disorder typically causes some
    degree of suffering for the person who has it,
    which may include anxiety, depression, and
    confusion.
  • In the case of several disorders, many and
    perhaps most of the associated problems are
    suffered by the people who must deal with the
    results (e.g., spouses, employers, friends, and
    sometimes even former friends).

10
Personality Disorders Social Aspects
  • These next three characteristics are not as
    fundamental as the first two discussed, however,
    they are often part of general patterns of
    behavior found in those diagnosed with a
    personality disorder.
  • Social
  • The symptoms manifest in interactions with other
    people other people must be present for the full
    expression of many psychological symptoms.

11
Stability of Symptoms
  • Stable
  • The cluster of behavioral symptoms associated
    with personality disorders are, by the usual
    definition, stable they may first become visible
    in adolescence or even childhood and persist
    throughout life.

12
Personality Disorders Can Be Ego-Syntonic
  • Ego-syntonic means that the people who have the
    symptoms of a personality disorder do not think
    anything is wrong they have little to no
    awareness of their unusual and problematic
    behavior.
  • Their symptoms may feel like normal and even
    valued aspects of their personalities.
  • They are more likely to see a disorder in the
    people who have problems with them.
  • Personality disorders that involve ego-syntonic
    ideas are difficult cases for therapists.
  • It is difficult to get the individual into
    therapy (they do not believe they need therapy
    the people trying to get them into therapy are
    the ones who need therapy).
  • Once at the therapists office, without an
    awareness of their symptoms, ego-syntonic people
    probably cannot self-report their symptoms
    accurately or completely, making it very
    difficult for a therapist to make a correct
    diagnosis.
  • This can be compared to people who suffer from
    Axis I disorders. These individuals generally
    experience their symptoms of confusion,
    depression, or anxiety as ego-dystonic
    afflictions of which they would like to be cured.

13
The Major Personality Disorders
  • The DSM-IV lists ten major disorders that
    describe patterns of personality so extreme that
    they can cause serious problems.
  • These problems can be placed roughly into three
    categories.
  • Personality disorders that are marked by
    emotional upset, fear, and anxiety
  • These include dependent, avoidant, and
    obsessive-compulsive personality disorders.
  • Personality disorders that are associated with
    patterns of behavior that interfere with social
    relationships, and can make a person difficult to
    be around and in some cases even dangerous.
  • These include paranoid, histrionic, antisocial,
    and narcissistic personality disorders.
  • Personality disorders that are serious mental
    problems characterized by severely confused
    thinking and lack of contact with reality.
  • These include schizotypal, schizoid, and
    borderline personality disorders.

14
Disorders of Unhappiness and Anxiety
Dependent Personality Disorder
Avoidant Personality Disorder
Obsessive-Compulsive Personality Disorder
  • Dependent Personality Disorder (among the most
    frequently reported personality disorders more
    common in women)
  • People with this disorder typically rely
    heavilytoo heavilyon a parent, sibling, or
    spouse to take care of everything for them, and
    this reliance goes beyond anything that might be
    reasonable due to age, illness, or physical
    handicap.
  • Because of their utter dependence, they may
    exhibit a submissive interpersonal style.
  • They are afraid to disagree with anybody about
    anything, because they fear having to think or
    even exist on their own. At the same time, you
    may detect a bitter, resentful edge to their
    behavior just under the surface. They dont
    really agree with you, after all they are just
    afraid to tell you that they dont, because then
    you might not take care of them.
  • This conflict resembles the neurotic push and
    pull between love and hate described by Melanie
    Klein and the object relations theorists, taken
    to an extreme.

15
Disorders of Unhappiness and Anxiety
Dependent Personality Disorder
Avoidant Personality Disorder
Obsessive-Compulsive Personality Disorder
  • Avoidant Personality Disorder (½ to 1 of the
    population)
  • The fundamental problem experienced by
    individuals with this disorder is that their fear
    of failure, criticism, or rejection may lead them
    to avoid normal activities of school, work, and
    interactions with others.
  • They expect the absolute worst from others
    criticism, contempt, and rejection.
  • They cannot join a group activity or have a
    relationship without constant reassurance that
    they will be uncritically accepted, and they may
    actively inhibit any emotional expression toward
    others because they fear being mocked and
    rejected.
  • As a result, others cannot get close to them, and
    their interpersonal world is constricted it is
    safer to stay at home with the blinds pulled and
    the phone off the hook.
  • This is very sad because, according to clinical
    psychologists who have studied people with this
    disorder, they really have deep cravings for
    affection and social acceptance, and they may
    spend much of their solitary time fantasizing
    about how much fun it would be to have friends or
    a lover.
  • They may have trouble in their careers as well,
    because they seek to avoid the meetings and
    social functions central to the business world.

16
Disorders of Unhappiness and Anxiety
Dependent Personality Disorder
Avoidant Personality Disorder
Obsessive-Compulsive Personality Disorder
  • Obsessive-Compulsive Personality Disorder (OCD
    1 of the population) (DSM-IV lists eight
    characteristics any combination of four are
    required for diagnosis)
  • Overconcern with rules and details
  • The obsessive-compulsive has a deep reverence for
    rules, organization, and details, to the point of
    absurdity.
  • Perfectionism
  • There is nothing wrong with wanting to do things
    as well as possible, but people with OCD take
    this inclination to the degree that it causes
    severe problems, because they think nothing is
    ever good enough.
  • Workaholic
  • People with OCD are often stereotypical
    workaholics they cannot take a weekend or even
    an evening off because they have so much to do.
    And yet, strangely, they never seem to get much
    done.

17
Disorders of Unhappiness and Anxiety
Dependent Personality Disorder
Avoidant Personality Disorder
Obsessive-Compulsive Personality Disorder
  • Obsessive-Compulsive Personality Disorder (OCD)
  • Inflexibility
  • People with OCD have set ways of thinking and
    behaving and are not open to change. They apply
    values, ethics, and principles mindlessly rather
    than with an appreciation for context, and even
    considering bending the rules can make them
    anxious and even more rigid.
  • Packrat
  • People with OCD may be compulsively unable to
    throw anything away, even things with no possible
    use or sentimental value. They become very
    anxious about discarding anything because they
    cannot escape feeling that they just might need
    it someday.
  • Inability to delegate
  • The obsessive-compulsive has to do everything for
    himself or herself, because nobody else can
    possibly do things right. There is one and only
    one way to wash a dish, mow a lawn, paint a wall,
    or even make a decision.

18
Disorders of Unhappiness and Anxiety
Dependent Personality Disorder
Avoidant Personality Disorder
Obsessive-Compulsive Personality Disorder
  • Obsessive-Compulsive Personality Disorder (OCD)
  • Miserly
  • People with OCD hoard pennies against unlikely
    future catastrophes, and they may live way below
    their means.
  • Rigid and stubborn
  • People with OCD like to do things the same way
    time after time, day after day even the
    contemplation of a change upsets them.

19
Disorders in Relating with Others
Antisocial Personality Disorder
Histrionic Personality Disorder
Paranoid Personality Disorder
Narcissistic Personality Disorder
  • Paranoid Personality Disorder (½ to 2½ of the
    population)
  • People with this disorder characteristically
    assume the worst, and may be quite skilled in
    identifying patterns of events and behaviors of
    others that prove they are being plotted
    against.
  • Not surprisingly, they are reluctant to trust or
    confide in anyone.
  • While they may at first appear calm, rational,
    and analytic, more often they eventually come off
    as angry, stubborn and bitter.
  • They frequently become embroiled in lawsuits.

20
Disorders in Relating with Others
Antisocial Personality Disorder
Histrionic Personality Disorder
Paranoid Personality Disorder
Narcissistic Personality Disorder
  • Histrionic Personality Disorder (2-3 of the
    population more frequently diagnosed in women)
  • Along with making themselves the center of
    attention through dress, behavior, or physical
    appearance, such individuals may vehemently
    express strong opinions that turn out not to have
    much basis. When asked to defend their views,
    they may lack the slightest idea what they really
    think and give the impression of having expressed
    the opinion just for effect..
  • Similarly, they may express strong emotions of
    happiness, sadness, liking, or disliking that
    suddenly change or disappear.
  • They may describe even casual acquaintances as
    dear, dear friends, and in general consider
    their relationships closer than they really are.
  • Not surprisingly, the people who know them may
    have trouble taking them seriously they are
    difficult to get along with, and they experience
    serious difficulties in their personal
    relationships and occupational life without
    understanding why.

21
Disorders in Relating with Others
Antisocial Personality Disorder
Histrionic Personality Disorder
Paranoid Personality Disorder
Narcissistic Personality Disorder
  • Antisocial Personality Disorder (diagnosed in
    about 3 of males and 1 of females)
  • This dangerous pattern includes behaviors such as
    vandalism, harassment, theft, and a wide variety
    of illegal activities such burglary and drug
    dealing.
  • People with this disorder are impulsive, and
    engage in risky behaviors such as reckless
    driving, drug abuse, and dangerous sexual
    practices.
  • They typically are irritable, aggressive, and
    irresponsible.
  • The damage they do to others bothers them not one
    whit. They have rationalizations easily available
    that include beliefs that life is unfair. The
    world is full of suckers, and if you dont take
    what you want whenever you can, then you are a
    sucker, too.
  • Upon first impression they may appear articulate
    and charming, but watch out.
  • Children unlucky enough to come under the care of
    someone with this disorder are at high risk for
    neglect or abuse.
  • A wide variety of negative outcomes may accompany
    this disorder including unemployment, divorce,
    drug addiction, imprisonment, murder, and suicide.

22
Disorders in Relating with Others
Antisocial Personality Disorder
Histrionic Personality Disorder
Paranoid Personality Disorder
Narcissistic Personality Disorder
  • Narcissistic Personality Disorder (less than 1
    of the general population are diagnosed)
  • While full-fledged diagnoses of narcissistic
    personality disorder are relatively rare, the
    related trait of narcissism is quite common and
    has important implications as we saw in the
    discussion of excessive self-esteem.
  • Each of its characteristics will most likely
    describe familiar tendencies that are present to
    some degree in more than a few people you know.

23
Disorders in Relating with Others
Antisocial Personality Disorder
Histrionic Personality Disorder
Paranoid Personality Disorder
Narcissistic Personality Disorder
  • Narcissistic Personality Disorder (DSM-IV lists
    nine characteristics any combination of five are
    required for diagnosis.)
  • Grandiose sense of self-importance
  • The narcissist believes, against all evidence,
    that he is a superior being, and expects
    recognition. This belief in superiority is
    independent of any real basis.
  • The narcissist expects recognition with or
    without a specific reason for it. He/she is
    genuinely surprised, even a bit bewildered,
    whenever this recognition is not forthcoming.
  • From the lack of recognition received from
    others, the narcissist is forced to conclude that
    other people are terribly unperceptive,
    unappreciative, or just plain jealous.

24
Disorders in Relating with Others
Antisocial Personality Disorder
Histrionic Personality Disorder
Paranoid Personality Disorder
Narcissistic Personality Disorder
  • Narcissistic Personality Disorder
  • Preoccupation with fantasies of ultimate
    attainment
  • The narcissist walks around much of the day with
    a head full of visions of unlimited wealth,
    absolute power, flawless beauty, or perfect love.
  • These fantasies may lead the narcissist to become
    detached from what is really going on, and
    unrealistic about achievement of goals.
  • Belief that he or she should associate only with
    others who are special
  • The narcissist seems to see his or her self-image
    reflected in those they associate with thus, the
    narcissist may feel that it is important to hang
    out only with people who are wealthy, famous,
    brilliant, or physically attractive.
  • Similarly, narcissists may be inordinately
    attracted to elite institutions such as famous
    universities, exclusive neighborhoods, and
    similar social circles mostly having to do with
    appearance, wealth, and fame.
  • In each case, the basis of the institutions
    appeal is not quality, pleasantness of the
    lifestyle, or excitement of the entertainment
    rather, the attraction is that most people cant
    get in, which is irresistible to the narcissist.

25
Disorders in Relating with Others
Antisocial Personality Disorder
Histrionic Personality Disorder
Paranoid Personality Disorder
Narcissistic Personality Disorder
  • Narcissistic Personality Disorder
  • Requirement for excessive admiration
  • Narcissists need to be admired by others. They
    may maneuver to evoke praise and the tactics are
    not necessarily subtle (e.g., How about my great
    new car?) or simply brag about accomplishments,
    wealth, friends, or appearance.
  • Tell a narcissist that their clothes, car,
    accomplishments, or haircut are the greatest you
    have ever seen. They will agree, and you will not
    be suspected of any insincerity.
  • This need for constant praise suggests that the
    narcissists seemingly high self-esteem is
    actually very fragile, even brittle.
  • Since it is not based on real accomplishment, the
    narcissists grandiose self-image is always in
    danger of destruction, which they appear to sense.

26
Disorders in Relating with Others
Antisocial Personality Disorder
Histrionic Personality Disorder
Paranoid Personality Disorder
Narcissistic Personality Disorder
  • Narcissistic Personality Disorder
  • Sense of entitlement
  • The narcissist expects special treatment.
  • Rules apply to other people (e.g., I should not
    have to wait in line!).
  • The narcissist is shocked when he isnt treated
    as exceptional.
  • There appears to be no upper limit to the sense
    of entitlement the narcissist never gets enough
    to conclude that they have received what they
    truly deserve.
  • Exploits others
  • The narcissist feels justified in taking
    advantage of others whenever possible the
    purpose is merely to get what he/she deserves
    anyway.
  • The narcissist may blithely lie, cheat, or simply
    leave the dirty work to be done by other people
    he or she has much more important things to do,
    and you do not.

27
Disorders in Relating with Others
Antisocial Personality Disorder
Histrionic Personality Disorder
Paranoid Personality Disorder
Narcissistic Personality Disorder
  • Narcissistic Personality Disorder
  • Lack of empathy
  • This exploitation is accompanied by a lack of
    empathy for others.
  • Empathy is not called for, from the narcissists
    point of view, because he is the only person on
    earth who really matters.
  • The narcissist assumes that everything about him
    or her must be of great interest, and may offer
    lengthy and inappropriately detailed monologues
    about his activities or feelings.
  • At the same time, the narcissist can be
    shockingly inconsiderate of the feelings of
    others, for example, happily bragging about how
    healthy he or she is, in front of someone who is
    ill.

28
Disorders in Relating with Others
Antisocial Personality Disorder
Histrionic Personality Disorder
Paranoid Personality Disorder
Narcissistic Personality Disorder
  • Narcissistic Personality Disorder
  • Enviousness
  • A further clue to the brittleness of the
    narcissists self-esteem is his or her proneness
    to envy.
  • The narcissist is acutely aware of small
    differences in prestige, wealth, or
    attractiveness, and simultaneously gloats over
    those he or she views as lower in these
    attributeswhile seething with envy over those
    perceived as superior.
  • Just about everybody would like to be better
    looking, have a bigger office, and make more
    money. The clue to narcissism is the peculiar
    structure of these desires the true narcissist
    would actually be perfectly happy with a small
    office as long as everyone elses were smaller.
  • Similarly, the narcissists obsession with wealth
    has much less to do with how much money she needs
    or wants to spend than with a need to feel
    superior to others.

29
Disorders in Relating with Others
Antisocial Personality Disorder
Histrionic Personality Disorder
Paranoid Personality Disorder
Narcissistic Personality Disorder
  • Narcissistic Personality Disorder
  • Arrogant behavior and attitudes
  • Narcissists are not generally difficult to spot
    their arrogance gives them away.
  • They belittle others and brag about themselves.
  • They are rude to service people, seeming to revel
    in their small (and temporary) degree of social
    superiority over waiters and cashiers.
  • They are boastful about small (or nonexistent)
    accomplishments, and sarcastic and condescending
    about the virtues or accomplishments of anybody
    else.

30
Narcissism is a Trait
  • Within the normal range, those who score
    relatively high on measures of narcissism
  • may appear superficially charming and make a good
    first impression, however, over time their
    characteristic arrogance typically becomes
    self-defeating
  • tend to defend their unrealistically inflated
    self-concept through means such as bragging, or
    making themselves look good at someone elses
    expense defenses that are likely to lead to
    social isolation or poor social relationships.
  • desperately crave feelings of power, prestige,
    success, and glory.
  • Rather than earning these feelings through hard
    work or being courageous they act impulsively and
    have difficulty delaying gratification,
    consequently, they express feelings of
    superiority whenever they experience the need,
    regardless of whether these feelings have any
    basis.
  • They feel better at the moment, but they alienate
    others and ultimately prevent the very success
    and admiration they so desperately crave.

31
Disorders of Thinking and Lack of Contact with
Reality
Schizotypal Personality Disorder
Schizoid Personality Disorder
Borderline Personality Disorder
  • Schizotypal Personality Disorder (3 prevalence
    rate in the populationmay be slightly more
    common in males)
  • Some people are idiosyncratic they experience
    odd thoughts, have seemingly strange ideas, and
    behave unconventionally.
  • They may wear odd and unkempt clothing, and
    espouse unique ideologies or theories of
    everything.
  • They possess an interpersonal awkwardness to the
    point of strangeness, and a discomfort with
    social interaction that only gets worse as
    interactions progress therefore, they have
    particular difficulty in close relationships.
  • None of these characteristics is especially rare,
    and taken one at a time they may not pose serious
    problems when they appear in combination and
    become extreme, a diagnosis of schizotypal
    personality disorder can be made.
  • At its extreme this disorder can dangerously
    approach schizophrenia, a serious Axis I
    condition characterized by major distortions of
    reality, jumbled thinking, and even
    hallucinations.

32
Disorders of Thinking and Lack of Contact with
Reality
Schizotypal Personality Disorder
Schizoid Personality Disorder
Borderline Personality Disorder
  • Schizoid Personality Disorder (extremely rare
    may be more common and more severe in males)
  • An inability to take pleasure from any kind of
    social interaction, ranging from interesting
    conversation to sexual activity.
  • Indifference to others opinions, rarely
    experiences strong feelings, and generally
    presents a bland facade to the world.
  • An important life event (e.g., loss of a job) may
    leave the individual literally at a loss as for
    how to react, and he or she may seem not to react
    at all.
  • People with this disorder live solitary lives
    (e.g., they are unlikely to marry), though they
    can sometimes perform adequately in jobs that do
    not require much interaction with others.
  • The disorder is reportedly rare, but such people
    seem unlikely to seek professional help.

33
Disorders of Thinking and Lack of Contact with
Reality
Schizotypal Personality Disorder
Schizoid Personality Disorder
Borderline Personality Disorder
  • Borderline Personality Disorder (BPD)
  • The hallmark of this disorder is emotional
    instability the persons mood can change rapidly
    from one moment to the next. The foundation of
    the disorder, according to some writers, is a
    sort of emotional hemophilia, in which a
    reaction, once stimulated, cannot be
    staunchedthe individual emotionally bleeds to
    death.
  • It is probably the most severe one on the list.
    Patterns of self-harm are often present that may
    range from self-defeating behaviors to
    self-mutilation to suicide.

34
Disorders of Thinking and Lack of Contact with
Reality
Schizotypal Personality Disorder
Schizoid Personality Disorder
Borderline Personality Disorder
  • Borderline Personality Disorder (DSM-IV lists
    nine characteristics, any combination of five are
    required for diagnosis)
  • Rapid mood shifts
  • Emotional vulnerability characteristically
    experience frequent shifts in mood, as often as
    every few hours or even less.
  • They can swing from happiness to sadness and from
    anger to affection quickly with little or no
    apparent cause shortly thereafter, the feelings
    will pass as if nothing ever happened.
  • Uncontrollable anger
  • They may frequently experience anger that is
    inappropriate, intense, or out of control, with
    very little impetus or none (that anybody else
    can see) at all like their other moods, anger
    will also pass quickly.

35
Disorders of Thinking and Lack of Contact with
Reality
Schizotypal Personality Disorder
Schizoid Personality Disorder
Borderline Personality Disorder
  • Borderline Personality Disorder
  • Self-destructive acts
  • A wide and dangerous range of self-destructive
    acts are possible, including suicide and
    self-mutilation.
  • Suicide attempts are common, and eventually 810
    percent are successful in their suicidal
    attempts this is a dangerous affliction, with
    death rates comparable to the most threatening
    physical diseases.
  • Even among the non-suicidal, self-mutilation is
    common and may include compulsively cutting
    (e.g., with fingernails or knives) parts of the
    body including the hands, arms, and even
    genitals.
  • The reason for cutting is not clear. Possible
    explanations include feeling guilty, indulging in
    self-punishment, and the possibility that these
    individuals are so emotionally disconnected that
    they must hurt themselves to know they are alive.

36
Disorders of Thinking and Lack of Contact with
Reality
Schizotypal Personality Disorder
Schizoid Personality Disorder
Borderline Personality Disorder
  • Borderline Personality Disorder
  • Self-damaging behaviors
  • Self-damaging behaviors are less directly
    physical than self-destructive acts, but they are
    still harmful acts may include drug abuse,
    compulsive gambling, eating disorders,
    shoplifting, reckless driving, etc.
  • A particular characteristic pattern appears to
    involve undermining oneself at (or just before)
    the moment of success (e.g., they may drop out of
    school just before graduation, break up a
    relationship when it starts to succeed, or quit
    working on and even destroy a major project when
    it is about to be finished.
  • Some cases of runaway brides (and grooms) may
    fit this pattern everything seems great until
    the moment just before completion then they
    appear to panic.

37
Disorders of Thinking and Lack of Contact with
Reality
Schizotypal Personality Disorder
Schizoid Personality Disorder
Borderline Personality Disorder
  • Borderline Personality Disorder
  • Identity disturbance
  • Many people with BPD literally do not know who
    they are.
  • They may have great difficulty understanding how
    they appear to others, and be confused about
    their values, career goals, and even sexual
    identities.
  • They do not understand their own actionscutters,
    for example, can say almost nothing meaningful
    about why they do itand BPD sufferers may try to
    be social chameleons, avoiding behavioral choices
    and fading into the background by doing what
    everybody else seems to be doing.
  • Chronic emptiness
  • They may complain of feeling empty and bored
    all the time they might indicate that they
    desperately need to get a life.
  • They seem unable to find activities that are
    satisfying and enjoyable, or to establish
    personal relationships that might give their
    lives purpose and meaning.

38
Disorders of Thinking and Lack of Contact with
Reality
Schizotypal Personality Disorder
Schizoid Personality Disorder
Borderline Personality Disorder
  • Borderline Personality Disorder
  • Unstable relationships
  • Their interpersonal relationships are confusing,
    chaotic, noisy, unpredictable, and unstable.
  • May be attributed to being prone to splitting it
    may be that the person is unable to handle the
    complex reality that people all have a mix of
    good and bad characteristics.
  • Fear of abandonment
  • Many people with BPD put a great deal of effort
    into frantically trying to fend off being
    abandoned by others sometimes fear of
    abandonment is realistic, often it is not.
  • In any case, they find it difficult to be
    separated from significant others for any length
    of time e.g., they might panic when someone is a
    few minutes late, because at the time they are
    certain that the person has left for good.
  • Self-destructive behaviors might, in some cases,
    be attempts to seek attention and/or to
    manipulate people into staying (e.g., If you
    leave me, Ill kill myself!).

39
Disorders of Thinking and Lack of Contact with
Reality
Schizotypal Personality Disorder
Schizoid Personality Disorder
Borderline Personality Disorder
  • Borderline Personality Disorder
  • Confusion and feelings of unreality
  • The fear of abandonment sometimes leads to
    confused thinking and feelings of being
    disconnected from reality.
  • This might include sudden, unrealistic, and
    paranoid fears, or even the inability to remember
    ones own name.
  • In general, the person becomes so upset that he
    or she literally cannot think straight.
  • These symptoms may come and go when the
    significant other returns, the sufferer may
    return to reality (relatively speaking) for a
    while.

40
Criteria for a DSM Diagnosis and the Prototype
Model
  • The DSM criteria for diagnosis involve
    manifesting a certain minimum number of
    behavioral characteristics for each disorder.
  • That means there are no clear-cut requirements
    for diagnosing a personality disordera fact that
    has a couple of important implications.
  • There are many different ways to exhibit each of
    the disorders.
  • For example, five out of nine characteristics are
    required to be present for BPD, which means 256
    different patterns (of five or more
    characteristics) are consistent with a diagnosis.
    Consequently, people with the same official
    diagnosis may be quite different from each other,
    creating some vagueness and confusion in clinical
    work and for research.
  • It is highly possible for a given individual to
    exhibit characteristics of several different
    disorders at once.
  • For example, it is not difficult to imagine
    someone who has rapidly shifting moods, a
    preference for solitary activities, and a view of
    him or herself as inferior, yet these are
    characteristics of three different disorders.

41
Criteria for a DSM Diagnosis and the Prototype
Model
  • The prototype model may be a better system for
    clinical diagnosis and for research purposes.
  • Most (perhaps all) natural categories are best
    thought of in terms of ideal exemplars, or
    prototypes.
  • Real objects may match a prototype more or less
    well, even while differing from each other.
  • Real objects may also fit more than one prototype
    category because fit is not absolute, it is a
    matter of degree.

42
Criteria for a DSM Diagnosis and the Prototype
Model
  • The prototype model may be a better system for
    clinical diagnosis and for research purposes.
  • Each of the personality disorders can be thought
    of as a prototype.
  • It is possible and meaningful to assess the
    degree to which an individual matches a single
    prototype, or more than one prototype .
  • No individual is likely to match any prototype
    perfectly, which acknowledges the complexity of
    diagnosis, the behavioral overlap among the
    categories, and the heterogeneity within
    categories.
  • This view goes a long way toward rescuing the
    system of categorizing and diagnosing personality
    disorders.
  • On the other hand, the psychiatrist or clinical
    psychologist probably needs to fill out the
    insurance form with just one billing code
    (although this potential obstacle to the
    prototype model could be overcome).

43
Bases for Diagnosis
  • The diagnosis of a personality disorder may be
    based upon several kinds of information each of
    which have advantages and disadvantages.
  • Clinical Impression
  • Self-Report Scales
  • Structured Interviews
  • Informant Report
  • The most information, from the widest possible
    number of sources, will lead to the most accurate
    diagnosis.

44
Organizing the Personality Disorders
  • The list of ten personality disorders in the
    DSM-IV does not exhaust the ways that individual
    differences can become extreme and problematic.
  • The DSM-IV also includes a catch-all category for
    personality disorder not otherwise specified.
  • Psychologists have proposed many other disorders.
  • The list of disorders is continuously being
    reorganized and rethought.
  • For example, passive-aggressive personality
    disorder has gone on and off the list over
    succeeding editions (at the moment it is off,
    pending further study, and has been tentatively
    renamed negativistic personality disorder).
  • A major project for the next revision of the DSM
    is a reconsideration of the organization of the
    personality disorders.
  • Organization is an important issue, because some
    kind of structure is necessary for comparing the
    disorders with each other and for seeking
    psychological processes, causes, or cures that
    apply to more than one disorder.

45
Organizing the Personality DisordersThe DSM-IV
Clusters
  • The DSM-IV organizes the ten personality
    disorders into three clusters that are different
    from the three groups presented earlier if you
    look at the research literature, you will find
    that the DSM-IVs A, B, and C labels are used
    frequently, and clinical psychologists often
    discuss and write about personality disorders in
    these terms
  • Cluster A contains disorders characterized by odd
    or eccentric patterns of thinking, including the
    schizotypal, schizoid, and paranoid personality
    disorders these are disorders that fundamentally
    involve dysfunctional thinking.
  • Cluster B includes disorders characterized by
    impulsive and erratic patterns of behavior,
    including the histrionic, narcissistic,
    antisocial, and borderline personality disorders
    for these disorders, behavior is the central area
    of concern.
  • Cluster C comprises disorders characterized by
    anxious and avoidant emotional styles, including
    the dependent, avoidant, and obsessive-compulsive
    personality disorders these disorders involve,
    most importantly, dysfunctional emotional
    processes.
  • Organizing the personality disorders into
    thinking, behavioral, and emotional groups
    oversimplifies the relations among the disorders,
    because all of them include dysfunctions in all
    three areas (thinking, emotion, and behavior).

46
Organizing the Personality DisordersDr.
Funders Groups
  • Dr. Funders organizing themes are similar, but
    not identical to the DSM-IV recall Dr. Funders
    groups from earlier
  • Those associated with unhappiness and anxiety
    (dependent, avoidance, and obsessive-compulsive
    the same as the DSMs Cluster C).
  • Disorders that primarily cause problems for other
    people (paranoid, histrionic, antisocial, and
    narcissistic).
  • Disorders associated with seriously distorted
    thinking (schizotypal, schizoid, and borderline).
  • Dr. Funders list has a similar problem of
    category overlap, which may be an inevitable
    problem of any system of organization.

47
Organizing the Personality DisordersDimensional
Structures and the Big Five
  • Several psychologists have attempted to identify
    key dimensions that underlie the personality
    disorders in some cases, their goal is similar
    to that of psychologists seeking to identify the
    essential traits of personality.
  • For example, Millon (1996) has offered a
    biosocial learning model that arranges the
    personality disorders according to the ways in
    which people focus on themselves or others, are
    active or passive, and primarily seek reward or
    avoid pain. This model is interesting, but
    empirical research has not consistently supported
    it.
  • Other theorists have proposed circumplex models,
    like those for goals and emotions, in which the
    disorders and other attributes of personality are
    arranged around a circle that shows how they are
    related.
  • Currently the best supported and most accepted
    way of organizing the personality disorders is
    probably the Big Five set of personality traits
    (extraversion, neuroticism, agreeableness,
    conscientiousness, and openness to experience).
  • Researchers studying the Big Five have proposed
    these traits as the foundation of most if not all
    of the variation in personality, with the idea
    that the 17,953 trait terms in the English
    language can be reduced to combinations of two or
    more of these five attributes.

48
Pathologizing
  • Pathologizing behaviorsdescribing them as the
    result of mental illness
  • There has been increasing amount of insight and
    imagination when formulating descriptions of many
    psychological disorders.
  • Personality disorders themselves describe bad
    ways to behave. Does this mean that bad people
    have personality disorders, by definition?
  • For example Psychologists have recently proposed
    that pathological bias, such as extreme racism,
    homophobia, or other strong feelings about
    certain groups, should be defined as a
    personality disorder. It has not yet been added
    to the DSM.

49
Too Much Pathologizing?
  • The notion that bad people have personality
    disorders is one of the eternal conundrums in
    the foggy area where psychology meets moral
    reasoning. It has been a long-standing dilemma in
    philosophy, religion, and law, and there is no
    resolution in sight.
  • Pathologizing is too easyand pathologizing has
    professional consequences.
  • Critics of the DSM-IV have enjoyed pointing out
    that it includes a label for everything from
    compulsive gambling to coffee nerves.
  • The DSM-IV describes so many behavioral patterns
    as illnesses that it threatens to undermine the
    meaning of the concept altogether.
  • Ask yourself this question If everything is a
    mental illness, then is nothing a mental illness?
  • A related question If everything is a mental
    illness, then having a mental illness would be
    normal (not abnormal, and not statistically
    unusual). So, if having a mental illness is
    normal, then why would anyone try and seek
    treatment for what is a normal condition?

50
Mental Health
  • Pathologizing tells us almost nothing about the
    nature of mental health.
  • Mental health certainly means more than not
    having any of the symptoms listed in the DSM-IV,
    even if that were possible, which it is not.
  • This is not merely a shortcoming of the DSM.
    Psychology has a history of paying much more
    attention to defining and attempting to cure
    mental illness than to describing the ideal state
    that one might aspire to achieve.
  • This omission is precisely what motivates the
    positive psychology movement.
  • The positive psychology movement aims to move
    beyond an exclusive focus on fixing whats wrong
    with people, and instead to promote meaningful
    and happy living.
  • Improving mental health requires an understanding
    of normal personality, not just mental illness
    and personality disorders.

51
Labeling
  • Along with pathologizing, there has been much
    debate (psychological and legal) about the
    virtues of labeling.
  • The specific categories in the DSM-IV have come
    in for a lot of criticism, and with good reason.
  • Nobody seems to quite fit the criteria for any
    category, many people exhibit characteristics of
    several categories at once.
  • Systems like the DSM-IVs list of personality
    disorders are difficult to apply consistently and
    reliably.
  • Thus, the labels in the DSM-IV are always a
    little bit misleading, and sometimes seriously
    misleading.
  • Using catch-all labels can shut off rather than
    promote further understanding, because once we
    have labeled a person as mentally ill, we may no
    longer feel that we have to take seriously his or
    her feelings, outlook, or even rights, or to
    empathize with his or her point of view.
  • A label is not an explanation, and the conclusion
    that someone has a personality disorder raises
    many more questions than it answers.

52
Labeling
  • On the other hand, the labels can be useful.
  • The syndromes described in the DSM-IV, while not
    as clear-cut as we would like, describe patterns
    that clinicians have noticed over many years. So,
    if you come across someone who exhibits one or
    more of the characteristics of a personality
    disorder, it might be worth your while to
    consider whether he or she might show some of the
    other symptoms as well.
  • No matter how uncomfortable we may be about
    labeling people, it is still worthwhile to learn
    the basic characteristics of the major
    personality disorders.
  • Finally, it must be acknowledged that labels are
    absolutely necessary there is simply no escaping
    them.
  • When a psychiatrist or clinical psychologist
    writes down impressions of a patient, it is
    necessary to write something, and the more
    precise the label, the better.
  • Research, or even serious discussion, about
    mental illness would be completely impossible
    without words labelsto refer to the different
    varieties that exist.
  • Do you remember that something usually beats
    nothing? (Funders Second Law) No matter how
    flawed they may beand they are flawedthe labels
    in the DSM-IV will persist until something better
    comes along.
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