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UNDERSTANDING PSYCHOPATHOLOGY: PERSONALITY DISORDERS

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Title: UNDERSTANDING PSYCHOPATHOLOGY: PERSONALITY DISORDERS


1
UNDERSTANDING PSYCHOPATHOLOGY PERSONALITY
DISORDERS DISORDERS OF CHILDHOOD
2
  • Paranoid
  • Schizoid
  • Schizotypal

CLUSTER A
odd, eccentric
  • Histrionic
  • Narcissistic
  • Borderline
  • Antisocial

CLUSTER B
dramatic, erratic
  • Avoidant
  • Dependent
  • Obsessive/Compulsive

CUSTER C
fearful
3
HOW COMMON ARE PDs?
4
BORDERLINE PERSONALITY DISORDER (BPD)
  • Definition
  • Pervasive pattern of instability of
    interpersonal relationships, self-image, and
    affects, and marked impulsivity beginning by
    early adulthood and present in a variety of
    contexts as indicated by 5 or more of 9 symptom
    categories.
  • Treatment Marsha Linehan (1995) Dialectical
    Behavior Therapy

5
THE CHALLENGES OF BORDERLINE PERSONALITY DISORDER
  • Most commonly diagnosed PD among patients in
    treatment
  • Represents a particularly challenging disorder to
    treat
  • High rates of suicidal or other self-harm
    behaviors, and of hostile behaviors
  • High rates of drop-out or treatment failure

6
THE DIALECTICAL APPROACH
  • Dialectics stresses the basic interconnectedness
    of reality to fully understand a person you have
    to understand his/her context.
  • Reality is composed of opposing forces (thesis
    and antithesis) (there can be no function without
    dysfunction distortion without accuracy).

7
THE DIALECTICAL APPROACH
  • The fundamental nature of reality is change.
    Resolution of the tension between polarities
    produces a new reality which, in turn, creates
    another set of polarities, and so on.
  • An implication of this premise is that people
    and their environment are in constant transition
    and need to adapt to inconsistency and
    change.

8
BORDERLINE BEHAVIOR AS THE RESULT OF DIALECTICAL
FAILURES
  • Polarization (splitting) Persons with BPD
    often view themselves and others in extremes
    (e.g., good, bad), and are unable to accept that
    both qualities can reside within the same person.
  • Unstable identity Lack of sense of
    interconnectedness renders it difficult to hold
    on to a stable sense of self.

9
THE DIALECTICS OF BORDERLINE BEHAVIOR
  • Emotional Vulnerability -vs- Self-Invalidation
  • Active-passivity -vs- Apparent Competence
  • Unrelenting Crises -vs- Inhibited Grieving

10
TREATMENT FOR BORDERLINE PD
11
From Personality Disorders to Disorders of
Childhood (or the other way around??!!)
12
ENDURING PATTERN…
  • B. is inflexible and pervasive across a broad
    range of situations
  • C. leads to clinically significant distress or
    impairment in important areas of functioning
  • D. is stable and onset can be traced back at
    least to adolescence or early adulthood
  • E. is not better accounted for by another mental
    disorder/ or
  • F. by physiological effect of a substance or
    general medical condition

13
Case Conference
14
CRITICISMS OF PD DIAGNOSES
  • Thresholds are not adequately justified
  • The thresholds vary for the 10 PDs, and the
    disorders likely vary in terms of the associated
    levels of impairment
  • PD criteria are gender biased
  • Application of PD criteria is open to gender bias

15
CRITICISMS OF PD DIAGNOSES
  • Many experts do not regard personality disorders
    disorders or illnesses
  • Kendell (2002)
  • A. Sociopolitical definition
  • B. Biomedical definition
  • C. Combination of sociopolitical and biomedical
  • Little relationship between DSM IV PD categories
    and major personality theories

16
CRITICISMS OF PD DIAGNOSES
  • Polythetic classification - heterogeneous
    categories core features not clearly defined.
    Examples
  • BP diagnosis requires 5 of 9 features to be
    present
  • Antisocial PD diagnosis requires 3 of 7 features
  • Related, PD are difficult to measure
  • Sokol et al. (1991) administered two standard
    interviews to diagnose PD in 100 patients.
    Despite good inter-rater reliability of each
    interview, the interviews classified patients
    accurately only 50 better then when diagnoses
    were made completely at random.

17
CRITICISMS OF PD DIAGNOSES
  • Low reliability of diagnoses
  • High degree of overlap between PDs
  • 85 of individuals with one PD also meet criteria
    for a second PD
  • Of those with only one PD diagnosis, only 1-2
    are described as representing the prototype of
    the particular PD (Clark et al., 1995).
    Prototypic cases are supposed to be the
    majority of the category (I.e., they DEFINE the
    category), not the exception.

18
CRITICISMS OF PD DIAGNOSES
  • The most common PD diagnosis is not one of the
    ten described in the DSM the most common PD is
    PD-NOS
  • Example Study of 18,000 clinic patients found
    that PD-NOS was the most common PD diagnosis
    (30).

19
CRITICISMS OF PD DIAGNOSES
  • Overlap between axis I and axis II diagnoses

20
PD and Axis I disorders with high degrees of
comorbidity
  • Schizotypal PD - Schizophrenia
  • Borderline PD - Anxiety Disorders
  • Antisocial PD - Substance Use Disorders
  • Avoidant PD - Social Phobia Fabrega et
    al. (1991) almost 80 of individuals with a PD
    also received an axis I diagnosis.

21
Common diagnoses Number with dx with at
least 1 comorbid dx
Somatization D. 67 100 Antisocial
PD 628 93 Panic 304
91 Schizophrenia/Schizophreniform D. 340
91 Dysthymia 703 86 Agoraphobia 1,281
84 Obsessive-compulsive D. 571 79 Drug
abuse/dependence 1,316 75 Depressive
episode 1,258 75
22
ECA DATA ON ANTISOCIAL PD
  • Reliability or Stability of diagnosis
    (enduring)?
  • Gender?
  • Age phenomenon?

23
ANTISOCIAL PERSONALITY DISORDER
Lifetime One-Year One-Month
Men 4.5 2.1 0.9 Women 0.8 0.4 0.2
Whites 2.6 1.2 0.5 Blacks 2.3 1.1 0.
4 Hispanics 3.4 1.6 0.7 lt
30 3.8 2.3 0.9 30-44 3.7 1.5 0.8 45-
64 1.4 0.2 0.1 p lt .001 Source
Robins, Tipp, Przybeck, 1985 ECA
24
ANTISOCIAL PERSONALITY DISORDER AND INCARCERATION
White Black Hispanic
Total incarcerated 0.3 1.8 0.3 ASPD
no 0.2 1.1 0.2 ASPD yes 2.7 14.6 1.8
Source Robins, Tipp, Przybeck, 1985 ECA
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