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Title: Personality%20Disorders


1
Personality Disorders
2
Bo r d e r l i n e
  • Neurotic Beh
  • Anxiety-based
  • No distortions in reality
  • Recognizes problem
  • No great personality disorganization
  • Psychotic
  • Gross distortions in reality (e.g., perception)
  • Some personality disorganization
  • Does not recognize problem

3
Personality Disorders
  • When behaviour patterns become inflexible and
    maladaptive to the point of causing distress or
    social/occupation impairment can say have
    Personality Disorder

4
Personality Disorders
  • Dont stem from reactions to stress but from
    gradual development of inflexible and distorted
    personality
  • Maladaptive ways of perceiving, thinking,
    relating to world

5
Personality Disorders
  • Excessively rigid patterns of behaviour or ways
    to relating to others that prevents people from
    adjusting to external demands and, thus, become
    self-defeating.
  • Have always been there for an individual

6
Personality Disorders
  • Mild Function reasonably well, viewed as
    troublesome, eccentric, etc.
  • Severe Extreme or unethical behaviour, may be
    incarcerated.

7
Quote From Lorna Benjamin (1996)
  • A great way to come down with a case of medical
    student disease (syndrome) is to read a survey
    of personality disorders

8
Some Trait Pattern Example
  • Suspiciousness
  • Excessive Self-regard
  • Fear of Rejection
  • Come to dominate reactions to new situations
  • Repetitive maladaptive behaviour

9
Difference between DSMs Clinical Syndromes PD
  • Clinical Syndrome? specific symptom clusters,
    time limited, ego-distonic (viewed as separate
    from self, unacceptable, objectionable and alien)
  • E.g., depression, anxiety disorders, psychotic
    disorders

10
Continued
  • Personality Disorder? Individual with PD are
    perceived as ego-syntonic (e.g., personality
    issues are acceptable, unobjectionable and part
    of the self). Tend to blame others for problems
    in their lives.

11
Difficulties with Diagnosis of Personality
Disorder
  • Need to infer traits to make diagnosis, do not
    have specific behaviours clinician can judge
  • Disorders and criteria are relatively new,
    therefore not as much research has been done on
    them
  • Great deal of overlap among the disorders
  • Hard to draw a line between disorder and normal
    behaviour

12
Personality Disorder Clusters
  • Cluster One Odd-Eccentric
  • Behaviours similar to schizophrenia,
    suspiousness, withdrawal, peculiar thinking

13
The Odd Eccentric PD Group
  • 1. Paranoid Personality Disorder
  • 2. Schizoid Personality Disorder
  • 3. Schizotypal Personality Disorder

14
Paranoid Personality Disorder
Reverend Jim Jones Peoples Temple
15
Paranoid Personality Disorder
  • suspicious of others motives
  • interprets actions of others as deliberately
    demeaning/threatening
  • expectation of being exploited
  • see hidden messages in benign comments
  • easily insulted/ bears grudges
  • appear cold and serious

16
Paranoid Personality Disorder Example
  • Undergraduate student/patient who followed

17
Schizoid Personality Disorder
Theodore Kaczynski Unabomber
18
Schizoid
  • indifferent to relationships
  • limited social range (some are hermits)
  • aloof, detached, called loners
  • no apparent need of friends, sex
  • solitary activities
  • seem to be missing the human part

19
Schizotypal
  • peculiar patterns of thinking and behaviour
  • perceptual and cognitive disturbances
  • magical thinking
  • not psychotic
  • perhaps a distant cousin of schizophrenia

20
Personality Disorder Clusters
  • Cluster Two Dramatic-Emotional
  • Behaviours are so dramatic, emotional, or erratic
    that it is almost impossible to have truly giving
    and satisfying relationships
  • More commonly diagnosed than other PDs

21
The Dramatic-Emotional PD Group
  • 1. Antisocial Personality Disorder (Dissocial)
  • 2. Borderline Personality Disorder
  • 3. Histrionic Personality Disorder
  • 4. Narcissistic Personality Disorder

22
Antisocial Personality Disorder
  • pattern of irresponsibility, recklessness,
    impulsivity beginning in childhood or adolescence
    (e.g., lying, truancy)
  • adulthood
  • criminal behaviour
  • little adherence to societal norms,
  • little anxiety
  • conflicts with others
  • callous/exploitive

23
  • Difficulties in establishing secure identity
  • Distrust
  • Impulsive and self-destructive behavior
  • Difficulty in controlling anger and other emotions

24
Narcissistic Personality Disorder
  • grandiose, sense of self-importance
  • lack of empathy
  • hyper-sensitive to criticism
  • exaggerate accomplishments/ abilities
  • special and unique
  • entitlement
  • below surface is fragile self-esteem

25
Armand Hammer
  • There has never been anyone like me, and my
    likes will never be seen again.

26
Armand Hammer - Again
The brilliance of my mind can only be described
as dazzling. Even I am impressed by it.
27
Histrionic Personality Disorder
  • excessive emotional displays/ dramatic behaviour
  • attention-seeking, victim stance
  • seek re-assurance, praise
  • shallow emotions, flamboyant, self-centred
  • very seductive, life of the party

28
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29
Personality Disorder Clusters
  • Cluster Three Anxious-Fearful
  • Display anxiety and fear typically
  • Similar to anxiety and depressive disorders but
    no real connection

30
The Anxious-Fearful Group
  • 1. Avoidant Personality Disorder
  • 2. Dependent Personality Disorder
  • 3. Obsessive-Compulsive Personality
  • Disorder (Anankastic)

31
Avoidant Personality Disorder
  • over-riding sense of social discomfort
  • easily hurt by criticism
  • always need emotional support
  • occasionally try to socialize
  • so distressing they retreat into loneliness

32
Dependent Personality Disorder
  • submissive, clingy behaviour
  • fear of separation
  • easily hurt by criticism

33
Obsessive Compulsive Personality Disorder
  • excessive control and perfectionism
  • inflexible
  • preoccupied with trivial details
  • judgmental/moralistic
  • workaholic/ignore family members
  • often humourless

34
Focus on Borderline PD
35
Borderline Personality Disorder
  • marked instability of mood, relationships,
    self-image
  • intense, unstable relationships
  • uncertainty about sexuality
  • everything is good or bad
  • chronic feeling of emptiness
  • recurrent threats of self-harm/ slashers

36
  • Single White Female (Jennifer Jason Leigh) or
    Fatal Attraction (Glen Close).

37
Good Depictions of BPD
38
Borderline Personality Disorder
  • Therapist killers (not really killers)
  • Very difficult to treat
  • Tend to be avoided by many clinicians
  • Takes lots of training and experience to treat
    effectively
  • Lots of turmoil in treatment

39
Borderline Personality Disorder Four Core
Elements
  • Difficulties in establishing secure
    self- identity
  • Distrust Splitting
  • Impulsive and Self Destructive Behaviour
  • Difficulty in controlling anger and other
    emotions

40
Borderline Examples From Therapist
  • First experience with BPD under my supervision

41
Identity Disturbance
  • In terms of identity disturbance, she relied
    heavily on a sort of reflected identity from
    others and saw herself as she believed others saw
    her.
  • With respect to her poor ego boundaries and the
    melding of her identity with my own, one
    particularly surprising thing she said to me was
    that she had googled my name on the internet and
    found out that I had won a presitious academic
    award. She said she felt really sad because she
    did not have an award herself.

42
Distrust and Splitting
  • She vascillated quite wildly between idealizing
    me (including telling me that she loved me and at
    times wanted us to sit together on the couch so I
    could hold her) and devaluing me (lots of anger
    in session, and a fairly caustic email that said
    "Ain't it so nice and easy. Tell you what M,
    go out and get ourself abused, loose that
    charming smile of yours and come back and tell me
    who's mentally ill", which was followed shortly
    after by an apologetic one.)

43
Continued
  • It was difficult for me to predict from week to
    week whether she would tell me I was dirt  or
    idealized. She was a good example of someone who
    used splitting defenses where she saw other
    people (me in particular) in all good or all bad
    terms and made rapid shifts between these two
    positions.

44
Affective Instability
  • Affective instability (went along with the wild
    swings between this sort of coy, coquettish
    behavior and the pronounced anger in session),
    but also exhibited shallow affect and incongruent
    affect.
  • For example, she often smiled or giggled when she
    told me about her difficulties and began to
    ocassionally exhibit sadness in session by
    crying. However, a little later in therapy she
    told me that in fact the tears were fake and that
    she was using them because she felt closer to me
    when I responded to her tears.

45
More on Distrust
  • She had a long history of interpersonal problems
    and difficulty connecting with people. She was
    quite paranoid about what others thought of her
    and this was quite evident in her comments about
    her co-workers whom she felt were against her
    (and, frankly, she may have been right) and in
    her desire to see her chart in the hopes that it
    would finally reveal the intense dislike for her
    that she imagined I felt.

46
Termination Always difficult
  • We spent about 2 months preparing for and
    discussing termination and it still went poorly.
    She was angry and her parting gift to me was a
    plant that contained a set of tiny clay pots
    (sort a decorative thing) partially submerged in
    the soil. She gave the clinic secretary the same
    thing, but she was careful to say "this one is
    for the secretary, and this one is for you", when
    I looked at the two later, the one that she gave
    me had the tiny clay pots smashed, while
    Geraldine's were intact. A final parting message.

47
Self-Destructive Behaviour
  • Drug abuse
  • Suicide threats
  • Lots of promiscuity

48
Classification Models with respect to PD
  • Classical Categorical Model Used by DSM - -
    Views disorders as discrete syndromes (i.e.,
    distinct boundaries between PDs and homogeneous
    within the boundaries)
  • Consistent with traditional conception of medical
    disorders

49
Dimensional Assessment of Personality Pathology
  • W. John Livesley at the University of British
    Columbia
  • Dimensions of PD and their traits
  • Emotional dysregulation
  • Dissocial behaviour
  • Inhibitedness
  • Compulsivity

50
Epidemiology
  • gender similar prevalence rates overall
  • consistent differences across disorders
  • bias in diagnoses?
  • temporal stability
  • culture
  • Wide variations in cultural expectations

51
Further Thoughts Impulse Control Disorders
  • psychological disorders characterized by lack of
    control over inappropriate behaviour
  • Intermittent Control Disorder
  • Pathological Gambling
  • Trichotillomania
  • Pyromania

52
Schizotypal Personality Disorder
  • increased prevalence among relatives of
    individuals with schizophrenia
  • some response to antipsychotic and antidepressant
    medications
  • poor response to insight-oriented psychotherapy

53
Borderline Personality Disorder
  • Historical
  • Kernbergs psychodynamic theory borderlines see
    people and events as good or bad
  • Etiology
  • sexual abuse
  • neurotransmitter dysregulation
  • Treatment
  • dialectical behaviour therapy (DBT)

54
Psychopathy
  • Associated with APD and Dissocial Personality
    Disorder
  • Not a disorder itself

55
Psychopathy
  • egocentric, deceitful, shallow, impulsive
    individuals who use and manipulate others
  • callous, lack of empathy
  • little remorse.
  • thrill-seeking
  • human predators (Hare, 1993)
  • no conscience

56
Psychopathy Checklist-Revised (Hare, 1991) 2
factors
  • FACTOR 2 social deviance
  • (e.g., early behaviour problems, impulsivity)
  • FACTOR 1 - emotional/ interpersonal
    characteristics
  • (e.g., lack remorse, shallow affect)

57
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58
Etiology
  • Biological
  • interaction of genetics and environment
  • Social
  • negative child/parent interactions
  • Psychological
  • affective impairment
  • lack of inhibition

59
Treatment
  • little evidence for treatment effectiveness
  • psychopaths may become worse
  • increased violent crimes following treatment
  • some treatment programs may help psychopaths
    manipulate others better

60
Dependent Personality Disorder
  • Historical
  • introduced in DSM-III
  • sociotropy dependency leads to depression
  • Etiology
  • little research
  • biological little evidence
  • psychological anxious/insecure attachment
  • Treatment
  • assertiveness training
  • problem-solving strategies

61
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62
Problems with Classical Model
  • Exaggerates similarity among patients
  • Inconsistencies in idiosyncracies are ignored
  • Focus on stereotypic features of patients

63
Classification Models with respect to PD
  • Prototype Categorical Model Used by Theodore
    Millon (big wig) attempts to place people in
    categories, but the categories are not
    necessarily discrete but have fuzzy boundaries.
  • Symptoms are often but not necessarily present
    (e.g., concept of bird includes flying creatures
    like blue jay, but also nonflying like penguins)

64
Prototype Categorical Model
  • Allows for multiple diagnoses
  • Improves reliability of diagnoses disagreement
    over single features less likely to affect
    agreement over presence or absence of disorder

65
Classification Models with respect to PD
  • Dimensional Model Does not place people into
    diagnostic categories
  • Key characteristics are identified and the degree
    to which a person has the key characteristic is
    determined.
  • Rather than asking is a PD present or absent, it
    asks how much?

66
Different Dimensions of PD
  • Eysenck Neuroticism, Psychoticism, and
    Introversion
  • Cloninger Novely seeking, Harm avoidance, and
    Reward dependence
  • Costa/McCrae Neuroticism, Extroversion,
    Openness, Agreeableness, and Conscientious

67
PDs Being considered
An Impulse Control Disorder can be loosely
defined as the failure to resist an impulsive act
or behaviour that may be harmful to self or
others. For purposes of this definition, an
impulsive behaviour or act is considered to be
one that is not premeditated or not considered in
advance and one over which the individual has
little or no control
68
There are six categories under this general
diagnosis Trichotillomania, Intermittent
Explosive Disorder, Pathological Gambling,
Kleptomania, Pyromania, and Not Otherwise
Specified. The first five are the most prevalent
and common Impulse Control Disorders.
69
The Negativistic (Passive-Aggressive) Personality
Disorder appears in Appendix B of the Diagnostic
and Statistical Manual (DSM), titled "Criteria
Sets and Axes Provided for Further Study."
People suffering from this disorder are
pessimistic and have negativistic attitudes. They
say things like "good things don't last", "it
doesn't pay to be good", "the future is behind
me". They frustrate others' expectations and
requests and resist even reasonable and minimal
demands to perform in workplace and social
settings. Passive-aggressives resent authority
figures (boss, teacher, parent-like spouse).
70
  • There are many form of passive-aggressive
    negativism procrastination, malingering,
    perfectionism, forgetfulness, neglect, truancy,
    intentional inefficiency, stubbornness, and
    outright sabotage. This misconduct affects the
    passive-aggressive's social milieu it obstructs
    the efforts of his colleagues in the workplace,
    for instance.

71
People diagnosed with the Negativistic
(Passive-Aggressive) Personality Disorder
resemble narcissists they chronically complain
and criticize. They feel unappreciated,
underpaid, cheated, and misunderstood. They blame
their failures, misfortune, and defeats on
others. Passive-aggressives sulk and give the
"silent treatment" in reaction to real or
imagined slights. They are counterfactually
convinced that, behind their backs, they are the
subjects of derision, contempt, and condemnation
("ideas of reference"). Some passive-aggressives
are mildly paranoid and believe in a wide-ranging
conspiracy against them. In the words of the DSM
"They may be sullen, irritable, impatient,
argumentative, cynical, skeptical and contrary."
They are also hostile, explosive, lack impulse
control, and, sometimes, reckless.
72
People diagnosed with the Negativistic
(Passive-Aggressive) Personality Disorder envy
the fortunate, the successful, the famous, their
superiors, those in favor, and the happy. They
are openly defiant, but, when reprimanded, they
immediately beg forgiveness, go on a charm
offensive,, and promise to behave and perform
better in the future.
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