Personality Disorders

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Personality Disorder (PD)

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DSM-IV-TR define "An enduring pattern of inner experience and bx that deviates markedlty from the expectations of the individual's culutre, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment" APA, 2000, p.686

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Facts about PD

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10 - 15 % of th general population meet criteria
Within clinical settings PD est. is above 50%
60% of inpatient w/in clinical settings dx w/ BPD
Antisocial personality disorder up to 50% of inmates
generally underestimated -due to lack of x to have comprehensive evaluations of personality functioning
Insurance co-deem PD untreatable

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Can there be a Healthy personality structure

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Empirical support for clincially and socially meaningful changes in response to psychosocial and pharmacologic tx. The dev of fully healthy person structure is unlikely to occur through course of tx; however moderate adj to personality funct can rep socially and clinicaly significant improvements

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Tentative revisions to DSM

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-No diagnositc criterion sets
-clinicians match their global perception of a patient to a paragraph description, considering th narrative as a whole rather than counting individual sx's
-supplementary dimensional model
-6-factor models see next three cards

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The First-6-Model factor by Watson, Clark, and Chmielewski

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First proposed 6- factor model : " neuroticism, introversion, antagonism, conscientiousness, openness, and oddity.

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The Second-6-Model factor by Clark and Kruger

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Revised 6-factor model : "negative emotinality , introversion, antagonism, compulsivity, disinhibithion, and schizotypy, with 37 underlying traits."

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Krueger et al revised 6-Model factor to 5 Dimensional Model:

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5 -dimensional Model:
emotional dysregulation
detachment
antagonism
disinhibition
peculiarity with 25 underlying traits.

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General goal of DSM-V

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Is to shift psychiatry towards a dimensional classificationof psychopathology.

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Lexical analysis of Languages -identified 5 fundamental dimensions

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Neuroticism or negatie affectivity vs emotional stability
introversion versus extraversion
closedness vs openness to experience
antagoism vs aggreableness
conscientiousness/ constraint vs disinhibition

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How the 5 domains match with DSM five fundamental dimensions

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Neuroticism aligns w/ DSM-5 emotional dysregulation
FFM intorversions aligns with DSM-5 detachment,
FFM antagonism aligns with DSM-5 antaonism,
FFM low conscientiousness aligns with DSM-5 disinhibition
FFM openeness aligns with DSM-5 schizotypy
FFM high conscientiousness aligns with DSM-5 compulsivity (if included).

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ADVANTAGES of Five Factor Model personality disorder:

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-addresses limitations of the categorical system (i.e. heterogeneity within diagnoses, inadequate coverage, lack of consistent diagnositc theresholds, and excssive diagnositc co-occurrence)
-A description of abnormal personality functioning w/in same model and language to describe general personality structure
-More comprehensive system to identify personalit strengths as well as deficits
-(psychiatric nomenclature )-Knowledge concerning orgins, development, universality, and stability of personality structure.
-Integration of psychiatry with psychology

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Neuroticism (vs. emotional stability)

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-Anxiousness
-Angry Hostility
-Depressiveness
-Self-Consciousness
-Impulsivity
-Vulnerability

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Extraversion (vs. introversion)

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Warmth (vs. coldness)
Gregariousness (vs. withdrawal)
Assertiveness (vs submissiveness)
Activity (vs. passivity)
Excitement-seeking
Positive Emotionality (vs. anhedonia)

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Openness (vs closedness)

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Fantasy
Aesthetics
Feelings (vs. alexithymia)
Actions
Ideas
Values

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Agreeableness (vs. antagonism)

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Trust (vs. mistrust)
Straightforwardness (vs. deception)
Altruism (vs. aggression)
Compliance (vs. aggression)
Modesty (vs. arrogance)
Tender-mindedness (vs. tough-minded)

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Conscientiousness (vs. disinhibition)

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Competence vs. laxness
Order vs. disordered
Dutifulness vs irresponsiility
Achievement-striving
Self-discipline (vs, negligence)
Deliberation (vs. rashness)

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DSM 5 traits : 5 -factor Model of personality

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Neuroticism: self harm, anxiousness, guilt, shame depressivity, low self esteem, pessimism, emotional liability, separation insecurity

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Extraversion:

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Intimacy avoidance, social withdrawal, social detachment Anhedonia, restriced affectivity and Histrionism

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Openess

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unusual pereceptions, unsual beliefs, eccentricity, dissociation proness and cognitive dysregulation

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Agreeableness

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Oppositionality, suspiciousness , hostility, aggression, callousness, manipulativeeness, deceitfulness and narcissim and submissiveness

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Conscientiousness

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Irresponsility, distractibility, impulsivity , recklessness, perfectionism, perservation, orderliness, risk aversion and rigidty.

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Rationale for deleting half of the disorders

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Most patients meet the diagnositc criteria for more than one personality dx.
Lack of coverage has also been a problem

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Antisocial Personality Disorder

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ASPD-prototypic personality disorder
Pervasive pattern
criminal activity
deceitfulness, impulsivity, recklessness, aggresiveness,
irresponsiblity, reckelessness, irresponsiblity and indiffernect to mistreatment of others.
-DSM -5 antisocial and psychopathy & narrative description included as additional traits
-Etiology and Pathology: criminal delinquent meet ASPD 50% of social anti-social bx; enviornmental influences account for 15 -20% in criminality or delinquency (i.e. low family income, inner-city residence, poor parntal supervison, single-parent household, rearing by antisocial parents, delinquent siblings, parental conflict etc..

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Genetic and enviornmental influences

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-difficult to separate
-Individual predisposed to antisocial bx such as peer pblm, academic difficulty and harsh discipline from parents.

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Psychopathic individual

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-Historically said to suffer from superego lacunae or a semantic dementia
-deficit of conscience or deficient processing of feelings and emotion

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Psychophysiological deficits:

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a low level of physicological arousal or fear response

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Cognitive functioning

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The psychopath's notoruious failure to accurately anticipate negtie consequencees suggest a cognitive deficit.
Stalbe deficits in the cognitive domains of attention and response modulation

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Differential Diagnosis

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-ASPD - closely associated with narcissistic personality traits
-Difficult to diferentiate from substance dependence disoder due to SD-engage in antisocial acts

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Gender influences

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-ASPD is more common in men than in women

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Course (p.285)

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ASPD is he only personality disorder for which much is known about childhood antecendents. Approx 40% of the children with conduct disorder grow up to meet criteria for ASPD adn the presence of conduct disorder is requiredf for the diagnosis of ASPD
-Chronic dx that persists into adulthood

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TREATMENT for ASPD:

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-The most diffficult personality disorder to treat
-Individuals w/ ASPD, seductively charming and declare a commitment to change
-lack sufficient motivation
-fail to appreciate the costs associated with antisocial acts
-stay in tx only due to external source/parole
-Residential programs for controlled enviornment of structure and supervision combined with peer confrontation-recommended
-Outpatient tx is not likely to be successful
-Focus on rational and utilitarian arguments against repeated past mistakes

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NARCISSISTIC PERSONALITY DISORDER

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Definition-(NPD)-a pervasive patern of grandiosity(in fantasy or bx) need for admiration or adullation, and lack of empathy. Grandiose sense of self-importance; preoccupation w/ success, power, brilliance, or beauty; the belief that he or she is special and can only be understood by high status individuals; excessive admiration; a strong sense of entitlement; an exploitation of others; a lack of empathy and arrogance

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Etiology and Pathology: NPD

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Predominant model for etiology of narcisim : social learning or psychodynamic

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NPD develops bythe following

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-excessive idealization by parental figures which are incorporated into the child's self-image
-Narcissism dev through unempathic, neglectful inconsistent or devaluing parents
-love of paent based on achievement/success and is conditional
As a child mistreated and conflicts and deficits w/ self-esteem

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Narcistic Individual charactheristics

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Excessive need for recognition of their achievements
Uncomfortale when they are not adequately being appreciated of their accomplishments
-feel grossly insulted or enraged when they feel unjustly slighted

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Differential Diagnosis

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-Overlaps with psychopathy
-More grandiose than ASPD patients & ASPD patients are more exploitative and have a superficial value and recurrent antisocial activities.
-Narcissistic patients is more passive, serving to enhance self-image by attaining praise or power
-No qualitatively distinct disorders but represent instead overlapping constellations of maladaptive personality traits.

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Epidemiology

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-diagnosed more frequenly in males
-men tend to be more arrogant than women
--Prevelant in as low as 2% in clinical settings

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Course

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-dont generally abate with age and may even becme more evident into middle or older age
-Individual w/this disorder might be seemingly well adjusted and even successful as a young adult
-large # of research assoc narcissism w/ relationship failure
-exploitative use of others
-indiv w/disorder may not recognize their pathology until substantial setbacks

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FFM Reformulation

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FFM antagonism is arrogance; entral trait of NPD

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Treatment for NPD

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-rarely seek treatment for narcissim
-usually seeek assistnace for another mental disorder such as SA, Mood dx or anxiety
-Indiv to seek tx attempts to dominate, impress or devalue the therapist.
--Indiv can also idealize their therapist

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Boderline Personality Disorder

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BPD-single most frequent diagnosed and studied personality disorder

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BPD-Definition

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The BPD is a pervasive pattern of impulsivity and instaility interpersonal relatinships, afffect, and self-image. Diagnositic criteria incude frantic efforts to avoid abandonment, unstale and intense relationships, impulsivity (i.e. sub abuse, binge eating, or sexual promiscuity), recurrent suicidal tghts, and gestures, self-multilation, an episodes of rage and anger.

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BPD Etiology and Pathology

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empirical support for a childhood hx of physical, sexual abuse , aprental conflict, losss and neglect.
-BPD will often describre quite intense disturbed, or abusive relationships with significant individuals in their past
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Differential Diagonses

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Axis I mental dx includes mood , dissociative, eatign substance use and anxiety disorders
-sx evident since adolescence
If chronic mood dx is presnet then the additional features of transient, stress relatd paranoid ideation, dissociatie exp, impulsiveity and anger dyscontrol of BPd

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Epidemiology

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1 to 2 % general population meet the DSM Iv criteria for Bpd p.290

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Course

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BPD ae likely to report having been emotionally unstable, impulsive and hostile as children
BPD Axis I dx eating, substance, mood dx
BPD dx in chidlren and adolescents (e.g. identity disturbance, hostility, and unstable relationships are sx)
Adults with BPD -hospitalized due to affect and impulse dyscontrol, psychotic like and dissociative sx and suicde attempts
3-10% indiv w/ BPD will commit suicide by 30

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Five Factor model Reformulation

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BPD primarily composed of excessive high neuroticism
Indiv are very highest range of anxiousness, anger , hostility, depressiveness, impulsiveness and vulnerability

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FFM Five Factor Model conceptualization

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BPD are likely to meet the DSM criteira fro at least one other pd, histrionic, dependent, antisocial, schizotypal, or passive aggressie personality disorder

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BPD Treatment

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Therapeutic relationship: unstable, intense, volatile,
Ongoing consulation w/ colleageue recomm
TXist negative reactions to clt (eg. distancing, rejecting, or abandoning the patient in response to feeligs of agner or frustatin and positive reactions (e.g. fantasies of being txist
who resuces or cures
Sessions should: build strong Therapeutic alliance, monitor self-destructive and sucidal bx, validate of suffering and abusive experience, take responsbility for actiotons , promote self-refelction vs impulsive action and limit self-destructive bx
Splitting (polariaation of an emotional response)
Monitor devaluation of prior therapist, cople with idelaiztion of current Therapist (TXist)
Psychotherapy and pharmacological tx of BPd
BPD-will have cmorbid Axis I disorders: major depressive dx, substance dependence or dissociative dx
CBT, MBT mentalization based tx, and DBT Dialectical bx tx

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CBT, MBT, and DBT

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Cognitive Behavior treatment - addressing thoughts/perception
A form of CBT is DBT-Dialectical bx therapy- overcoming suffering through acceptance; no longer fight advesity; meditative technique of mindulness in which one attempts to empty one mind of all thoughts, reduce self-harm and teaches coping skills
Mentalization based treatment -structured techniques to help BPD to mentalize or stand outside their feelings, and more accurately observe the feeligns within themselves and otehrs\

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Schizotypal Personality Disorder (STPD)

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a pervasive pattern of social and interpersonal deficits marked by an acute discomfort w/close relationships, eccentricities of bx, and cognitive-perceptual aberrations.

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Diagnositic criteria STPD

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-diagnositc test set from biological relatives diagnosed with schizophrenia
STPD include odd beliefs, magical thining, social withdrqal, unusual perceptual experiences, odd speech, inappropriate or constrictd affect, social anxiety and social withdrawl

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Etiology and Pathology STPD

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-Is not included within the personality disorder section of the ICD-10
-predominant model for the psychopathology of STPD is deficits or defects in the attention and selection processes that organize a person's cognitive-perceptual evaluation of and related ness to his or her enviornment

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Predominant model for the psychopathology of STPD

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-deficits or defects in the attention and selction proccesses that organize a person's cognitive perceptual evaluation of and relatedness to his or her enviornment
-deficits may lead to discomfort within social situations, misperceptions, and suspicions, and a coping strategy of social isolation
-Central nervous system dysfunction

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Differential Diagnosis

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An initial concern for many clinicians when confronted with a person with STPD is schizophrenia a more appropriate diagnosis.
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STPD is evidence by

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social anxiety, social withdrawal, magical thinking , odd bx and perceptual aberrations since childhood and not characterized by any recent deterioration in functioning.

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STPD

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STPD is much more comorid w/ other personality disorders than with psychotic disorder
-is much more comorbid w/ other personality dx than w/ psychotic dx and schizotypal symptomatology
-schizoid personlaity dx is an anhedonia that provides temperament basis for the social withdrawal
-avoidant personality disorder also share s feature of social withdrawal and social anxiety

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STPD More severe disorder

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Includes the cognitive and perceptual aberrations that are not seen i those with avoidant personality disorder

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Epidemiology

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STPD makes up 3% of the general population
occurs somewhat more often in males
Common Axis I disorder maj depressive dx and genrealized social phobia

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Course

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Studies on infant and childhood neurodevelopmental abnormalities of those with STPD
-As a child seemed odd ; teased; or ostracized
school impairment; heavily involved with esoteric fantasies and pecuuliar and odd to heir peers and peculiar interests
As adult drifts toward esoteric, fringe grops that support their magical thinking and aberrant beliefs
STPD does not appear to remit with age

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Five Factor Model STPD

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FFM -reformulation STPD propes it is a disorder of personlaity , including intoversion (social withdrawal and the anxiousness facet of neuroticism
-Key to StPD are the magical ideatin, cognitie perceptual aberrations, and ecceentric bbx / the FFm of pd to be maladaptive variants of openness to ideas, fantasies an actions.

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Treatment

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STPD seek tx for anxiousness, perceptual disturbamces or depression
CBT and behavior, supportive or pharcologic options
Intimacy and emotionality of reflective, exploratory psychotherapy to be too stressful and they have the potential for psychotic decompensation

Sessions should be well structured cur loos eand tangential ideation
Therapist should serve as the patients counselor or guide to more adaptive decisions: w/ every day pblms such as finding an apartment , interviewing for a job, and personal appearnce
STPD should receive social skills training directed at their awkward and odd behavior, mannerisms, dress, and speech.

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STPD consider themselves

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Not as problematic or maladaptive but simply eccentric, creative and nonconformist

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Dependent Personality Disorder

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A new addition; passive dependent personality trait disturbance

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DPD definition

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DPD involves a pervasive and excessive need to e takein care of that leads to submissiveness, clinging, and feras of separation

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Diagnositc criteria

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inlcude extreme difficulty making decisions without others input , need for others to assume responsiblity for most aspects of daily life, exteme difficulty disagreeing with othrs, inability to initiatte prjets due to lack of self-confidnece an going to excessive lngths to get others approval.

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Etiology and Pathology

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Insecure interpersoanl attachment is consdered to be central to etiology and pathology of DPD.
combination of an anxious or inhibited temprament w/ inconsistent or overprotective parenting may also generate and xacerbrate dependent personality traits.

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Differential Diagnosis

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Excessively dependent x (debilitating mental and physical conditions) such as agoraphobia, schizophrenia, demntia, or folllowign severe injuries.
-DPD requires the presene of the dependent traits to e presentt since late chldhood or adolescence.
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Course

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Individual sith DPD ae prone to mod dx such as maj dep dx and dythymia and anxiety dx agoraphobia, social phobia and panic dx.
-Dependent person
-Unstable relationship
-dependency is more in women than men
emotional instability
helplessness
needy
undesirable

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Five Factor Model Reformulation

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-Dependent personality is characterized in terms of the FFm by maladaptively hgih levles of agreeableness (meek, gulliale, and compliant) and th neuroticism of facets of anxiousness , self- consciousnees ad vulnerabilty

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DPD-gender

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diagnosed more in females

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Treatment

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TX ased on anecdotal clinical experience
Individual with DPD often be in treatment for Axis I disoders: mood depressie or anxiety dx
Dependent clt fear succes in the trx bcause of termination
-support during tx
-CBT -address inadequacey , helplessness, to procide training in assertieness, and prolem solving techniques, Group therapy, interpersonal feedback

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Reasons Personality disorder not diagnosed frequently

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Dificulty to obtain insurance coverage for treatment
some PD has maladaptive personality traits like borderline and antisocial/ social and publich health care costs

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Proposed DSM changes

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deletion of 1/2 dianoses; removal diagnositc criterion sets for proto type matching, new dimensional models,
-Advantages: understanding pd in terms of dimensional model are the provison of more specific descriptions of individual patients the avoidance of arbitarary categorical distinctions.