Personality Disorders

When Our Patterns of Relating are Maladaptive

What Are Personality Disorders?

Personality Disorders isorders:
Long-standing, maladaptive, inflexible ways of relating to the environment. E.g., E g maladaptive personality traits. traits Begin early and tend to be stable. Difficult to diagnose and treat. A deviant way of life
vs. a deviation from ones way of life.

DSMDSM -IV Personality Disorders

DSM recognizes PDs as different from symptom disorders, placing them on Axis II. Cluster A: OddOdd-Eccentric
Paranoid, Schizoid, & Schizotypal

Cluster B: Dramatic Dramatic-Emotional

Antisocial, Borderline, Histrionic, & Narcissistic

Cluster C: AnxiousAnxious-Fearful
Avoidant, Dependent, & Obsessive-compulsive

Biopsychosocial Model
Millon et al, 2000
Biological predisposition re temperament + ineffective parenting lead to PD
e.g., child is born with a difficult temperament & parents are unable bl to t handle h dl it (either ( ith neglect, l t overharsh, h h overindulgent, or overprotective)

Different combinations of temperament & parenting lead to different PDs

Anxious & fearful Avoidant or Schizoid Impulsive & AggressiveBorderline & Antisocial Labile & overemotionalBorderline & Histrionic

Odd or Eccentric Cluster

Similar symptoms to schizophrenia, but not psychotic. e.g., odd behavior, speech or beliefs; flat affect or chronic suspicion. Part of the schizophrenia spectrum Paranoid PD weak relationship Schizoid PD moderate relationship Schizotypal PD strong relationship

Paranoid Personality Disorder

Key Clinical Features
Expects to be harmed, deceived, or exploited by others. friends Preoccupied with doubts about the loyalty of friends. Read hidden meaning into benign remarks or events. Bears grudges. Pathologically jealous.

Etiology and Treatment

Biological
Small increased risk in families with schizophrenia.

Cognitive g
Distorted belief that people are evil & deceptive.

Treatment
Cognitive therapy to correct mistaken assumptions.

Schizoid Personality Disorder

Key Clinical Features
Extreme detachment from social relationships. Socially isolated - loners. Restricted range of emotion (flatness, coldness). Little pleasure in any activities. Appear dull or bland.

Prevalence = .4% to 1.7% More common in males.

Etiology and Treatment

Biological
Some genetic link with schizophrenia. Low density DA receptors? Inheritance of low sociability y & warmth.

Cognitive
Over-intellectualized beliefs.

Treatment
Increasing awareness of own feelings and increasing social skills and contacts.

Schizotypal Personality Disorder

Key Clinical Features
Cognitive and perceptual distortions.
Paranoia or suspiciousness Ideas of reference Magical thinking Illusions

Inappropriate/constricted affect. Odd and peculiar appearance or behavior. Lack of close friends. Excessive social anxiety.

Etiology and Treatment

Biological strong family link with schizophrenia
Genetic transmission of vulnerability. Problems with attention and focus. Some evidence of increased dopamine & enlarged ventricles.

Treatment similar to schizophrenia

Antipsychotics, social skills, group therapy, some cognitive therapy

Dramatic, Emotional, & Erratic Cluster

Erratic, emotional and impulsive behaviour reflected in disturbed relationships. Behaviours show lack of concern for their own safety or needs of others:
Manipulative, attention-seeking, volatile, and potentially violent Reasons for impulsive/dramatic behaviour vary with the disorder Linked with increased violence (ASPD) and suicidal (BPD) behaviours.

Histrionic Personality Disorder

Key Features
Shifting moods, unstable relationships; & behaviour designed to seek attention or approval
e.g., g , dramatic and seductive

Want attention rather than being self-doubting (like BPD) Seen as self-centred, shallow, and demanding Prevalence: 1.3 2.1% Generally women Increased risk of depression, anxiety & suicide Runs in families with BPD, ASPD & somatization

Theories and Treatment

Psychodynamic - deep dependency needs have been unmet & emotions are repressed
Attention seeking & shallowness

Cognitive - maladaptive assumptions

I am inadequate

Biopsychosocial (e.g., Millon)

High need for stimulation + many changes as adult

Treatment - find reason for dramatics and replace with socially acceptable behavior

Narcissistic Personality Disorder

Key Features
Grandiose thoughts & overvaluing ones worth; selfcentred behaviour that reflects lack of concern for others needs ( (e.g., g , arrogant g & exploitative). p ) Dismissive of others opinions Over-inflated self-worth Make unreasonable demands on others Sense of entitlement and superiority Prevalence: less than 1% Mostly male

Theories and Treatment

Psychodynamic - unreliable parent leads child to only rely on self
Parental rejection results in low self-esteem

Social Learning g Theory y - over-evaluation of childs worth by parents replicated Cognitive - unrealistic assumptions of self-worth due to early indulgence Treatment usually CBT
Challenge unrealistic thoughts Develop sensitivity to others

Borderline Personality Disorder

Key Clinical Features
Frantic efforts to avoid abandonment Unstable relationships Impulsive Persistently unstable self-image Intense mood swings Recurring self-harming or suicidal gestures Chronic feelings of emptiness Intense, inappropriate expressions of anger Transient episodes of dissociation

Etiologic Factors
Early childhood trauma & unstable attachments.
High rates of abuse including emotional (73%), physical (59%), and sexual (61%) abuse (Zarini et al., 1997).

Inborn biological temperament of emotional vulnerability with an emotionally invalidating environment.

Results in an increased perception of threat in interpersonal situations.

AnxiousAnxious -Fearful Cluster

Extreme concern about criticism or abandonment, leading to dysfunctional relationships
lack self-confidence and chronic self-doubt

Chronic anxiety and fear

not to same level as anxiety disorders

Behaviour designed to ward off feared situations

reasons for anxiety vary with disorder

Avoidant Personality Disorder

Key Clinical Features
Ongoing anxiety, feelings of inadequacy, fear of rejection/criticism. Leads to social avoidance and nervousness. Hypersensitive to evaluation and criticism. Similar to Social Phobia. Usually depressed and lonely but feel unworthy of relationships. Prevalence: 1% No gender differences in rates Increased risk for mood disorders & anxiety disorders

Theories and Treatment

Biological
transmission of shy or fearful temperament high physiological arousal level

Cognitive
Dysfunctional attitudes about worthlessness due to early rejection I must be a bad person for mom to treat me bad

Treatment typically CBT

Exposure to social settings, social skills, challenge negative thoughts about social situations

Dependent Personality Disorder

Key Clinical Features
Ongoing self-sacrifice, need to be cared for and fear of abandonment. Leading to dependence on and submission to others. Similar to Separation Anxiety & Dysthymia Cling to others and indecisive Need relationship to function and high risk for abuse Prevalence 1.6 6.7% Mainly women Increased risk for major depression and chronic anxiety

Theories and Treatment

Psychodynamic
Fixation in oral stage

Biopsychosocial (e.g., Millon)

Fearful temperament + warm, overprotective parents Treatment Must reduce dependency Usually CBT assertiveness, stress management, exposure, challenging faulty assumptions

Obsessive-Compulsive Personality Disorder

Key Clinical Features
Excessive rigidity in behaviour and relationships (e.g., extreme perfectionism, intolerance for and anxiety about change, h and d constricted t i t d emotions). ti ) Detail-oriented and self-controlled Humorless, severe, emotionally restricted Prevalence 1.7 6.4% More males

Theories and Treatment

Biological
No genetic link with OCD

Psychodynamic
Fixation in anal stage

Biopsychosocial (e.g., Millon)

Overcontrolling punishment for mistakes + lack of praise for successes

Treatment
CBT for compulsive behaviour and supportive therapy for emotionally corrective experience

Critique
Concept of personality disorders is controversial:
Pathologize the continuum of normal personality Overlap in diagnostic criteria Vague V criteria i i & lowest l diagnostic di i reliability li bili of f any of the disorders Fundamental attribution error
i.e., the belief that behaviours are due to personality traits rather than situational factors

Problem of gender bias in criteria and diagnosis

Alternatives
Theories of normal personality have been increasingly used to explain PDs
Five Factor Model Interpersonal I t l Ci Circumplex l Model M d l

Theories are dimensional not categorical, and allow for prediction and development of new PDs