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Chapter 13 personality disorder jbh
This document provides information about personality disorders as categorized in the DSM-5. It discusses 10 specific personality disorders separated into 3 clusters: odd/eccentric, dramatic/emotional/erratic, and anxious/fearful. For each cluster, it describes some representative disorders and their diagnostic criteria. It notes that personality disorders typically emerge in adolescence/early adulthood and can be difficult to treat. The document also discusses issues with the categorical approach to personality disorders and limitations in reliability and validity. It provides some information about prevalence, risk factors, differential diagnosis, and treatments for several specific disorders.
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Chapter 13 personality disorder jbh
- 1.
- 2. Personality •What is personality? •Personalityis a unique and long-term pattern of inner experience and outward behavior •Tends to be consistent and is often described in terms of “traits” •Also flexible, allowing us to learn and adapt to new environments •For those with personality disorders, however, that flexibility is usually missing 2
- 3. Personality Disorders • Anenduring, rigid pattern of inner experience and outward behavior that impairs sense of self, emotional experience, goals, and capacity for empathy and/or intimacy • The rigid traits of people with personality disorders often lead to psychological pain for the individual or others 3
- 4. Personality Disorders •A personalitydisorder typically becomes recognizable in adolescence or early adulthood and symptoms last for years •Among the most difficult psychological disorders to treat •Many sufferers are not even aware of their personality disorder •Estimated that 9% to 13% of all adults may have a personality disorder 4
- 5. Personality Disorders • Highcomorbidity • complicates a person’s chances for a successful recovery from other psychological problems 5
- 6. Classifying Personality Disorders •The DSM-5 identifies ten personality disorders and separates these into three groups or “clusters”: • Odd or eccentric behavior • Paranoid, schizoid, and schizotypal • Dramatic, emotional, or erratic behavior • Antisocial, borderline, histrionic, and narcissistic • Anxious or fearful behavior • Avoidant, dependent, and obsessive-compulsive 6
- 7. Classifying Personality Disorders •ThisDSM listing is called a categorical approach •It assumes that: •Problematic personality traits are either present or absent •A personality disorder is either displayed or not •A person who suffers from a personality disorder is not markedly troubled by personality traits outside of that disorder •It turns out, however, that these assumptions are frequently contradicted in clinical practice 7
- 8. Classifying Personality Disorders •In fact, the symptom of the personality disorders overlap each other so much that it can be difficult to distinguish one from another • In addition, diagnosticians sometimes determine that particular individuals have more than one personality disorder • This lack of agreement has raised concerns about the validity (accuracy) and reliability (consistency) of these categories 8
- 9. Classifying Personality Disorders Oddor eccentric Extreme suspiciousness, social withdrawal, and peculiar ways of thinking and perceiving things
- 10. Paranoid Personality Disorder •Includes four or more of the following: • Suspiciousness of others • Unjustified doubts about disloyalty • Reluctance to confide in others • Reading threatening meanings into benign events • Persistent tendency to bear grudges • Tendency to feel attacked and counterattack • Unjustified suspiciousness about infidelity of partner
- 11. Diagnostic Criteria 301.0(F60.0) A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her. 2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. 3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her. 4. Reads hidden demeaning or threatening meanings into benign remarks or events.
- 12. 5. Persistently bearsgrudges (i.e., is unforgiving of insults, injuries, or slights). 6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. 7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition. Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e., “paranoid personality disorder (premorbid)*
- 13. Associated Features SupportingDiagnosis • May experience very brief psychotic episodes (lasting minutes to hours). • In some instances, paranoid personality disorder may appear as the premorbid antecedent of delusional disorder or schizophrenia. • Individuals with paranoid personality disorder may develop major depressive disorder • May be at increased risk for agoraphobia and obsessive-compulsive disorder. • Alcohol and other substance use disorders frequently occur
- 14. PREVALENCE • A prevalenceestimate for paranoid personality based on a probability subsample from Part II of the National Comorbidity Survey Replication suggests a prevalence of 2.3%, while the National Epidemiologic Survey on Alcohol and Related Conditions data suggest a prevalence of paranoid personality disorder of 4.4%.
- 15. RISK AND PROGNOSTICFACTORS • Genetic and physiological. There is some evidence for an increased prevalence of paranoid personality disorder in relatives of probands with schizophrenia and for a more specific familial relationship with delusional disorder, persecutory type.
- 16. DIFFERENTIAL DIAGNOSIS • Othermental disorders with psychotic symptoms. Paranoid personality disorder can be distinguished from delusional disorder, persecutory type; schizophrenia; and a bipolar or depressive disorder with psychotic features because these disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations). • Personality change due to another medical condition. • Substance use disorders. • Other personality disorders and personality traits.
- 17. Treatments for Paranoid PersonalityDisorder •People with paranoid personality disorder do not typically see themselves as needing help • Few come to treatment willingly • Those who are in treatment often distrust and rebel against their therapists •As a result, therapy for this disorder, as for most of the other personality disorders, has limited effect and moves slowly 17
- 18. Schizoid Personality Disorder •Includefour or more of the following: • Neither desires nor enjoys close relationships • Almost always chooses solitude • Little if any interest in sexual relationships • Takes pleasure in few activities • Lacks close friends • Indifferent to praise or criticism • Emotional coldness, detachment or flatness
- 19. Diagnostic Criteria 301.20(F60.1) A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Neither desires nor enjoys close relationships, including being part of a family. 2. Almost always chooses solitary activities. 3. Has little, if any, interest in having sexual experiences with another person. 4.Takes pleasure in few, if any, activities.
- 20. 5. Lacks closefriends or confidants other than first-degree relatives. 6. Appears indifferent to the praise or criticism of others. 7. Shows emotional coldness, detachment, or flattened affectivity. B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition. Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e., “schizoid personality disorder (premorbid).”
- 21. •Schizotypal Personality Disorder Fiveor more of the following: Ideas of reference Odd beliefs or magical thinking Unusual perceptual experiences Odd thinking and speech Suspiciousness or paranoid ideas Inappropriate or constricted affect Odd, eccentric or peculiar behavior or appearance Lack of close friends Excessive social anxiety
- 22. How DoTheorists Explain SchizotypalPersonality Disorder? • Because the symptoms of schizotypal personality disorder so often resemble those of schizophrenia, researchers have hypothesized that similar factors are at work in both disorders • Schizotypal symptoms are often linked to family conflicts and to psychological disorders in parents • Researchers have also begun to link schizotypal personality disorder to some of the same biological factors found in schizophrenia, such as high dopamine activity • The disorder has also been linked to mood disorders, especially depression 22
- 23. Treatments for Schizotypal PersonalityDisorder • Therapy is as difficult in cases of schizotypal personality disorder, as in cases of paranoid and schizoid personality disorders • Most therapists agree on the need to help clients “reconnect” and recognize the limits of their thinking and powers • Cognitive-behavioral therapists further try to teach clients to objectively evaluate their thoughts and perceptions and provide speech lessons and social skills training • Antipsychotic drugs appear to be somewhat helpful in reducing certain thought problems 23
- 24. “Dramatic” Personality Disorders •Behaviors so dramatic, emotional, or erratic that it is almost impossible for them to have relationships that are truly giving and satisfying • More commonly diagnosed than the others • Only antisocial and borderline personality disorders have received much study • Causes of the disorders not well understood • Treatments range from ineffective to moderately effective 24
- 25. Antisocial Personality Disorder Includesthree or more of the following: • Failure to conform to lawful behavior • Deceitfulness • Impulsivity • Irritability or aggressiveness • Reckless disregard for safety of self and others • Consistent irresponsibility • Lack of remorse
- 26. Antisocial Personality Disorder •Aside from substance use disorders, this is the disorder most linked to adult criminal behavior • The DSM-5 requires that a person be at least 18 years of age to receive this diagnosis • Most people with an antisocial personality disorder displayed some patterns of misbehavior before they were 15 years old (conduct disorder). 26
- 27. Antisocial Personality Disorder •4times more common in men than women •Often arrested, therefore researchers frequently look at prison populations •Higher rates of alcoholism/substance use disorders 27
- 28. How DoTheorists Explain AntisocialPersonality Disorder? • Psychodynamic theorists propose that this disorder begins with an absence of parental love, leading to a lack of basic trust; Lack of superego • Many behaviorists have suggested that antisocial symptoms may be learned through modeling or unintentional reinforcement 28
- 29. How DoTheorists Explain AntisocialPersonality Disorder? • Cognitive view says that people with the disorder hold attitudes that trivialize the importance of other people’s needs • Biological factors may play a role: • Lower levels of serotonin, impacting impulsivity and aggression • Deficient functioning in the frontal lobes of the brain • Lower levels of anxiety and arousal, leading them to be more likely than others to take risks and seek thrills 29
- 30. Treatments for Antisocial PersonalityDisorder • Treatments are typically ineffective • A major obstacle is the individual’s lack of conscience or desire to change • Most have been forced to come to treatment • Some cognitive therapists try to guide clients to think about moral issues and the needs of other people 30
- 31. Borderline Personality Disorder Fiveor more of the following: Frantic efforts to avoid abandonment Unstable and intense relationships Unstable self image Impulsivity (self destructive) Suicidal behavior Affective instability Chronic feelings of emptiness Inappropriate, intense anger
- 32. Borderline Personality Disorder •Closeto 75% of those diagnosed are women •Highly comorbid •The course of the disorder varies •In the most common pattern, the instability and risk of suicide reach a peak during young adulthood and then gradually wane with advancing age 32
- 33. How DoTheorists ExplainBorderline Personality Disorder? •Because a fear of abandonment tortures so many people with the disorder, psychodynamic theorists look to early parental relationships to explain the disorder •Lack of early acceptance or abuse/neglect by parents 33
- 34. How DoTheorists ExplainBorderline Personality Disorder? •Biological abnormalities: such as an overly reactive amygdala and an underactive prefrontal cortex •In addition, sufferers who are particularly impulsive apparently have lower brain serotonin activity •Close relatives of those with borderline personality disorder are 5 times more likely than the general population to have the disorder 34
- 35. Treatments for Borderline PersonalityDisorder •It appears that psychotherapy can eventually lead to some degree of improvement for people with this disorder •It is extraordinarily difficult, though, for a therapist to strike a balance between empathizing with a patient’s dependency and anger and challenging his or her way of thinking 35
- 36. Treatments for Borderline PersonalityDisorder • “Dialectical behavior therapy” •Largely from the cognitive-behavioral treatment model and borrows heavily from zen buddism. •DBT is often supplemented by the clients’ participation in social skill-building groups 36
- 37. Treatments for Borderline PersonalityDisorder •Antidepressant, mood stabilizing, antianxiety, and antipsychotic drugs have helped some individuals to calm their emotional and aggressive storms •Given the numerous suicide attempts by these patients, their use of drugs on an outpatient basis is controversial •Most clients seem to benefit from a combination of drug therapy and psychotherapy 37
- 38. Histrionic Personality Disorder Fiveor more of the following: Uncomfortable if not the center of attention Inappropriately seductive or provocative Rapidly shifting and shallow emotions Use of appearance to draw attention Speech is impressionistic and lacking in detail Self-dramatization, theatricality Suggestibility Considers relationships more intimate than they are
- 39. How DoTheorists Explain HistrionicPersonality Disorder? •Most psychodynamic theorists believe that, as children, people with this disorder experienced unhealthy relationships in which cold parents left them feeling unloved •To defend against deep-seated fears of loss, the individuals learned to behave dramatically, inventing crises that would require people to act protectively39
- 40. Treatments for Histrionic PersonalityDisorder •Unlike people with most other personality disorders, more likely to seek treatment on their own •Working with them can be difficult because of their demands, tantrums, seductiveness, and attempts to please the therapist 40
- 41. •Narcissistic Personality Disorder •Five or more of the following: • Grandiose sense of self-importance • Preoccupied with fantasies of unlimited success, power, brilliance, etc. • Belief that he or she is “special” • Requires excessive admiration • Sense of entitlement • Interpersonally exploitative • Lacks empathy • Often envious • Arrogant or haughty
- 42. How DoTheorists Explain NarcissisticPersonality Disorder? •Psychodynamic theorists more than others have theorized about this disorder, focusing on cold, rejecting parents •Interpret this grandiose self-presentation as a way for people with this disorder to convince themselves that they are self- sufficient and without need of warm relationships •Research has found increased risk for developing the disorder among abused children and those who lost parents through adoption, divorce, or death 42
- 43. How DoTheorists Explain NarcissisticPersonality Disorder? •Cognitive-behavioral theorists propose that narcissistic personality disorder may develop when people are treated too positively rather than too negatively in early life •Those with the disorder have been taught to “overvalue their self-worth” 43
- 44. “Anxious” Personality Disorders •Peoplewith these disorders typically display anxious and fearful behavior •Although many of the symptoms are similar to those of anxiety and depressive disorders, researchers have found no direct links between this cluster and those diagnoses •As with most of the personality disorders, research is very limited •But treatments for this cluster appear to be modestly to moderately helpful, considerably better than for other personality disorders 44
- 45. Avoidant Personality Disorder Fouror more of the following: Avoids activities due to fear of criticism, disapproval or rejection Unwilling to get involved with people unless certain of being liked Restrained in relationships due to fear of being shamed or ridiculed Preoccupied with criticism or rejection in social situations Inhibited in new situations due to feelings of inadequacy Views self as inept, unappealing, inferior Reluctant to take personal risks
- 46. How DoTheorists Explain AvoidantPersonality Disorder? •Theorists often assume that avoidant personality disorder has the same causes as anxiety disorders, including: •Early trauma •Conditioned fears •Upsetting beliefs •Biochemical abnormalities •Research has not directly tied the personality disorder to the anxiety disorders 46
- 47. How DoTheorists Explain AvoidantPersonality Disorder? •Cognitive theorists believe that harsh criticism and rejection in early childhood may lead people to assume that their environment will always judge them negatively 47
- 48. Dependent Personality Disorder •Peoplewith dependent personality disorder have a pervasive, excessive need to be taken care of •As a result, they are clinging and obedient, fearing separation from their loved ones •They rely on others so much that they cannot make the smallest decision for themselves •The central feature of the disorder is a difficulty with separation 48
- 49. Dependent Personality Disorder Fiveor more of the following: Excessive need for advice and reassurance to make decisions Needs others to assume responsibility for most areas of life Difficulty expressing disagreement Difficulty initiating or doing things on own Goes to excessive lengths for nurturance or support Feels helpless when alone, due to exaggerated fears of being unable to care for self Urgently seeks new relationship if close relationship ends Preoccupied with fears of being left to care for self
- 50. Obsessive-Compulsive Personality Disorder Personalitytraits involving preoccupation with orderliness, perfectionism, and control at the expense of spontaneity, flexibility, and enjoyment
- 51. Obsessive-Compulsive Personality Disorder Fouror more of the following: Preoccupation with rules, lists, order, schedules, etc. Perfectionism Excessive devotion to work and productivity Over-conscientious, scrupulous, inflexible about morality Inability to discard worn-out or worthless objects Reluctance to delegate tasks or work with others unless they submit to exactly his or her way of doing things Miserly spending style Rigidity and stubbornness
Editor's Notes
- #17 must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the direct effects of another medical condition on the central nervous system. Substance use disorders. Paranoid personality disorder must be distinguished from symptoms that may develop in association with persistent substance use. Paranoid traits associated with physical handicaps. The disorder must also be distinguished from paranoid traits associated with the development of physical handicaps (e.g., a hearing impairment).