Personality Personality DisordersDisorders

Personality Disorders (Axis II):Personality Disorders (Axis II):

Are Are long-standinglong-standing, , pervasivepervasive, & , & inflexibleinflexible patterns patterns of behavior.of behavior.

Usually impair social & occupational functioning.Usually impair social & occupational functioning.

Are often comorbid with Axis I disorders.Are often comorbid with Axis I disorders.

   Make treating an Axis I disorder more difficult. Make treating an Axis I disorder more difficult.

Personality disorder clusters in the DSM-IVPersonality disorder clusters in the DSM-IV

Cluster ACluster A (paranoid, schizoid, & (paranoid, schizoid, & schizotypal): odd/eccentricschizotypal): odd/eccentric

   Cluster BCluster B (antisocial, borderline, histrionic, (antisocial, borderline, histrionic,

& narcissistic): dramatic/erratic& narcissistic): dramatic/erratic   Cluster CCluster C (avoidant, dependent, & (avoidant, dependent, &

obsessive-compulsive): anxious/fearfulobsessive-compulsive): anxious/fearful

I. Odd/Eccentric Cluster:I. Odd/Eccentric Cluster:

1. 1. Paranoid Personality DisorderParanoid Personality Disorder: : PPDPPDSuspiciousness of others is hallmark of personality. Suspiciousness of others is hallmark of personality.    --secretiveness; hostility & anger--secretiveness; hostility & anger --assume others are out to harm them--assume others are out to harm them --reluctant to confide in others;--reluctant to confide in others; --blame others when they are at fault--blame others when they are at fault --jealous & accusatory --jealous & accusatory -read hidden messages in others actions-read hidden messages in others actions

Prevalence (1%): occurs mostly in menPrevalence (1%): occurs mostly in men

How does PPD differ from paranoid How does PPD differ from paranoid schizophrenia?schizophrenia?

Hallucinations & other symptoms Hallucinations & other symptoms (negative) aren’t present in PPD.(negative) aren’t present in PPD.

Impairment in functioning is less than in Impairment in functioning is less than in schizophrenia. schizophrenia.

**Also differs from delusional disorder **Also differs from delusional disorder because delusions are not full-blown.because delusions are not full-blown.

2. Schizoid personality disorder2. Schizoid personality disorder

People with this:People with this: appear dull, bland, aloofappear dull, bland, aloof -don’t show warmth for or interest in others-don’t show warmth for or interest in others -report little enjoyment in life-report little enjoyment in life -are indifferent to praise, criticism; -are indifferent to praise, criticism; -show flat affect; are loners-show flat affect; are loners

Prevalence (less than 1%); occurs more in men Prevalence (less than 1%); occurs more in men

3. Schizotypal personality disorder:3. Schizotypal personality disorder: Have interpersonal problems of people with schizoid PD & Have interpersonal problems of people with schizoid PD &

excessive social anxiety that does not diminish.excessive social anxiety that does not diminish.

These people:These people: -are superstitious (magical thinking)-are superstitious (magical thinking) -think they’re clairvoyant & telepathic-think they’re clairvoyant & telepathic -behavior & dress oddly-behavior & dress oddly -may show paranoid ideation-may show paranoid ideation -may show flat affect-may show flat affect

Is like a mild version of schizophrenia; prevalence-3%; Is like a mild version of schizophrenia; prevalence-3%; mostly in malesmostly in males

Etiology of Odd/Eccentric clusterEtiology of Odd/Eccentric clusterMay be genetically linked. May be genetically linked.

Relatives of schizophrenics & patients with major depression are Relatives of schizophrenics & patients with major depression are at increased risk for schizotypal personality disorder.at increased risk for schizotypal personality disorder.

  Family studies of PPD find higher rates of disorder in relatives Family studies of PPD find higher rates of disorder in relatives

of schizophrenics.of schizophrenics.

No clear pattern has emerged for schizoid personality No clear pattern has emerged for schizoid personality disorder. Is higher among relatives with schizotypal disorder. Is higher among relatives with schizotypal personality disorder.personality disorder.

    

II. Dramatic/erratic cluster:II. Dramatic/erratic cluster: 1. 1. Borderline personality disorder (BPD)Borderline personality disorder (BPD):: Core features are impulsivity & instability in relationships, mood, & Core features are impulsivity & instability in relationships, mood, &

self-image.self-image.

-attitudes, thoughts, & emotions are erratic-attitudes, thoughts, & emotions are erratic -emotions shift abruptly from idealization to contemptuous anger (angel -emotions shift abruptly from idealization to contemptuous anger (angel

to devil)to devil) -argumentative, irritable, sarcastic, defensive-argumentative, irritable, sarcastic, defensive -indulge in self destructive behaviors (drugs, sex)-indulge in self destructive behaviors (drugs, sex) -lack of coherent sense of self-lack of coherent sense of self -self mutilation (cutting with razor/knife)-self mutilation (cutting with razor/knife) -suicide attempts-suicide attempts -intense fear of abandonment-intense fear of abandonment

  

Borderline PD: FactsBorderline PD: Facts Prevalence is 1 to 2 %; more common in women than Prevalence is 1 to 2 %; more common in women than

in men. in men.

Treatment prognosis is very poor; extremely difficult Treatment prognosis is very poor; extremely difficult to treat.to treat.

In a 7 year follow-up study, 50% of patients still had In a 7 year follow-up study, 50% of patients still had disorder.disorder.

   Comorbidity with Axis I mood disorder, substance Comorbidity with Axis I mood disorder, substance

abuse, PTSD, and eating disordersabuse, PTSD, and eating disorders

Kellerman’s account:Kellerman’s account: ““The borderline patient is a therapist’s nightmare...because The borderline patient is a therapist’s nightmare...because

borderlines never really get better. The best you can do is help them borderlines never really get better. The best you can do is help them coast, without getting sucked into their pathology...They’re chronically coast, without getting sucked into their pathology...They’re chronically depressed, the determinedly addictive, the compulsively divorced, living depressed, the determinedly addictive, the compulsively divorced, living from one emotional disaster to the next. Bed hoppers, stomach pumpers, from one emotional disaster to the next. Bed hoppers, stomach pumpers, freeway jumpers, and sad-eyed bench-sitters with arms stitched up like freeway jumpers, and sad-eyed bench-sitters with arms stitched up like footballs and psychic wounds that can never be sutured. Their egos are as footballs and psychic wounds that can never be sutured. Their egos are as fragile as spun sugar, their psyches irretrievably fragmented, like a jigsaw fragile as spun sugar, their psyches irretrievably fragmented, like a jigsaw puzzle with crucial pieces missing. They play roles with alacrity, excel at puzzle with crucial pieces missing. They play roles with alacrity, excel at being anyone but themselves, crave intimacy but repel it when they find being anyone but themselves, crave intimacy but repel it when they find it. Some of them gravitate toward stage or screen; others do their acting it. Some of them gravitate toward stage or screen; others do their acting in more subtle ways.in more subtle ways.

Borderlines go from therapist to therapist, hoping to find a magic Borderlines go from therapist to therapist, hoping to find a magic bullet for the crushing feelings of emptiness. They turn to chemical bullet for the crushing feelings of emptiness. They turn to chemical bullets, gobble tranquilizers and antidepressants, alcohol and cocaine. bullets, gobble tranquilizers and antidepressants, alcohol and cocaine. Embrace gurus and heaven-hucksters, any charismatic creep promising a Embrace gurus and heaven-hucksters, any charismatic creep promising a quick fix for the pain. And they end up taking temporary vacations in quick fix for the pain. And they end up taking temporary vacations in psychiatric wards and prison cells, emerge looking good, raising psychiatric wards and prison cells, emerge looking good, raising everyone’s hopes. Until the next letdown, real or imagined, the next everyone’s hopes. Until the next letdown, real or imagined, the next excursion into self-damage. What they don’t do is change.”excursion into self-damage. What they don’t do is change.”

Causes of BPDCauses of BPD 1. Object-Relations Theory1. Object-Relations Theory Adverse childhood experiences (receiving praise, but Adverse childhood experiences (receiving praise, but

not warmth) cause children to develop insecure egos.not warmth) cause children to develop insecure egos.   Patients engage in splitting– where they lump objects Patients engage in splitting– where they lump objects

into all good or all bad categories (black-n-white into all good or all bad categories (black-n-white thinking). thinking). 

   Evidence:Evidence: *BPD patients report low level of maternal care*BPD patients report low level of maternal care *families are emotionally unexpressive, high in *families are emotionally unexpressive, high in

conflict. conflict. *childhood sexual & physical abuse common*childhood sexual & physical abuse common

Linehan’s Diathesis-Stress theoryLinehan’s Diathesis-Stress theory

BPD occurs when people with a biological diathesis (possibly BPD occurs when people with a biological diathesis (possibly genetic) of emotion dysregulation are raised in a family genetic) of emotion dysregulation are raised in a family environment that is invalidating. environment that is invalidating.

   An invalidating environment-the persons wants and feelings are An invalidating environment-the persons wants and feelings are

discounted and disrespected.discounted and disrespected. (child abuse)(child abuse)

  dysregulation & invalidation interact in a dynamic system.dysregulation & invalidation interact in a dynamic system.      

2. 2. Histrionic personality disorder Histrionic personality disorder (HPD)(HPD)

Applies to people who are overly dramatic & Applies to people who are overly dramatic & attention seeking.attention seeking.

   Symptoms:Symptoms: -attention to physical appearance-attention to physical appearance -may act inappropriately sexual -may act inappropriately sexual -needs to be center of attention-needs to be center of attention -displays of emotion are extravagant & shallow-displays of emotion are extravagant & shallow   Prevalence (2-3 %), occurs more in women than Prevalence (2-3 %), occurs more in women than

men.men.

3. 3. Narcissistic personality disorder (NPD)Narcissistic personality disorder (NPD)

Core feature: they are the “center of the universe”Core feature: they are the “center of the universe”

-grandiose view of one’s own importance-grandiose view of one’s own importance -great fantasies of success-great fantasies of success -extremely self-centered-extremely self-centered -require constant attention & admiration-require constant attention & admiration -lack empathy for others; expect special -lack empathy for others; expect special

considerationsconsiderations -malignant arrogance-malignant arrogance Prevalence (less than 1%)Prevalence (less than 1%)

Causes of NPD:Causes of NPD: Parents did not provide unconditional love & Parents did not provide unconditional love &

empathy they needed. empathy they needed.

Rather, parents placed their own needs above Rather, parents placed their own needs above the needs of the child. the needs of the child.

People with NPD spend lives trying to bolster People with NPD spend lives trying to bolster low sense of self, through endless quests for low sense of self, through endless quests for love & attention.love & attention.

4. Antisocial Personality Disorder (APD):4. Antisocial Personality Disorder (APD): DSM diagnosis: DSM diagnosis:

1. The presence of a conduct disorder before 1. The presence of a conduct disorder before the age of 15the age of 15

Truancy; running away from homeTruancy; running away from home Theft; compulsive lyingTheft; compulsive lying Arson; vandalismArson; vandalism

2. The continuation of this pattern of 2. The continuation of this pattern of behavior into adulthood.behavior into adulthood.

APD features:APD features: Irresponsible & antisocial behaviorIrresponsible & antisocial behavior Criminality (breaking laws)**core featureCriminality (breaking laws)**core feature IrritabilityIrritability Physically aggressivePhysically aggressive Default on debtsDefault on debts ImpulsivityImpulsivity Pathological lyingPathological lying Lack of remorse ***Not necessary for diagnosis***Lack of remorse ***Not necessary for diagnosis***

Prevalence: 3% of males; 1% of femalesPrevalence: 3% of males; 1% of females

PsychopathsPsychopathsCore features-Core features-

Psychopaths lack remorsePsychopaths lack remorse Poverty of emotions (positive & negative)Poverty of emotions (positive & negative)

Psychopaths are:Psychopaths are:Superficially charmingSuperficially charmingPathological liars & cheaters Pathological liars & cheaters Impulsive; sensations seekersImpulsive; sensations seekersManipulative, will change story to fit factsManipulative, will change story to fit factsLess responsive to fear/anxietyLess responsive to fear/anxietyImmoral Immoral Prevalence greater among menPrevalence greater among men

Psychopaths identified by Hare checklistPsychopaths identified by Hare checklist Two clusters:Two clusters:

1. Emotional detachment cluster (a selfish 1. Emotional detachment cluster (a selfish remorseless individual with inflated self-remorseless individual with inflated self-esteem who exploits others.)esteem who exploits others.)

2. Antisocial lifestyle cluster- marked by 2. Antisocial lifestyle cluster- marked by impulsivity & irresponsibility.impulsivity & irresponsibility.

Problems with diagnosis of APD:Problems with diagnosis of APD: 1. You can’t trust reports made by antisocial 1. You can’t trust reports made by antisocial

personalities (they are chronic liars).personalities (they are chronic liars).

2. Many researchers believe psychopathology 2. Many researchers believe psychopathology should not be synonymous with criminality.should not be synonymous with criminality.

3. “Lack of remorse,” a core symptom of 3. “Lack of remorse,” a core symptom of psychopathy is not required for diagnosis of psychopathy is not required for diagnosis of APD. APD.

Causes of APD & PsychopathyCauses of APD & Psychopathy FamilyFamily Lack of affection & severe parental rejection Lack of affection & severe parental rejection

may cause psychopathic behavior (McCord & may cause psychopathic behavior (McCord & McCord, 1964)McCord, 1964)

Fathers of psychopaths likely to be antisocial Fathers of psychopaths likely to be antisocial themselves.themselves.

Genetic factors: APDGenetic factors: APD 1. Higher concordance rate for MZ twins than 1. Higher concordance rate for MZ twins than

for DZ twins.for DZ twins.

2. Higher rate of antisocial behavior in 2. Higher rate of antisocial behavior in adopted children of biological parents with adopted children of biological parents with APD.APD.

Emotions & PsychopathyEmotions & Psychopathy

Psychopaths feel emotions less intensely than Psychopaths feel emotions less intensely than normal individuals.normal individuals.

Psychopaths not under-aroused compared to Psychopaths not under-aroused compared to normal Ss, but are better at tuning out unpleasant normal Ss, but are better at tuning out unpleasant stimuli.stimuli.

They lack empathyThey lack empathy

III. Anxious/Fearful Cluster:III. Anxious/Fearful Cluster: 1. Dependent Personality Disorder:1. Dependent Personality Disorder:

Core feature: lack of self-confidence & Core feature: lack of self-confidence & autonomyautonomy

--need to be taken care of--need to be taken care of --uncomfortable with self--uncomfortable with self --intense fear of abandonment--intense fear of abandonment --need to be in relationships--need to be in relationships

2. Obsessive-compulsive Personality 2. Obsessive-compulsive Personality disorder:disorder: Core feature—perfectionist person preoccupied Core feature—perfectionist person preoccupied

with details, schedules, & rules.with details, schedules, & rules.

--work oriented--work oriented --difficulty making decisions--difficulty making decisions --poor interpersonal relationships--poor interpersonal relationships --stubborness; need to control events--stubborness; need to control events --rigid thinking—overly moralistic--rigid thinking—overly moralistic Does not include obsessions & compulsionsDoes not include obsessions & compulsions