Personality Disorders

The Nature of Personality Disorders Chapter 12 Personality Disorders • Enduring patterns of perceiving, relating to, and thinking about the world and oneself • Manifest across many life areas • Are inflexible and maladaptive, and cause either significant impairment or distress to self or others • Dimensional vs. Categorical – Problem of degree vs. Problem of kind • DSM-IV – Categorical View – Axis II – Ten Types • Cluster A “Odd” or “Eccentric” Paranoid Schizoid Schizotypal • DSM-IV Clusters Cluster A: “Odd / Eccentric” Cluster B: “Dramatic / Emotional / Erratic” Cluster C: “Anxious / Fearful” • Paranoid Personality Disorder – Pervasive unjustified distrust – Excessively suspicious – Tend not to confide in others – Think others want to harm them – Meaningful relationships are very difficult because of the profound mistrust – Obviously hostile toward others – Appear tense & ready to pounce when they think they’ve been slighted – Very sensitive to criticism – Excessive need for autonomy • Causes – – – – – Still unclear Biological vulnerability Distorted thoughts Roots of these perceptions are in early upbringing Cultural factors • Treatment – Unlikely to initiate treatment – Trigger for seeking therapy is crisis in one’s life or anxiety or depression – Difficulty establishing trust in treatment – Use CT to address mistaken assumptions – No evidence that treatment works! 1 • Schizoid Personality Disorder – Extreme social detachment (loner) – They neither desire nor enjoy closeness with others, including romantic relationships – Limited range of emotions in interpersonal situations – Lack emotional expressiveness – Appear aloof, cold, indifferent – Many are homeless – Extreme social deficiencies • Schizotypal Personality Disorder – Also socially isolated – BUT behavior is more unusual – Often considered odd or bizarre because of how they relate to other people, think & behave & even dress – They tend to be suspicious & have odd beliefs • Ideas of reference • Magical thinking • Illusions • Causes and Treatment – Possibly a biological dysfunction similar to that found in autism – They rarely request treatment except in response to a crisis – Treatment teaches value of social relationships, & involves education about emotions, empathy training, social skills training, & role playing – Treatment prospects are poor • Causes – Viewed by some as one phenotype of a schizophrenia genotype • Treatment – 30-50% of the people seeking treatment for this also have MDD – Limited research into treatment – Teach social skills to help reduce their isolation from & suspicion of others – Medical treatment similar to that for people with schizophrenia Antisocial Personality Disorder Cluster B “Dramatic, Emotional, Erratic” –Antisocial –Borderline –Histrionic –Narcissistic • Long histories of –Violating cultural norms –Violating rights of others –Impulsivity & aggressiveness –Lack of remorse –Substance abuse is common (83%) • Long–term outcome often is poor • Many met the criteria for conduct disorder during childhood • Antisocial personality disorder, psychopathy & criminality 2 Causes • Genetic and Developmental Influences – Family, twin, & adoption studies all suggest a genetic influence – There’s a gene–environment interaction • Neurobiological Influences – Under–arousal Hypothesis – Fearlessness Hypothesis – Jeffrey Gray’s model of brain functioning • Individuals with Antisocial PD may have an imbalance between the reward system (REW) & the behavioral inhibition system (BIS), with REW >>> BIS • Treatment – Most do not seek treatment – Can be very manipulative with their therapists – Poor prognosis – Most common treatment strategy for children involves parent training – Focus on prevention • Treatment – Few Controlled Studies – Medications • Antidepressants and Lithium – Marcia Linehan’s Dialectical Behavior Therapy (DBT) • Multifactorial – Teaches problem solving – Teaches identification & regulation of emotions – Social skills training – Re–experience prior traumatic events to help extinguish associated fear • Psychological & Social Influences – Once they set their sights on a reward goal, they’re less likely to be deterred despite signs that the goal is no longer achievable – Gerald Patterson • Coercive family process • Developmental Influences – Rate of antisocial behavior declines markedly around age 40 Borderline Personality Disorder • Unstable & intense relationships • Unstable self-image • Unstable moods • Impulsive behavior • Causes – Runs in families – Connection with mood disorders – Contribution of early abuse, especially sexual & physical abuse Histrionic Personality Disorder • • • • • • Overly dramatic Emphasis on appearance Seductive & provocative Center of attention Seek reassurance & approval Tend to be impulsive & have difficulty delaying gratification • Impressionistic style; vague speech • Causes – Little research – Ancient Greeks & hysteria – Relationship with Antisocial PD 3 • Treatment – Again few controlled studies – Modify attention seeking behavior – Focus on changing relationship styles – Shown more appropriate behaviors • Causes – Lack of early experiences with empathy / altruism – A function of the “me generation” • Treatment studies are limited – Therapy focuses on grandiosity, hypersensitivity to evaluation, & lack of empathy toward others – CT aims to replace their fantasies with a focus on attainable day–to–day pleasurable experiences – Relaxation training to help them face & accept criticism – Focus on feelings of others – Treatment for depression Avoidant Personality Disorder • Because they are hypersensitive to others’ opinions – They avoid social relationships • Because of extreme low self-esteem – High fear of rejection, – They become very dependent on those few they feel comfortable with • Take few risks • Socially inhibited & anxious • Different from Schizoid PD Narcissistic Personality Disorder • Grandiose • Require & expect special attention • Requires admiration • Little sensitivity for others or empathy • Exploits others for their own interests • Frequently depressed because they often fail to live up to their own expectations >Cluster C “Anxious or Fearful” Avoidant Dependent Obsessive-Compulsive • Causes – May be born with a difficult early temperament • Treatment – Several well controlled studies – Target anxiety and social skills – Treatment similar to social phobia • Systematic Desensitization • Behavioral Rehearsal – Modest improvements with fear of negative evaluation, social avoidance & distress 4 Dependent Personality Disorder • • • • Excessive reliance on others Fear abandonment & rejection Submissive, timid & passive Cling to relationships • Causes – Disruption in early attachment due to neglect, rejection, or early death – Because early bonding is interrupted, they’re constantly anxious they’ll lose people close to them • Very limited research into treatment effectiveness • Causes – Weak genetic contribution – May require parental reinforcement of conformity & neatness • Few controlled treatment studies – Address fears underlying need for orderliness – Relaxation and distraction techniques to redirect the compulsive thoughts Obsessive-Compulsive PD • Fixation on doing things “the right way” • Preoccupation with –Orderliness & perfectionism –Control –Details & rules • Rigid and stubborn, leading to poor interpersonal relationships • Very work–oriented • Only distantly related to OCD Personality Disorders Under Study • Depressive personality disorder – Self–criticism, dejection, judgmental stance toward others, & a tendency to feel guilt – It may be a PD distinct from dysthymic disorder • Negativistic personality disorder – Passive aggression in which people adopt a negativistic attitude to resist routine demands & expectations – May be a subtype of Narcissistic PD 5