Disordered Personalities
Bart Abplanalp, Ph.D.
Bruce Gage, M.D.
Agenda
•  What are mental disorder and personality
disorder?
•  Development – how we become who we are
–  Biological
–  Cognitive
–  Moral
–  Personality
•  Personality disorder examples
–  Phenomenology
–  General principles of interaction
•  Role playing
Mental Disorder – DSM-5
•  Clinically significant disturbance in
–  Cognition
–  Emotion regulation
–  Biological or developmental processes underlying mental functioning
•  Usually associated with significant distress or disability in social,
occupational, or other important activities.
•  DSM-5 does NOT consider the following to qualify as mental
disorder:
–  Expectable or culturally approved response to a common stressor or loss,
such as the death of a loved one.
–  Socially deviant behavior (e.g., political, religious, or sexual) and conflicts
that are primarily between the individual and society are not mental
disorder unless the deviance or conflict results from a dysfunction in the
individual, as described above.
General Personality Disorder – DSM-5
A.  An enduring pattern of inner experience and behavior that
deviates markedly from the expectations of the individual’s
culture. This pattern is manifested in two (or more) of the
following areas:
1.
2.
3.
4.
Cognition (i.e., ways of perceiving and interpreting self, other people, and
events)
Affectivity (i.e., the range, intensity, lability, and appropriateness of
emotional response.)
Interpersonal functioning
Impulse control
B.  The enduring pattern is inflexible and pervasive across a
broad range of personal and social situations.
General Personality Disorder – DSM-5
C.  The enduring pattern leads to clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
D.  The pattern is stable and of long duration, and its onset can be
traced back at least to adolescence or early adulthood.
E.  The enduring pattern is not better explained as a manifestation or
consequence of another mental disorder.
F.  The enduring pattern is not attributable to the physiological effects
of a substance (e.g., a drug of abuse, a medications) or another
medical condition (e.g., head trauma).
Prevalence of Personality Disorder
•  Community (DSM-IV)
Θ  All PD – 10-15%
–  Cluster A - odd
•  Paranoid – 0.5-2.5%
•  Schizoid – “uncommon in clinical
settings”
•  Schizotypal – 3%
–  Cluster B - dramatic
•
•
•
•
ASPD – 3% male, 1% female
BPD – 2%
Narcissistic – <1%
Histrionic – 2-3%
–  Cluster C - anxious
•  Obsessive-Compulsive – 1%
•  Avoidant – 0.5-1%
•  Dependent – “among the most
frequently reported in MH clinics”
•  Prison(Arroyo and Ortega,
2009) – most studies show
higher prevalence
Θ
–
–
–
–
–
–
All PD – 30%
ASPD – 12%
BPD – 12%
Narcissistic – 2%
Paranoid – 3%
Schizoid – 2%
Others small
•  Most studies show PD on
the order of 50%,
predominantly Cluster B
Intrauterine Brain Development
The brain develops from ectoderm, which also becomes skin.
Damage to the brain at different times and/or by different means
can lead to very different functional and behavioral problems.
The Cortex and Neuronal Pruning Computation
•  Neurons develop many new connections in the first years
of life.
•  During adolescence, neurons are lost and connections are
“pruned”.
•  Thereafter, few new neurons are created but connections
are made and pruned throughout life, though not at as
high a rate.
Note: frontal areas,
serving emotion and
executive functions
(such as decisionmaking), develop last.
Myelin Formation
Improving Communication within the Brain
Myelination is not complete until well into adulthood.
Here again, the frontal lobes are myelinated last.
Genetics of Personality
•  Modern studies are finding that around 50% of the
variance in personality is genetic (most modern studies
are between 1/3 and 2/3 and vary some with
personality type)
–  Twins reared apart and other typical genetic methods
–  Temperament (e.g. sensation seeking, fearfulness)
–  Extraversion/introversion, activity, self-control, purpose,
agency, growth (psychic, learning), positive social relations
Cognitive Development (Jean Piaget)
•  Sensorimotor stage (0-2 years old)
–  Learn through sensory observation
–  Key development is object
permanence
•  Preoperational thought (2-7 years
old)
–  Thinking intuitive more than
reasoned
–  Egocentric
–  Cannot think deductively
–  Key development: use of language
and symbols
Cognitive Development (Jean Piaget)
•  Concrete operations (7-11 years old) – some stay here
–  Able to use outside information (see from others’ perspective)
–  Basic logical thought processes (grouping, what a rule is)
–  Basic deduction
•  Formal operations (11- young adult)
•  Abstraction becomes possible – manipulation of symbols, images,
concepts
•  Complex logic – hypothesis testing, inductive logic
•  Reasoning about situations they have not personally experienced
•  Thinking about the future
•  Searching systematically for solutions to problems.
Moral Development
(Kohlberg & Gilligan)
•  The Heinz dilemma
–  A woman was near death from a unique kind of
cancer. There is a drug that might save her. The drug
costs $4,000 per dosage. The sick woman's husband,
Heinz, went to everyone he knew to borrow the money
and tried every legal means, but he could only get
together about $2,000. He asked the doctor scientist
who discovered the drug for a discount or let him pay
later. But the doctor scientist refused.
Should Heinz break into the laboratory to steal the
drug for his wife? Why or why not?
Stages of Moral Development
•  Level 1 (Pre-Conventional)
–  Obedience and punishment orientation –
avoid punishment, defer to authority
•  Blind egoism – it’s good because I like it
–  Self-interest orientation – what's in it for me?
•  Quid pro quo – I’ll scratch your back if you’ll
scratch mine
Stages of Moral Development
•  Level 2 (Conventional)
–  Interpersonal accord and social conformity – good
boy/good girl
•  Golden Rule – behave well in hope of being treated well
–  Authority and social-order maintaining orientation –
law and order morality
•  Morality dictated by outside force
•  Most adults are here
Stages of Moral Development
•  Level 3 (Post-Conventional or Principled)
–  Social contract orientation - law as contract rather
than rigid rule
•  Valuation of compromise and inclusion
–  Universal ethical principles – principled conscience
•  Laws only valid if just
•  Acts done because they are right not for ends (ends do
not justify means)
•  Mutual respect as universal principle
•  Rights and values are relative and contextual (but not
egocentric)
Personality Development
•  Attachment (bonding) – the reciprocal
relationship between parents and infant
–  Full attachment not complete until 3 months or
beyond
–  Those deprived of early attachment
•  Show retardation in other aspects of development (e.g.
cognitive)
•  Are socially disabled throughout life, often diagnosed
with personality disorders
Personality Development
•  Differentiation or autonomy – the process of
differentiation from the parents takes place in
stages
–  Parents need to be responsive but not too
responsive
•  Child may be overly dependent or independent in
future relationships
•  Patterns of behavior that we call personality
result from experience (given the particular
organism)
Prominent Theories
•  All incorporate biological/genetic development to
some degree, though not always explicitly
–  Behaviorism (e.g. B.F. Skinner, John Watson)
•  Conditioning and reinforcement
–  Social Learning (e.g. Albert Bandura)
•  Behaviorism plus modeling
–  Psychosexual theory (e.g. Sigmund Freud)
•  Focus on sexual and aggressive drives
•  Ego, Id, Superego
Prominent Theories
•  Object relations theory (e.g. Otto Rank, Donald
Winnicott, Melanie Klein)
–  Focuses on the drive toward and the nature and evolution of
relationships, primarily within the nuclear family
–  This leads to unconscious psychic structures (e.g. the parental
imago) that drive our responses to others
•  Psychosocial (e.g. Erik Erikson)
–  Focus on social interaction at a macro level
–  Each life stage has its specific challenge
•  Interpersonal (e.g. Harry Stack Sullivan, Timothy Leary)
–  Focus on relationship and the patterns of social interaction
that emerge from interpersonal experience
–  Relatively unconcerned with the infrastructure subserving
those patterns
Impact of Abuse
•  Repeated trauma (physical, sexual, severe neglect) has
a variety of common effects mediated at least in part
through changes in the amygdala and hippocampus
–  Emotional instability
–  Impaired cognitive development
–  Sympathetic nervous system reactivity or arousal
•  “Fight or flight” – on high alert
–  Self-destructive, self-defeating, and/or antisocial behavior
–  Unstable interpersonal relationships, e.g.
•  Have great difficulty accurately assessing the intentions of others
•  Insatiable neediness (abused people and animals often develop
overly dependent attachment on the abuser)
Impact of Abuse
–  Unstable self-image even to the point of not having a sense
of identity
–  A tendency to see others as all good or all bad – may
change rapidly
–  Sexual promiscuity
–  Substance abuse
–  Medical problems – especially those with substantial
psychosomatic element
•  Allergies, arthritis, asthma, bronchitis, hypertension, ulcers
•  Poorer overall physical health and poor adherence to treatment
Impact of Abuse
•  Many people end up with diagnosis of Borderline
Personality Disorder or other personality disorders
•  Jails and prisons have many men and women with abuse
histories
–  11 times more juvenile arrests
–  2.7 times more adult arrests
–  3.1 times more arrests for violence (adult & juvenile)
•  About 1/3 go on to abuse their own children
•  Cost to society close to $100 billion per year
•  Most data from US Dept. of Health and Human Services
Transference
•  Refers to the patient “transferring" feelings
from key figures from earlier in their lives onto
the professional.
–  negative or positive feelings
•  attraction or repulsion
–  conflicts
–  attitudes and expectations
•  Arises from unresolved or
unsatisfactory experiences with
parents or other important figures
Transference
•  Make assumptions about the likes, dislikes, values, and
attitudes of others (doctors, nurses, MH, custody)
•  Often not consciously aware of it
•  Example: Patient’s father was an punitive, unreliable, and
abusive
Patient develops maladaptive assumptions about
male authority figures
Patient reacts to male DOC staff in the same
way he reacted to his father
Transference
•  The patient may make inferences about your reaction or
thoughts
–  “I know what you are thinking”
•  Their responses may be irrational and disproportionate to the
situation
•  Countertransference – transference is from doctor to patient
–  It is more than just a patient reminding you of someone
•  Don’t be surprised if it happens to you, we all have issues
•  Be aware that this is a very real aspect of our work
•  Support and consultation are helpful
Obsessive Compulsive
Disorder and Personality
•  Shared feature is a quality of rigid adherence but
they are very different
•  Obsessive-Compulsive Disorder
–  Ritual behavior (compulsions) and recurrent
intrusive thoughts (obsessions) are paramount
•  Consume a significant amount of time and energy
•  Resisting them results in tremendous anxiety, ultimately
necessitating that the person yield and engage in the action
or indulge the thought
–  Personality may be relatively normal
Obsessive Compulsive
Disorder and Personality
•  Obsessive-compulsive personality
–  Obsessions and compulsions may be a small part
–  Primarily a preoccupation with orderliness,
perfectionism and control
•  Often self-righteous, nit-picking, “can’t see the forest
for the trees”
Obsessive Compulsive
Disorder and Personality
•  Shared feature is a quality of rigid adherence but
they are very different
•  Obsessive-Compulsive Disorder
–  Ritual behavior (compulsions) and recurrent
intrusive thoughts (obsessions) are paramount
•  Consume a significant amount of time and energy
•  Resisting them results in tremendous anxiety, ultimately
necessitating that the person yield and engage in the action
or indulge the thought
–  Personality may be relatively normal
Obsessive Compulsive
Disorder and Personality
VIDEO CLIP
•  Matchstick Men: Pharmacy Scene
Narcissistic Personality Disorder
•  Grandiose sense of self worth
–  Pre-occupied with fantasies of power, unlimited
success, brilliance, beauty, and/or ideal love
•  Entitled
–  Expects to be seen and treated as special, admired
Narcissistic Personality Disorder
•  Lack of empathy
–  Exploitative – takes advantage of others for
own ends
•  Concerned with appearances and impression
on others
–  Hyper-sensitive to criticism, often responding
with rage
Narcissistic Personality Disorder
VIDEO CLIP
•  Wall Street: Limo Scene
Borderline Personality Disorder (BPD)
•  Very difficult for custody and mental health
–  If there is a lot of staff friction, consider BPD
•  Very frequently associated with repeated childhood
abuse
–  Genetic temperament and other parenting factors
important
Borderline Personality Disorder (BPD)
•  Pathological fear of
abandonment
–  Inappropriate, intense
anger or difficulty
controlling anger
–  Emotional instability –
often inappropriately
diagnosed bipolar
–  Chronic loneliness,
boredom, emptiness
–  Unstable and volatile
interpersonal relations
Borderline Personality Disorder (BPD)
•  Brief paranoid ideation and/or
dissociative symptoms
•  May become psychotic, but
usually brief
•  May have sense of themselves or
circumstances not being real, not
being inside their own body, or
looking at world from afar (but
not delusional)
•  Recurrent self-harm and
related behavior
Borderline Personality Disorder (BPD)
•  Brief paranoid ideation and/or
dissociative symptoms
•  May become psychotic, but
usually brief
•  May have sense of themselves or
circumstances not being real, not
being inside their own body, or
looking at world from afar (but
not delusional)
•  Recurrent self-harm and
related behavior (can be
severe)
Borderline Personality Disorder
VIDEO CLIP
•  Sid & Nancy: Phone Booth Scene
PTSD
•  Person experienced or witnessed event involving
threat of death or harm to self or others & their
response involved intense fear, helplessness or horror
•  One or more of the following
–  Flashbacks and/or intrusive memories of event
–  Recurrent dreams of event
–  Distress and/or physiologic reactivity when reminded of
event
PTSD
•  Person experienced or
witnessed event involving
threat of death or harm to
self or others & their
response involved intense
fear, helplessness or horror
•  One or more of the
following
–  Flashbacks and/or intrusive
memories of event
–  Recurrent dreams of event
–  Distress and/or physiologic
reactivity when reminded of
event
PTSD
•  Avoidance of stimuli associated with the trauma and
numbing of general responsiveness
•  Increased arousal – insomnia, irritable/angry, poor
concentration, hypervigilance, startle
Psychopathy
•  Not the same as Antisocial Personality
Disorder
ASPD
Psychopathy
Psychopathy
•  Malignant narcissism – it’s all about me
•  Cheaters – get the goodies as easily as possible
–  Not intrinsically violent
•  But generally not averse to hurting others to get what
they want
•  Biological component
–  Genetic component
–  Differences in brain electrical responses
–  Punishment has limited ability to change behavior
•  Biological foundation
Psychopathy Checklist - Revised
•  Aggressive Narcissism
–  Glibness/superficial charm
–  Grandiose sense of selfworth
–  Pathological lying
–  Cunning/manipulative
–  Lack of remorse
–  Shallow affect
–  Callousness
–  Failure to accept
responsibility
•  Socially Deviant Lifestyle
–
–
–
–
–
–
–
–
–
Need for stimulation
Parasitic lifestyle
Poor behavioral control
Lack of realistic long-term
goals
Impulsivity
Irresponsibility
Juvenile delinquency
Early behavioral problems
Revocation of conditional
release
Psychopathy Checklist - Revised
•  Other items
•  Sexual promiscuity
•  Many short-term (marital)
relationships
•  Criminal versatility
•  Acquired behavioral
sociopathy
Psychopathy
VIDEO CLIPS
•  A Clockwork Orange:
•  Dissent Among Droogs Scene
•  Droogs in the Water Scene
•  Droogs in Pub Scene
Interacting with PD in Clinical Settings
•  Manage your reactions
–  Know what bugs you
–  Actively monitor your
behavior, thoughts and
emotions
–  Learn to modulate your
external behavior
•
•
•
•
Facial expressions
Posture
Tone of voice
Professional but
dispassionate
•  Red flags
–  Rescue fantasy
–  Guilt
•  Not doing enough
–  Feelings of inadequacy
–  Destructive impulses
•  Kick out
•  Withhold treatment
•  Treat with less desirable
approaches
–  Missing/dreading work
Interacting with PD in Clinical Settings
•  General principles
–  Structure appointments
•  Time for listening
–  Opportunity to figure
out what type of PD
–  Each type has
different need(s)
•  Summary and brief
corrections
•  Exam
•  Findings
•  Options
–  Regularly scheduled
appointments
•  “Emergencies”
–  Deal only with the
emergency –
everything else at
regular appointment
–  Matter of fact approach
•  “Nothing works”
–  Don’t need to do
anything if nothing to
do
–  What if it will simply
be like this?