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PSYC 340 Fundamentals of Psychopathology Lucy Farisello
Fundamentals of Psychopathology (Concordia University)
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Gender differences in MDD: Biological
Hormones
Gender differences in MDD: Social
- Social support
- Co-rumination
Gender differences in MDD: Psychological
- Ruminative coping
- Brooding (moody pondering)
Stigma and discrimination -> experienced stress -> places them
at risk for many negative mental and physical health outcomes.
Minority Stress Model
*Hostile and unique stressors (homophobic victimization)
Early descriptions of Schizophrenia
Greek: schizein (to split), phren (mind).
Early figures in diagnosis of Schizophrenia
1. Emil Kraepelin (1898/1899)
2. Eugen Bleuler (1908)
German psychiatrist.
Emil Kraepelin
Unified distinct categories of schizophrenia (hebephrenic, catatonic, and paranoid) under the name DEMENTIA PRAECOX.
Swiss psychistrist.
Eugen Bleuler
Introduce the term schizophrenia (splitting of the mind).
Disorder characterized by psychosis.
Schizophrenia
Psychosis: major disturbances in thought, emotion, and behaviour.
4 characteristics of schizophrenia
1. Disordered thinking in which ideas are not logically related.
2. Faulty perception and attention.
3. Flat or inapropriate affect.
4. Bizarre disturbances in motor activity.
Patients withdraw from others and reality into a fantasy life of
delusions and hallucinations.
Prodromal phase (precedes the onset of clinical psychotic symptoms).
1-2 years before more serious symptoms.
Less severe but unusual...
Development of Schizophrenia
a) ideas of reference
b) magical thinking
c) increased anxiety/irritability
d) attention problems
e) social withdrawal
f) obsessive behaviors
*Begins in childhood but appears in late adolescence or early
adulthood.
1-2 years after symptom onset.
Diagnosis of Schizophrenia
- Relapse and recovery
- Most (78%) experience several episodes
- Poor prognosis
High mortality rates:
Mortality of Schizophrenia
- Illicit drug use
- Lower family involvement
- Longer time to the initial remission of symptoms (remission
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tioning, earlier treatment response, shorter duration of untreated
psychosis).
*Shorter life expextancy by 20 years.
Co-morbidity of Schizophrenia
- Substance abuse
- Depression
- Social anxiety
*Co-morbid conditions play a role in the development, severity and
course of the disorder.
Gender differences in Schizophrenia
Significantly higher in males than in females.
No essential symptom must be present for a diagnosis.
Diagnosis for Schizophrenia
- First episode of multiple episodes
- Acute
- Partial or full remission
- Continuous
- Unspecified
- With catatonia
Severity: each symptom may be rated for current severity on a
5-point scale from 0 (not present) to 4 (present and severe).
Positive symptoms of Schizophrenia
Presence of too much of a behaviour that is not apparent in most
people.
Positive symptoms: excesses or distortions
1. Disorganized speech (formal thought disorder)
2. Delusions
3. Hallucinations
Formal thought disorder: disorganized thought expressed in disorganized speech.
Problems organizing ideas and speaking.
Disorganized speech
- Incoherent conversations.
- Loose associations in speech (derailment): more successful in
communicating but difficulty sticking to one topic.
- Neologism: new words appear in patient's speech.
Beliefs that is fixed and firmly held despite clear contradictory
evidence (reality).
Delusions
*Found among more than half of the people with schizophrenia.
*Present in other diagnoses (mania and delusional depression but
schizophrenia delusions are more bizare and highly implausible).
1. Made feelings or impulses: thoughts, feelings, actions controlled
by external agents.
2. Thought broadcasting: private thoughts are being broadcasted
indiscriminately to others.
Types of Delusions
3. Thought insertion: thoughts are being inserted into one's brain
by some external agent.
4. Thought withdrawal: some external agency has robbed one of
one's thoughts.
5. Delusion of reference: neutral environment event is believed to
have special and personal meaning.
6. Delusion of body changes: organs don't work or were removed.
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Sensory experience that seems real to the person having it but
occurs in the absence of any external perceptual stimulus.
- More auditory than visual.
- Increased activity in Broca's area and visual center.
Hallucinations
*Produced by the brain, no interplay of external stimuli (hallucinations negative due to fear).
- Hearing their own thoughts spoken by another voice.
- Hear voices arguing.
- Hear voices commenting on their behaviour.
Examples of hallucinations
Absence of a behaviour that should be evident in most people.
Negative symptoms of Schizophrenia
*Tend to endured beyond an acute episode.
1. Reduced expressive behaviour.
a) Affect (blunt, flat)
b) Alogia
Broad domains of negative symptoms
2. Reductions in motivation or in experience of pleasure.
a) Avolition
b) Anhedonia
c) Asociality
No emotional response, no stimulus can elicit a response.
*Feel internal emotion but inability to express them.
Flat affect
- Facial expressions as flat with vacant stare.
- Lifeless expression in their face.
- Flat, toneless voice.
*Found in a majority of people with schizophrenia.
a) Poverty of speech: amount of speech greatly reduced.
Alogia
b) Poverty of content of speech: amount of speech reasonable but
gives little information and tends to be vague/repetitive.
Inability to initiate or persist in goal-directed activity (lack of energy
and seeming absence of interest).
Avolition
- Lack if interest in or inability to do daily activities like grooming and personal hygiene (uncombed hair, dirty nails, disheveled
clothes).
- Apathy as a predictor of poorer life functioning and negative
quality of life.
- Hard time maintaining their job or going to school.
- May spend much of their time sitting around not doing much.
Diminished ability to experience pleasure (ONLY in people who
DID experience pleasure in the past).
Anhedonia
- Lack of interest in recreational activities.
- Lack of interest in sex, inability to develop close friendships with
people.
*Clients aware of this symptoms and report that normally pleasurable activities are not enjoyable for them.
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Severely impaired social relationships.
- Few friends, poor social skills, little interest in being with other
people (lower sociability and greater shyness).
- Childhood 'social troubles'.
Asociality
*Takes a toll on having a support system (negative linger after
having an episode).
Why it is difficult to get out of the 5 As
Lack of social support for 'unproblematic' non-socials, stigma,
forced to withdraw.
Defined by several motor abnormalities.
- Repeated gestures, odd patterns of gestures (peculiar and complex sequences)
- Unusual increase in their overall level of activity
- Appears similar to mania
Catatonia
Catatonic immobility:
- Adopt unusual postures and maintain them for very long time.
- Waxy flexibility: another person can move the person's limbs into
strange positions and that they maintain for extended periods.
Inappropriate affect
Emotional responses out of context (shift rapidly from one emotional state to another without apparent reason).
Schizophrenia included in the DSM-IV-TR
1. Disorganized
2. Catatonic
3. Paranoid
4. Undifferentiated
5. Residual
Disorganized speech , disorganized behaviour, flat or inappropriate affect.
- Hallucinations/delusions do not have a theme.
Disorganized (hebephrenic) Schizophrenia
- Catatonia NOT present.
- Early and gradual onset, poor prognosis.
- Asociality present (isolation)
*Type that tends to not take care of their appearance.
Psychomotor disturbances (when having an episode).
Catatonic Schizophrenia
- Motor immobility (stupor or waxy flexibility)
- Excessive motor activity
- Extreme negativism (do everything opposite to what the people
around them want them to do)
- Mutism (no talking)
- Posturing (catalepsy, staying in awkward positions)
- Echolalia (echo speech of others)
- Echopraxia (repeating gestures)
*Both echolalia and echopraxia is for yourself and/or others.
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Delusions or frequent auditory hallucinations.
- Delusions typically a persecutory (paranoid) and/or grandiose.
- Hallucinations often related to delusions.
- Usually organized around a theme.
- Good prognosis.
Key aspects of prominent delusions (DELUSIONS OF PERSECUTION):
Paranoid Schizophrenia
a) Grandiose delusions: exaggerated sense of importance, power,
knowledge, identity.
b) Delusional jealousy: unsubstantiated belief that their partner is
unfaithful (feeds into paranoia, makes it seem like there is validity
to belief).
c) Ideas of reference: incorporate unimportant events within a
delusional framework (real personal significance into trivial activities of others).
*No disorganized speech, disorganized or catatonic behaviour, or
flat affect.
Individuals typically agitated, argumentative, angry, violent.
Undifferentiated Schizophrenia
Residual Schizophrenia
Presence of symptoms for a schizophrenia diagnosis but criteria
for paranoid, disorganized or catatonic type is not met.
At least one episode of schizophrenia but there are no longer
prominent positive/disorganized symptoms.
- Continued negative symptoms or attenuated positive symptoms.
Genetic factors of Schizophrenia
- Higher concordance in MZ (15-65%) than in DZ twins (3-14%).
- First-degree relatives (parents, sibling, offspring).
- Second-degree relatives who share only 25% of their genes with
the proband, lifetime prevalence closer to 3%
- Negative symptoms appear to have a stronger genetic component.
- Relatives at increased risk for schizotypal personality disorder.
Schizophrenogenic mother.
Early Theories of Family and Schizophrenia
- cold, dominant, conflict-inducing mother produced schizophrenia
offspring.
- rejecting, overprotective, self-sacrificing, impervious to the feelings of others, rigid and moralistic about sex, fearful of intimacy.
*Destructive view: blamed the mother for severe psychiatric disorder in a child.
Schizophrenia not due to a specific single gene.
Genetics and Schizophrenia
- Predisposition to schizophrenia transmitted genetically.
- Relatives of people with schizophrenia are at increased risk and
the risk increases as the genetic relationship between proband
and relative becomes closer.
The Adoptive Family Study of Schizophrenia
Adoptive Family
- Adopted-away children of all women in Finland who were hospitalized for schizophrenia between 1960 and 1979.
- Over 21 year-follow-up.
Result: the adoptees developed more schizophrenia and schizophrenia-related disorders than did the controls.
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Children of women with schizophrenia were more likely to be
diagnosed as mentally defective, psychopathic, neurotic.
Genotype-environmental interaction: children raised in dysfunctional families + high risk for schizophrenia = developed schizophrenia-related disorders themselves.
Biopsychosocial.
Genetic factors can only predispose individuals to schizophrenia.
Best model for etiology of schizophrenia
Some kind of stress is required to render the predisposition an
observable pathology.
Excess levels of dopamine (too many or oversensitive dopamine
receptors).
- Dopamine not regulated in a neurotypical fashion.
- Too little in pre-frontal cortex that manages limbic system
(prefrontal cortex underactivated, less control, less motor activity)
*Prefrontal cortex especially relevant to negative symptoms.
- Too much in the mesolimbic system (amygdala,
hippocampus)
Dopamine Hypothesis
- Reduced mass/matter, larger ventricles, atrophy in some areas.
*Longest standing biologically based theory of schizophrenia.
- Drugs effective in treating schizophrenia decrease dopamine
activity.
Evidence FOR Dopamine Hypothesis
- Amphetamines may induce symptoms of psychosis that closely
resembles paranoid schizophrenia.
- Homovanillic acid (HVA): not found in greater amounts in people
with schizophrenia.
Evidence AGAINST Dopamine Hypothesis
- Excess of or oversentitive dopamine receptors (rather than hight
levels of dopamine) that cause schizophrenia.
- Viral infections (no real evidence)
- Rhesus incompatibility
- Pregnancy and Birth Complications
- Early Nutritional Deficiency
- Maternal Stress
- Gene and Environment interaction
Other possible causes of Schizophrenia: congenital and developmental considerations
Psychological stress interacts with biological vulnerability.
- Increased life stress leads to increases likelihood of relapse.
Psychological stress and Schizophrenia
*Patients who take part in stress-management program are less
likely to be readmitted to the hospital in the year following treatment.
Increased rates of schizophrenia in central city areas with high
population + low socio-economic status.
SES and Schizophrenia
Sharp difference in amount of people with schizophrenia in high
SES vs low SES.
1. Sociogenic hypothesis
2. Social-selection theory
Sociogenic hypothesis
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Stressors associated with being in a low social class may cause
or contribute to the development of schizophrenia.
During the course of their developing psychosis, people with
schizophrenia may drift into poverty.
Social-selection theory
- Growing cognitive and motivational problems impair earning
capabilities (cannot afford to live elsewhere).
- Choose to move to areas of little social pressure (escape intense
social relationships).
1. Antipsychotic medication
a) First-generation (neuroleptics)
b) Second-generation (atypical) antipsychotics.
2. Psychological treatments
a) Psychosocial treatments
b) Cognitive behavioural interventions
Treatment for Schizophrenia
Shock and psychosurgery.
Biological Treatments
- Prefrontal lobotomy: surgery that destroys tracts connecting
frontal lobes to lower centres of the brain.
Many side effects that people will suffer from.
Issue with antipsychotic medication
- People stop taking medication if they start feeling better.
Due to symptoms, many patients quit after one or two years (high
non-compliance rates).
Dopamine antagonists (D2 receptors, lowers dopamine levels)
- Chlopromazine (calming effect, Thorazine), haloperidol (Haldol)
- Mainly effective on positive symptoms (decrease of dopamine).
- Affect mainly mesolimbic area
First-generation (neuroleptics) antipsychotics
- Extrapyramidal side effects (symptoms similar to parkinsons,
difficulty speaking, involuntary facial movements).
- Tardive dyskinesia (involuntary motor movements).
- Neuroleptic malignant syndrome (can be fatal, muscle rigidity,
coma).
*If go too far in blocking dopamine -> polar opposite, suffering from
lacking dopamine.
Block broader range of receptors (not just dopamine)
- Clozapine, Risperidone
(improvements in satisfaction, quality of life, thinking, mood, alertness)
Second-generation (atypical) antipsychotics
- Works both on positive AND negative symptoms.
- Less likely to cause side effects (better compliance).
*Blocks dopamine and serotonin receptors.
Learn skills in specific domains (interpersonal situations).
Social Skills Training (psychosocial treatment)
a) receiving skills
b) processing skills
c) Behvaioural responses in social interaction
- Employment, relationships, self-care (medication adherence)
- Help breaking down of tasks to make them easier
- May not improve global functioning.
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*modelling, role playing, training in goal setting.
Educate clients and their families about biological vulnerability,
cognitive problems inherent, symptoms, signs of relapse.
Help improve communication and problem-solving skills within the
family.
Family Therapy and Reducing Expressed Emotion (psychosocial
High expressed emotion as a result of a family environment chartreatment)
acterized by
- Criticism , emotional overinvolvement, hostility, law warmth linked
to relapse and re-hospitalization.
- Main focus on the amount of perceived criticism in close meaningful relationships.
Cognitive techniques for dysfunctional attitudes, internalization of
stigma and defeatist attitudes.
Cognitive restructuring to help them understand that the voices
cannot actually hurt them.
Cognitive-Behavioural Therapy
Command hallucinations: person believes they are being commanded to do something.
- Most distressing, high risk and treatment resistant of all symptoms of schizophrenia.
- Power beliefs about voices.
CBT to facilitate motivation and engagement in social and vocational activities + limit command hallucinations from occurring
(limiting maladaptive beliefs).
*CBT effective reduce negative symptoms, best treatment for reducing hallucinations and delusions, good effects on depression
and anxiety symptoms and social functioning.
Dysfunctional attitudes predict reduced functioning in schizophrenia patients + lead to internalization of stigma.
Beck's cognitive model
- Mental health professionals endorsed less stigmatizing attitudes
than people from the general public
Destigmatization of Schizophrenia
- General practitioners endorsed stigmatizing beliefs.
- People with higher education and younger age (teenagers) show
more acceptance and understanding.
heterogeneous group of disorders that are
a) long-standing
b) pervasive
c) inflexible (rigid)
patterns of behaviour.
Personality Disorders
*Extremes of traits that are inflexible
Described by others as
a) difficult
b) eccentric
c) hard to get to know
Manifestation of Personality Disorders
Manifested in at least 2 of
a) cognition
b) affectivity
c) interpersonal functioning
d) impulse control
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Affectivity
the degree of a person's response or susceptibility to pleasure,
pain, and other emotional stimuli.
Positive affectivity
positive emotions and expressions (cheerfulness, pride, enthusiam, energy, joy)
Negative affectivity
negative emotions and expression (sadness, disgust, lethargy,
fear, distress)
Rigidity of Personality Disorders
Cannot adjust their thoughts, feelings, behaviours to fit circumstances and people they encounter.
a) Rigid and inflexible: difficulty altering behaviour according to
changes in situation.
Traits to differentiate "Personality" vs "Personality Disorder"
b) Self defeating: vicious cycles that get them away from goals.
c) Structural instability, fragility: self that 'cracks' under conditions
of stress.
1. Extraversion
2. Agreeableness
3. Openness
4. Conscientiousness
5. Neuroticism
Personality Disorders as extremes of the Big 5 (Ocean)
Maladaptive - Adaptive - Maladaptive
a) Existence: personal motivators and drives.
Life enhancing (pleasure) vs Life sustaining (pain)
- Basic survival.
- Driven towards pleasure or the avoidance of pain (surviving avoiding pain vs thriving).
b) Adaptation: engagement in life.
Millon's Personality vs Personality Disorder
Accommodating (passive) vs Modifying (active)
- Seeking out life experiences or disengaged.
c) Replication: associated with social dimensions.
Independent (self) vs Dependent (others)
- Self oriented, narcissistic, egocentric
- Goal of leaving something behind, leaving part of the self for
others.
Difficult tasks for Personality Disorders.
1. Intrapersonal: forming stable, coherent representation of self
and others.
Three life tasks (Livesley)
a) Realizing your place in the world.
b) Forming a sense of who you are.
2. Interpersonal: develop capacity for intimacy and positive affiliations with others.
3. Social group: engaging in prosocial and cooperative behaviours.
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Cluster A: seem odd, eccentric.
a) Paranoid
b) Schizoid
c) Schizotypal
- Avoidance of social contact.
- Similarities with schizophrenia.
Cluster B: seem dramatic, emotional, erratic.
a) Anti-social
b) Borderline
c) Histrionic
d) Narcissistic
3 Clusters of Personality Disorders
- Behaviours extrapunitive and hostile.
- Malignant group.
Cluster C: seem fearful.
a) Avoidant
b) Dependent
c) Obsessive-Compulsive
- Attachment issues.
10-12% of people meet criteria for at least one personality disorder.
Cluster C disorders as most common (7%).
Prevalence of Personality Disorders
Comorbid with
a) anxiety disorders,
b) mood disorders,
c) substance problems,
d) sexual difficulties and disorders.
*Substance abuse as a coping mechanism for personality disorders.
Challenges in Personality Disorder Research
- Diagnostic criteria not sharply defined.
- Diagnostic reliability and validity are still low.
- High level of comorbidity among disorders.
- Little prospective research has been conducted (little research
foretells the development of a personality disorder).
Assessing Personality Disorders
1. Clinical Interviews
2. MMPI
3. MCMI-IV
Challenge: many personalities are ego syntonic (don't think there's
a problem).
Clinical interviews
Person with a personality disorder unaware that a problem exists +
may not be experiencing significant personal distress (lack insight
into their own personality).
Objective tests, not used very often.
MMPI
PSY-5 scales.
Good prediction of paranoid, schizotypal, narcissistic and anti-social personality disorder symptoms.
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Provides subscale measures of 15 clinical personality scales
- schizoid, avoidant, melancholic, dependent, histrionic, turbulent, narcissistic, antisocial, sadistic, compulsive, negativistic,
masochistic.
MCMI-IV
and 3 severe personality pathology scales.
- schizotypal, borderline, paranoid.
Cluster A: Odd/Eccentric
1. Paranoid
2. Schizoid
3. Schizotypal
Paranoid Personality Disorder (PPD)
- Suspicious of others
- Expect to be mistreated or exploited by others
- Reluctant to confide in others (low trust)
- Tends to blame others
- Can be extremely jelous
Hallucinations NOT PRESENT.
Full-blown delusions NOT PRESENT.
- "The government is out to get everyone"
Differentiated Diagnosis and Comorbidity of Paranoid Personality
Less impaired and occupational functioning (than schizophrenia).
Disorder
Comorbid with
a) schizotypal
b) borderline
c) avoidant
- No desire for enjoyment or social relationships (no close friends)
- Appear dull, bland, aloof
- Rarely report strong emotions
- No interest in sex
- Few pleasurable activities
- Indifferent to praise or criticism
- Solitary interests (loners)
- Extremely high levels of introversion (low warmth, low positive
emotions).
Schizoid Personality Disorder
- Low openness to feelings (openness to experience)
- Low openness to achievement striving
Symptoms of Schizoid precede Psycotic illness in some cases.
Differentiated Diagnosis and Comorbidity of Schizoid Personality
Disorder
- Severe disruption in sociability (severe impairment of underlying
social and emotional bonds)
Maladaptive schemas (proposed by cognitive theorists): view
themselves as self-sufficient loners and others as intrusive.
Comorbid with
a) schizotypal
b) avoidant
c) paranoid
Common trait of social impairment.
Link between schizoid personality and autism spectrum disorders
Do not want to seek relationships.
Biological genetic component of Schizoid
Parents likely have it if child has it.
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- Similar interpersonal difficulties of Schizoid personality disorder
(social detachment, restricted affect).
Schizotypal Personality Disorder
Key Schizotypal features:
- Odd beliefs or magical thinking
- Recurrent illusions
- Odd speech
- Ideas of reference (suspiciousness, paranoid ideation, eccentric
behaviour and appearance).
1. Histrionic
2. Narcissistic
3. Borderline
4. Antisocial
Cluster B: Dramatic/Erratic
Histrionic Personality Disorder
- Overly dramatic and attention seeking
- Use physical appearance to draw attention
- Self-centered
- Inappropriately sexually provocative and seductive (but overall
appropriate in the way they talk and act)
- Impressionistic speech lacking detail (no depths to them or their
stories, embellished)
*Maintains the notion of Hysteria?
Cognitive theory: maladaptive schemas about the need for attention to validate self-worth.
Etiology of Histrionic Personality Disorder
Psychoanalytic theory: seductiveness encourage by parental upbringing (talk about sex as something dirty in childhood but behaved as though it was exciting and desirable).
Comorbid with
a) depression
b) BPD
c) antisocial
d) narcissistic
e) dependent
Comorbidity of HPD
Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others (could if they wanted to).
*unwilling to experience empathy (when empathy expressed to
them, perceived as form of manipulation)
Narcissistic Personality Disorder
- Exaggerated sense of self-importance
- Preoccupation with being admired
- Preoccupied with fantasies (of unlimited success, power, brilliance, beauty, love)
- Believes to be special and unique and can only be understood
by other special and high-status people (or institutions)
- Required excessive admiration
- Sense of entitlement
- Often envious of others or believes that others are envious of
them
- Arrogant, haughty behaviours or attitudes
*Projective world (project sense of being strong or having a sense
of control)
Subtypes of Narcissistic Personality Disorder
1. Grandiose
2. Vulnerable
Grandiose NPD
- Extreme grandiosity
- Overestimate one's own abilities and accomplishments + underestimate those of others
- Portray themselves as larger than life
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- OVERT narcissist
- Hide fragility and insecurity
1. Entitlement rage
2. Exploitativeness
3. Grandiose fantasy
4. Self-entitlement
4 factors to assess narcissistic Grandiosity
- Fragile and unstable sense of self-esteem
- Arrogance, condescension as a façade for intense shame and
hypersensitivity to rejection and criticism (condescending but slip
into victim mentality)
Vulnerable NPD
- COVERT: show their insecurity and fragility
- Center of attention by acknowledging that they messed up or are
the victim
*Most likely to FAKE empthay.
3 factors to assess narcissistic vulnerability
1. Contingent self-esteem: contingent on admiration from others.
2. Hiding the self
3. Devaluating: bringing down others.
- Less than 1%
- Comorbid with BPD
Etiology and Comorbidity of NPD
- Kohut view of emerging self (check further down)
- Product of our times and system of values (set up a society where
getting validation and standing out is encouraged and set up as
positive).
- First stage
- Attachment, security
All born ID (primary narcissism for survival and attachment).
Narcissism as proposed by Freud
- Infants must realize they are one being separate from the rest
of the world (lines blurred, no clean break due to latency at anal
stage)
- Do not develop a sense of self if lack of needed love growing up
(attachment).
Self-objects: merging with others.
One's experience of another person (object) as part of one's self
(rather than as separate and independent form).
Everybody seen as an extension of themselves.
'Selfobject' experiences and NPD
Inability to find your own self = frail identity.
Self-object experience: experience caregivers as part of themselves instead of a separate entity.
Narcissistic tendencies as a result of not resolving seeing the self
and others as separate.
1. Mirroring: caregivers to experience same emotions as child
(empathize with child).
3 Needs of Children
2. Idealization: want someone to look up to (be able to idealize
caregivers).
3. Twin ship/alter ego: be similar to caregiver and to model them
(phallic stage: sons model their fathers).
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*If these needs are not met, narcissistic personalities develop.
Lack of 3 needs in childhood leads to...
1. Mirror-hungry personalities
2. Ideal-hungry personalities
Kohut's narcissistic personalities (5)
3. Alter-ego personalities
4. Merger-hungry personalities
5. Contact-shunning personalities
Individuals who crave self-objects that confirm and admire them
to increase their feelings of self-worth.
Mirror-hungry personalities
- Create others that will admire their success.
- Seek validation and attention.
Ideal-hungry personalities
Individuals who experience themselves as worthwhile (value
themselves) as long as they can related to people they can admire.
- Only value important/high-status people.
Individuals who feel worthwhile (value themselves) only if they
have a relationship with a self-object who looks and dresses like
them (and has similar opinions and values).
Alter-ego personalities
- Want others to be like them (surround themselves with people
that always agree with them).
Individuals who experience others as their own self.
Merger-hungry personalities
- Between parents and children
- Have absorbed people into their sphere (child does not have a
life of their own)
- Engulfing relationship
Intense longing to merge with self-objects.
Contact-shunning personalities
- Individuals highly sensitive to rejection, to avoid it they avoid
social contact.
- Approach-avoidance situation
- Sensitive to others' pain
Combination of Narcissism, Psychopathy, Machiavellianism.
Dark Triad (Paulhus & Williams)
+Sadism (enjoy harming others)
Characteristics:
- Attitudes and feelings toward others vary dramatically
- Erratic emotions that shift abruptly
- Argumentative, irritable, sarcastic, quick to take offence.
Traits:
Borderline Personality Disorder
- High neuroticism
- Low agreeableness (trust, compliance)
- Transitory episodes of paranoia, dissociation
- Dichotomous Thinking ("I hate you, don't leave me")
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*Borderline between neurosis and schizophrenia
- 5 out of 9 symptoms required
1. Affect instability: difficulty regulating emotions.
- Inappropriate anger, drastic mood shifts
- Reactive mood
- Feelings of emptiness
2. Dysfunctional relationships: fear of abandonment (polarity).
3 Dimensions of BPD
- Unstable and intense relationships
- Efforts to avoid abandonment
3. Impulsivity: self-harm.
- Impulsive self-damaging behaviours
- Attempts at self-harm or suicide
- Strong genetic component in twin studies.
- Heritability of impulsivity and affective instability.
- Reduced response to SEROTONIN in orbital, ventromedial and
cingulate cortices linked impulsive aggressivity, emotional processing and social cognition.
Biology of BPD
*Serotonin related because SSRI can help with emotional reactivity.
- Increased noradrenergic responsiveness linked to affective instability.
*Traits modelled by caregivers (learnt behaviour) vs genetic hard
to differentiate.
Psychological factors of BPD
- Negative experiences in childhood: abuse, neglect, separation or
loss, trauma.
- Parental psychopathology
- Genetic/biological diathesis: affective instability and impulsivity
traits.
Diathesis-stress model
- Stress: trauma, parental failure or psychopathology, loss/rejection.
Interaction between child's genetic vulnerability and harsh environment (how BPD develops over time).
Invalidating environment + biological emotional vulnerability ->
emotional dysregulation.
Linehan's diathesis-stress theory (biosocial)
Invalidating environment: invalidation of personal experiences and
emotions (high emotional uncontrolled states vs suppression).
Emotional disregulation, demainds on the family that might not
have the tools to deal with it -> family may invalidate child (punishments and ignoring demands) -> exacerbates the child -> greater
feelings of loss of control.
Treatment of BPD
Dialectic Behaviour Therapy (DBT) by Marsha Linehan
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Cognitive and behavioural therapy adapted for BPD (whose default is intolerance).
Encourage patients to accept negative affect without engaging in
self-destructive or other maladaptive behaviours.
- Tools to understand that both opposites are possible at the same
time.
Dialectic Behaviour Therapy (DBT) by Marsha Linehan
a) Distress tolerance
b) Interpersonal tolerance
c) Emotional regulation
d) Mindfulness
Problem-focused treatment.
Based on hierarchy of goals.
*Learn to sit in intolerance (grey area)
Regulation and BPD
Regulation reduces impulsivity.
Stigmatizing terms: needy, explosive, manipulative, attention
seeking, self-destructive, treatment resistant.
Changing the narrative of BPD
- Treatable (can recover).
- Living fulfilling lives.
1. Conduct disorder present before age 15 (running away from
one, theft, arson).
2. Pattern of antisocial behaviour continues into adulthood (lifetime
pattern).
Two main components of Antisocial Personality Disorder
a) Irresponsible and anti-social behaviour
b) Work only inconsistently (difficulty holding a job)
c) Break laws
d) Physically aggressive
*Sample: prisoners
Substance abuse.
Comordibity of Antisocial Personality Disorder
Skewed towards men (legal system less tolerant amongst men,
don't know how it is manifested amongst women).
Criminality and APD have heritable components.
- Greater concordance for Monozygotic twins vs Dizygotic twins.
Genetic component of APD
*Environmental influences have a greater impact:
- High parental conflict, high negativity, low parental warmth all
predict antisocial behaviours.
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Ineffective parenting (neglectful, too aggressive).
Backdrop: parental psychopathology (some level of disorder or
subtance abuse).
a) Employment (low income, absent parent due to work) that lead
to lack of supervision
b) divorce and transition (violent or aggressive split)
c) neighbourhood (finding acceptance and friends or troublesome
relationships) lead to..
a) childhood anti-social behaviour
b) deviant peers infleunce
Developmental perspective and APD
which lead to..
a) early arrest
b) chronic delinquency
and an antisocial lifestyle.
- lack of help directed towards the young diagnosis, to foster
self-esteem and education -> facilities turn into a 'crime school'
which feeds the cycle.
*Lack of appropriate attention from caregiver (inconsistent discipline as difficult to navigate) leads to higher impact from school
and neighbourhood which leads to negative consequences.
Key characteristic: POVERTY OF EMOTIONS (both positive and
negative.
- Lack of remorse
- No sense of shame
- Superficially charming
- Manipulates others for personal gain
- Lack of anxiety (nervous system stays cool, resting state more
calm than others).
Psychopathy
All psychopaths are diagnosed with APD.
*Many with APD do not meet criteria for psychopathy.
Anti-social Personality Disorder and Psychopathy
- 75%-80% of convicted felons meet criteria for APD.
- 15%-25% of convicted felons meet criteria for psychopathy.
*20% of people with APD score high on Hare PCL-R (test for
psychopathy)
- Reduced amygdala volume
- Reduced amygdala response to negative stimuli
*Amygdala codes for danger.
Etiology of Psychopathy
- Reduced response to aversive conditioning, fearful, sad faces.
- Decreased Prefrontal Cortex activity (more impulsivity, less regulation)
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Factor 1: Affective/Interpersonal
a) Superficial charm
b) Gradiose sense of self-worth
c) Manipulative
d) Lack of empathy and remorse
e) Shallow affect
Factor 2: Anti-social Lifestyle
Differentiating between Psychopathy and Anti-social Personality
Disorder (PCL-R)
a) Failure to conform
b) Impulsivity
c) Irresponsibility
d) Aggression
e) Deceitful/lying
f) Disregard for others
*Psychopathy: both Factor 1 AND Factor 2
*Anti-social PD Factor 2
1. Avoidant
2. Dependent
3. Obsessive Compulsive
Cluster C: Anxious/Fearful
*Dependent on early attachment
Most prevalent and stable features: feeling inept, socially inadequate.
Avoidant Personality Disorder
- Sensitive to possibility of criticism, rejection, disapproval
- Reluctant to enter relationships unless sure will be liked
- Higher levels of life impairment (compared to other personality
disorders)
*Will want to connect but pulls away
Comorbidity of Avoidant Personality Disorder
- Dependent personality disorder
- Depression
- Generalized social phobia
Etiology of Avoidant Personality Disorder
- Innate "inhibited temperament"
- Shy and inhibited in new and ambiguous situations
- Modest genetic influence
- Fear of being negatively evaluated (moderately heritable)
- Introversion and neuroticism
- Intense need to be taken care of
- Lack self-reliance
- Overly dependent on others (sense of autonomy)
- Uncomfortable when alone
- Subordinate own needs
Dependent Personality Disorder
*People pleasers: "love me".
Prevalence less than 1%
- Culture laden: connecting with others as more valued in collectivistic cultures (compared to North America individualism).
Prevalence and Comorbidity of Dependent Personality Disorder Comorbid with
a) Bipolar Disoders
b) Depression
c) Anxiety Disorders
d) Bulimia
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- 30-60% of variance attributed to genetic factors.
- Neuroticism and agreeableness have a genetic component.
Etiology of Dependent Personality Disorder
- Predisposition to dependence and anxiousness (prone to effects
of authoritarian and overprotective parents).
- Cognitive theorists: underlying maladaptive schemas.
- Perfectionistic approach to life
- Preoccupied with details, rules, schedules
Comorbid with
a) OCD (20%)
b) Panic Disorder
c) Depression
d) Avoidant Personality Disorder
Obsessive-Compulsive Personality Disorder (not OCD)
Differential diagnosis to Obsessive-Compulsive Personality Dis- OCPD does not have the obsession and compulsions that define
order
Obsessive Compulsive disorder (OCD) - no rituals.
- Excessively high levels of conscientiousness.
- High assertiveness (facet of extraversion)
- Low compliance (facet of agreeableness)
Etiology of Obsessive-Compulsive Personality Disorder
- Low levels of novelty seeking and reward dependence
- High levels of harm avoidance
Fixation at the anal stage.
Psychoanalytic theories of OCPD
- Need for perfection.
- Know how to do things well (low compliance, agreeableness)
- Treating symptoms as beneficial.
- Personality as a default system (challenge default).
- Reducing subjective distress.
- Changing specific dysfunctional behaviours.
Treating Specific Personality Disorders
Schema therapy: challenge existing schemas they have of themselves and the world (therapeutic technique in cognitive approach).
- Monitoring automatic thoughts, challenging faulty logic, assigning behavioural tasks.
*Personality disorders (clusters A and/or B) have difficulty forming
a therapeutic relationship.
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