Personality Disorders

Personality Disorders: An Overview
 Enduring and pervasive predispositions
 Perceiving
 Relating
 Thinking
 Inflexible and maladaptive
 Distress
 Impairment
 Coded on Axis II

Personality Disorders
 10 specific personality disorders
 Several under review for DSM-V
 3 clusters
 High comorbidity with Axis I disorders
 Poorer prognosis
 Therapist reactions
 Countertransference

Personality Disorders: An Overview
 Categorical vs. Dimensional Views
 “Kind” vs. “Degree”
 DSM is categorical
 Reifies concepts
 Less flexible
 Loss of individual information
 Sometimes arbitrary

Personality Disorders: An Overview
 Five factor model of personality (“Big Five”)
 Openness to experience
 Conscientiousness
 Extraversion
 Agreeableness
 Emotional stability

DSM Personality Disorder Clusters
 Cluster A
 Odd or eccentric
 Paranoid, schizoid, schizotypal
 Cluster B
 Dramatic, emotional, erratic
 Antisocial, borderline, histrionic, narcissistic
 Cluster C
 Fearful or anxious
 Avoidant, dependent, obsessive-compulsive

Personality Disorders: Facts and Statistics
 Prevalence = 0.5 - 2.5%, may be closer to 10%
 Outpatient = 2 - 10%
 Inpatient = 10 – 30%
 Origins and Course
 Begin in childhood
 Chronic course
 High comorbidity

Personality Disorders: Gender Differences
 Differences in diagnostic rates
 Borderline (75% female)
 Clinician bias
 Assessment bias
 Measures
 Criterion bias
 Histrionic = extreme “stereotypical female”
 No “macho” disorder

Personality Disorders: Gender Differences

Personality Disorders Under Study
 Individual disorders
 Sadistic
 Self-defeating
 Categories of disorders
 Depressive
 Negativistic
 Passive aggressive

Cluster A: Paranoid Personality Disorder
 Clinical Description
 Mistrust and suspicion
 Pervasive
 Unjustified
 Few meaningful relationships
 Volatile
 Tense
 Sensitive to criticism

Cluster A: Paranoid Personality Disorder
 Causes
 Possible relationship to schizophrenia
 Possible role of early experience
 Trauma
 Abuse
 Learning
 “World is dangerous”

Cluster A: Paranoid Personality Disorder
 Treatment
 Unlikely to seek on own
 Crisis
 Focus on developing trust
 Cognitive therapy
 Assumptions
 Negative beliefs
 No empirically-supported treatments

Cluster A: Schizoid Personality Disorder
 Clinical Description
 Appear to neither enjoy nor desire relationships
 Limited range of emotions
 Appear cold, detached
 Appear unaffected by praise, criticism
 Unable or unwilling to express emotion
 No thought disorder

Cluster A: Schizoid Personality Disorder
 Causes
 Limited research
 Precursor: childhood shyness
 Possibly related to:
 Abuse/neglect
 Autism
 Dopamine

Cluster A: Schizoid Personality Disorder
 Treatment
 Unlikely to seek on own
 Crisis
 Focus on relationships
 Social skills therapy
 Empathy training
 Role playing
 Social network building
 No empirically-supported treatments

Cluster A: Schizotypal Personality Disorder
 Clinical Description
 Psychotic-like symptoms
 Magical thinking
 Ideas of reference
 Illusions
 Odd and/or unusual
 Behavior
 Appearance
 Socially isolated
 Highly suspicious

Cluster A: Schizotypal Personality Disorder
 Causes
 Schizophrenia phenotype?
 Lack full biological or environmental contributions
 Preserved frontal lobes
 Cognitive impairments
 Left hemisphere?
 More generalized?

Cluster A: Schizotypal Personality Disorder
 Treatment Options
 Treatment of comorbid depression
 Multidimensional approach
 Social skill training
 Antipsychotic medications
 Community treatment

Cluster B: Antisocial Personality Disorder
 Clinical Description
 Noncompliance with social norms
 “Social Predators”
 Violate rights of others
 Irresponsible
 Impulsive
 Deceitful
 Lack a conscience, empathy, and remorse

Cluster B: Antisocial Personality Disorder
 Nature of psychopathy
 Glibness/superficial charm
 Grandiose sense of self-worth
 Proneness to boredom/need for stimulation
 Pathological lying
 Conning/manipulative
 Lack of remorse
 Overlap with ASPD, criminality
 Intelligence

Cluster B: Antisocial Personality Disorder

Cluster B: Antisocial Personality Disorder

Cluster B: Antisocial Personality Disorder
 Developmental considerations
 Early histories of behavioral problems
 Conduct disorder
 Families history of:
 Inconsistent parental discipline
 Variable support
 Criminality
 Violence

Causes of Antisocial Personality
 Gene-environment interaction
 Genetic predisposition
 Environmental triggers
 Arousal hypotheses
 Underarousal
 Fearlessness

Causes of Antisocial Personality
 Gray’s model of brain functioning
 Behavioral inhibition system (BIS)
 Low
 Reward system (REW)
 High
 Fight/flight system (F/F)

Causes of Antisocial Personality
 Interactive, integrative model
 Genetic vulnerability
 Neurotransmitters
 Environmental factors
 Family stress
 Reinforcement of antisocial behaviors
 Alienation from good role models
 Poor occupational/social function

Antisocial Personality Disorder
 Treatment
 Unlikely to seek on own
 High recidivism
 Incarceration
 Early intervention
 Parent training
 Prevention
 Rewards for pro-social behaviors
 Skills training
 Improve social competence

Cluster B: Borderline Personality Disorder
 Clinical Description
 Patterns of instability
 Labile, intense moods
 Turbulent relationships
 Impulsivity
 Fear of abandonment
 Very poor self-image
 Self-mutilation
 Suicidal gestures

Cluster B: Borderline Personality Disorder
 Comorbid disorders
 Depression – 24-74%
 Suicide – 6%
 Bipolar – 4-20%
 Substance abuse – 67%
 Eating disorders
 25% of bulimics have BPD

Cluster B: Borderline Personality Disorder
 Causes
 Genetic/biological components
 Serotonin
 Frontolimbic circuit
 Cognitive biases
 Early childhood experience
 Neglect
 Trauma
 Abuse

Cluster B: Borderline Personality Disorder
 Treatment
 Highly likely to seek treatment
 Antidepressant medications
 Dialectical behavior therapy
 Reduce “interfering” behaviors
 Self-harm
 Treatment
 Quality of life
 Outcomes
 Demonstrated efficacy
 Cortical activation changes

Cluster B: Borderline Personality Disorder

Cluster B: Histrionic Personality Disorder
 Clinical Description
 Overly dramatic
 Sensational
 Sexually provocative
 Impulsive
 Attention-seeking
 Appearance-focused
 Impressionistic
 Vague, superficial speech
 Common diagnosis in females

Cluster B: Histrionic Personality Disorder
 Causes
 Little research
 Links with antisocial personality
 Sex-typed alternative expression?

Cluster B: Histrionic Personality Disorder
 Treatment
 Problematic interpersonal behaviors
 Attention seeking
 Long-term consequences of behavior
 Little empirical support

Cluster B: Narcissistic Personality Disorder
 Clinical Description
 Exaggerated and unreasonable sense of self-importance
 Require attention
 Lack sensitivity and compassion
 Sensitive to criticism
 Envious
 Arrogant

Cluster B: Narcissistic Personality Disorder
 Causes
 Deficits in early childhood learning
 Altruism
 Empathy
 Sociological view


Increased individual focus
“Me generation”

Cluster B: Narcissistic Personality Disorder
 Treatment focuses on:
 Grandiosity
 Lack of empathy
 Hypersensitivity to evaluation
 Co-occurring depression
 Little empirical support

Cluster C: Avoidant Personality Disorder
 Clinical Description
 Extreme sensitivity to opinions
 Avoid most relationships
 Interpersonally anxious
 Fearful of rejection

Cluster C: Avoidant Personality Disorder
 Causes
 Sub-schizophrenia disorder?
 Difficult temperament
 Early parental rejection
 Interpersonal isolation and conflict

Cluster C: Avoidant Personality Disorder
 Treatment
 Similar to social phobia
 Increase social skills
 Reduce anxiety
 Importance of therapeutic alliance
 Moderate empirical support

Cluster C: Dependent Personality Disorder
 Clinical Description
 Rely on others for major and minor decisions
 Unreasonable fear of abandonment
 Clingy
 Submissive
 Timid
 Passive
 Feelings of inadequacy
 Sensitivity to criticism
 High need for reassurance

Cluster C: Dependent Personality Disorder
 Causes
 Little research
 Early experience
 Death of a parent
 Rejection
 Attachment

Cluster C: Dependent Personality Disorder
 Treatment
 Limited empirical support
 Caution: dependence on therapist
 Gradual increases in:
 Independence
 Personal responsibility
 Confidence

Cluster C: Obsessive-Compulsive Personality Disorder
 Clinical Description
 Fixation on doing things the “right way”
 Rigid
 Perfectionistic
 Orderly
 Preoccupation with details
 Poor interpersonal relationships
 Obsessions and compulsions are rare

Cluster C: Obsessive-Compulsive Personality Disorder
 Causes
 Limited research
 Weak genetic contributions
 Predisposed to favor structure?

Cluster C: Obsessive-Compulsive Personality Disorder
 Treatment
 Similar to OCD
 Address fears related to the need for orderliness
 Decrease:
 Rumination
 Procrastination
 Feelings of inadequacy
 Limited efficacy data

Personality Disorders: Future Directions
 Completely rethinking personality disorders
 Dimensional models