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Personality features versus Disorder
Categorical versus Dimensional Approaches
Overview of major disorders
Issues and concerns
Antisocial Personality Disorder
Borderline Personality Disorder

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Personality = the enduring patterns of thinking, feeling and reacting that define a person
Personality Disorder = “an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture”
APA,2000
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Must fit both the general and the specific criteria for DSM diagnosis
Pattern of deviation must be evident in two or more of the following domains: cognition, emotional responses, interpersonal functioning, or impulse control
Pattern must be inflexible and pervasive across a broad range of personal and social situations
Must be a source of clinically significant distress or impairment in social, occupational or other important areas of functioning
Must be stable and of long duration, with an onset that can be traced back to at least adolescence of early adulthood

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Personality Disorders are a construct (clinical) used to understand, describe and communicate about the complex phenomena that result when the personality system is not functioning optimally
Categorical Classification (DSM-IV) – Axis II Disorders
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Cluster A: odd or eccentric behaviour including paranoid, schizoid, schizotypal personalities
Cluster B: erratic, emotional and dramatic presentations including antisocial, borderline, histrionic and narcissistic personalities
Cluster C: characterised by anxiety and fearfulness including avoidant, dependent and obsessive-compulsive personalities

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Dimensional Classification: personality disorders are normal traits amplified to the extreme
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E.g. Five-Factor Model of Personality: neuroticism, extraversion, openness to experience, agreeableness and conscientiousness
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Facilitates assessment and research

Very
Low
Very
Introverted
Very
Low
Very
Low
Very
Low
Neuroticism
Extraversion
Openness
Agreeableness
Conscientiousness
Very
High
Very
Extraverted
Very
High
Very
High
Very
High

 Aetiology Models:
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Biopsychosocial Model: holistic and inclusive
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Diathesis-Stress Model: individual levels of tolerance
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Psychodynamic theory: driven by the unconscious
General Systems Theory
 Aetiology Factors:
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Genetic Predisposition
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Attachment Experience
Traumatic events
Family factors and dysfunction
Sociocultural and political forces

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Varies according to gender, social factors and type
Approx. 10-14% overall
Most prevalent = Obsessive Compulsive,
Dependent, Schizotypal
Least prevalent = Narcissistic, Schizoid
Most visible = Borderline, Antisocial
Assumption of stability over time, but some more than others (e.g. schizotypal > borderline)

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Cluster A: odd/eccentric
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Paranoid: pervasive distrust and suspicion of others
Schizoid: Social detachment/indifference and limited emotional experience & expression
Schizotypal: cognitive and perceptual distortions; eccentric behaviour; discomfort with close relationships

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Cluster B: dramatic/emotional/erratic
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Antisocial: disregard for and violation of (the rights of) others
Borderline: instability of interpersonal relationships, self-image, emotions, and control over impulses
Histrionic: excessive emotionality and attentionseeking
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Narcissistic: grandiosity; inflated sense of selfimportance; need for attention; lack of empathy

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Cluster C: anxious or fearful
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Avoidant: social withdrawal; feelings of inadequacy, hypersensitive to criticism
Dependent: excessive need to be taken care of; clinging and submissive
Obsessive-compulsive: preoccupation with orderliness, perfection and control at the expense of flexibility

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Borderline:
Narcissistic:
Paranoid:
Antisocial:
Histrionic:

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Socially and culturally sensitive diagnoses
Can be adaptive?
Gender biases
Clinically arbitrary thresholds for diagnosis (who decides?)
Stigma
Clinical hopelessness

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Traditionally PDs considered very difficult to treat because of their pervasive, entrenched nature
Psychoanalysis (esp. Cluster B:
Borderline, Dependent, Antisocial etc.)
Cognitive Behavioural Therapy
Other psychotherapies: RET, Gestalt,
Narrative etc. (individual and group)
Medication

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More studied than any other personality disorder
Origins usually traced back to earlier periods in development
(Conduct Disorder), although can not be diagnosed until late adolescence (DSM criteria)
Has the distinction between ASPD and criminality been blurred? Not all psychopaths are criminals, and not all serious offenders are psychopaths.
Psychopathy includes ”shallow, deceitful, unreliable and incapable of learning from emotional experience” and seemingly lacking in basic emotions: shame, guilt, anxiety, remorse (conscience).
Increasing age can bring a change (lessening) in overt antisosial behaviours: less obvious impulsivity, recklessnes, social deviance. Some argue that the behaviours merely go
”underground”.

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Biological Factors: seems to be a genetic loading, esp.
Father-son, but outcome strongly determined by environment (adoption studies)
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Temperament and family environment interaction: parenting (punitive, inconsistent, low warmth), peers, school
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Behavioural and social reinforcers: learned behaviour resistant to change, modelling, consequence ”trap”, peer support

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Psychological factors: inability to anticipate punishment, lack of anxiety regarding punishment/negative consequences. Does moral judgement cause anxiety or vica versa?
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Consequent participation in risk-taking, self-promoting behaviour with reduced ability to interpret (or pay attention to) nonverbal cues esp. fear, distress, anger, anxiety. Deficit or decision?
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Some people ”born bad”? (GSR, emotional responsiveness, empathy studies)

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Seldom seek treatment
Often coerced into treatment by the legal system, however, participation does not always equate with success
Difficulty building a therapeutic relationship
Very high recurrance of behaviour
Limited success with behavioural techniques

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Often present due to other complaints (e.g. somatic, self-harm, anxiety, depression, abuse history). Large degree of comorbidity
Initially conceptualised as the ”borderline” between neurosis and schizophrenia but this no longer the case
Very poor sense of/integration of self leads to uncertainty about personal values, identity, worth and choices = erratic, impulsive and selfdamaging behaviour

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Fear abandonment and crave relationships but are incapable of maintaining these due to unrealistic expectations and lack of self-cohesion
Subject to chronic feelings of depression, worthlessness, ’emptiness’ leading to self-harm and self-deprecating behaviour (e.g. sexual activity, substance abuse, eating)
May demonstrate dissociation during intense distress
”Splitting” – tend to see people and events as either all good or all bad, and can shift rapidly between these.

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Biological/genetic: seems to run in families and may be associated with genes that contribute to anxiety, frontal lobe dysfunction
Object Relations: the internalisation of early caregiving relationships (e.g. inconsistency = insecurity & ego confusion leads to ego defence such as splitting)
Diathesis-stress: vulnerability thresholds overwhelmed e.g. by abuse & trauma

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Perceived as very difficult clients
Therapeutic relationship is key but threatening to person with BPD therefore attrition is high, and therapy is made very challenging
Psychoanalysis uses the transference relationship to interpret and integrate

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Developed by Marsha Linehan (1993)
Based on strategies of both behaviour therapy and supportive psychotherapy
”Dialectic” refers to strategies used by therapist to help client balance contradictory needs
Rogerian acceptance is first established
Aim is to become more comfortable with difficult emotions, followed by helping to re-interprete these and then regulate
Other CBT strategies also employed
Contracts are made about self-harm to communicate support without acceptance.
Some preliminary evidence to support this treatment model