Chapter 12

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