Personality Disorders

Definition of Personality

“Enduring patterns of perceiving, relating to, and thinking about the environment and oneself, which are exhibited in a wide range of important social and personal contexts”

Definition of Personality Disorders

Personality disorders are “enduring patterns of perceiving, relating to, and thinking about the environment and oneself” that “are exhibited in a wide range of important social and personal contexts,” and “are inflexible and maladaptive, and cause either significant functional impairment or subjective distress” (DSM-IV, p. 630)

Main Features of PDs

Extreme patterns of thinking, feeling, and behaving that deviate from a person’s culture

Listed on Axis II of the DSM-IV-TR Begin early in life and remain stable

- not contextual or transient Inflexible and maladaptive Cause significant functional impairment and

subjective distress - ego-syntonic vs. ego-dystonic

Problems with the PDs

Low levels of inter-rater reliability Comorbidity with both Axis I and Axis II Problems with classification system

- Categorical vs. Dimensional System

DSM-IV-TR Personality Disorders Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder

Antisocial Personality Disorder Borderline Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder

Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder

Cluster A: Odd or Eccentric

Paranoid PD – is a pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent

Schizoid PD – is a pattern of detachment from social relationships and restricted range of emotional expression

Schizotypal PD – is a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour

Paranoid Personality Disorder

suspicious of other’s motives interprets actions of others as deliberately

demeaning/threatening expectation of being exploited see hidden messages in benign comments easily insulted/ bears grudges appear cold and serious

Schizoid Personality Disorder

indifferent to relationships limited social range (some are hermits) aloof, detached, called loners no apparent need of friends, sex solitary activities seem to be missing the “human part”

Schizotypal Personality Disorder

peculiar patterns of thinking and behaviour

perceptual and cognitive disturbances magical thinking not psychotic

perhaps a distant “cousin” of schizophrenia

Cluster B: Dramatic, Emotional, or Erratic

Antisocial PD – is a pattern of disregard for, and violation of, the rights of others

Borderline PD – is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity

Histrionic PD – is a pattern of excessive emotionality and attention seeking

Narcissistic PD – is a pattern of grandiosity, need for admiration, and lack of empathy

Antisocial Personality Disorder

pattern of irresponsibility, recklessness, impulsivity beginning in childhood or adolescence (e.g., lying, truancy)

adulthood: criminal behaviour little adherence to societal norms, little anxiety conflicts with others callous/exploitive

Psychopathy

Egocentric, deceitful, shallow, impulsive individuals who use and manipulate others

Callous, lack of empathy Little remorse Thrill-seeking “human predators” (Hare, 1993) No “conscience”

Psychopathy Checklist-Revised (Hare, 1991) – 2 Factors

Glib and superficial Egocentric and

grandiose Lack of remorse or

guilt Lack of empathy Deceitful and

manipulative Shallow emotions

Impulsive Poor behavior

controls Need for excitement Lack of responsibility Early behavior

problems Adult antisocial

behavior

Quote of the day

“I’m the most cold-hearted son of a b---- you will ever meet” Ted Bundy

Borderline Personality Disorder

marked instability of mood, relationships, self-image

intense, unstable relationships uncertainty about sexuality everything is “good” or “bad” chronic feeling of “emptiness” recurrent threats of self-harm/

“slashers”

Borderline and comorbidity

High degree of overlap with both Axis I and Axis II disorders

24%-74% also diagnosed with major depression; 4% to 20% bipolar

25% of bulimics also diagnosed with BPD 67% also diagnosed with substance use

disorder

Histrionic Personality Disorder

excessive emotional displays/ dramatic behaviour

attention-seeking, victim stance seek re-assurance, praise shallow emotions, flamboyant, self-

centred very seductive, “life of the party”

Narcissistic Personality Disorder

grandiose, sense of self-importance lack of empathy hyper-sensitive to criticism exaggerate accomplishments/ abilities special and unique

entitlement below surface is fragile self-esteem

Cluster C: Anxious or Fearful

Avoidant PD – is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation

Dependent PD – is a pattern of submissive and clinging behaviour related to an excessive need to be taken care of

Obsessive-Compulsive PD – is a pattern of preoccupation with orderliness, perfectionism, and control at the expense of flexibility

Avoidant Personality Disorder

over-riding sense of social discomfort easily hurt by criticism always need emotional support occasionally try to socialize

so distressing they retreat into loneliness

Dependent Personality Disorder

submissive, clingy behaviour fear of separation easily hurt by criticism

Obsessive-Compulsive Personality Disorder

excessive control and perfectionism inflexible preoccupied with trivial details judgmental/moralistic workaholic/ignore family members often humourless

Personality Disorder Not Otherwise Specified

Meets general criteria for a PD but no specific criteria for a specific PD.

Exhibit at least 10 symptoms of PDs across all subtypes

Comorbidity

Average number of PD diagnoses per patient:

- 4.6 (Skodal et al., 1988)

- 2.8 (Zanaarini et al., 1987)- 3.75 (Widiger et al., 1986)

DSM – Categorical Approach

Based on the medical model

Disorder is present or absent

Assumptions of the DSM

Personality pathology is suited to be classified into discrete types or disorders

These disorders group themselves into three clusters

The diagnostic criteria naturally fall into the particular personality disorders to which they have been assigned

Empirical Evidence doesn’t support these assumptions!!!

David Klonsky – University of Virgina

“the DSM practice of putting expert opinions into writing and only then conducting tests of reliability and validity cannot lead to an acceptable classification system. Rather it directs scientists to conduct research on, and practitioners to put their trust in, diagnostic labels that may or may not map onto valid constructs that exist in nature. Instead, researchers must turn to objective, empirical methodologies to discover the dimensions or personality pathology, letting the data fall where they may and letting the data determine how personality disorder is best classified”

John Livesley - UBC

Dimensional Assessment of Personality Pathology Basic Questionnaire (DAPP)

4 Dimensions: Emotional Dysregulation; Dissocail Behaviour; Inhibitedness; Compulsivity

“ …the evidence on this point is so unequivocal that the only issue to explain is the field’s reluctance to accept empirical evidence”

~ W. John Livesley, (2000) Journal of Personality Disorders, 14, 2, p. 139-140.

The “Big 5” Personality Traits

Openness to experience Conscientiousness Extraversion Agreeableness Neuroticism

personality disorders represent extreme variations of OCEAN

Advantages of Categorical System

Ease in conceptualization and communication

Familiarity Consistency with clinical decision

making

Disadvantages of the Categorical Approach

Complex and cumbersome Arbitrary cut-off points Loss of important information

Advantages of the Dimensional Model

Resolution of a variety of classification dilemmas

Retention of Information Flexibility

Disadvantages of the Dimensional Approach

Lack of clinical utility? Lack of familiarity?

Bottom line: not too many disadvantages and most researchers favor it – likely to be adopted in DSM-V