Personality Disorders. Overview. Overview. The Nature of Personality Disorders. Categorical vs. Dimensional Views of Personality Disorders

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1 Personality Disorders Overview The Nature of Personality Disorders Enduring and relatively stable predispositions (i.e., ways of relating and thinking) Predispositions are inflexible and maladaptive, causing distress and/or impairment Coded on Axis II of the DSM-IV and DSM-IV- TR Categorical vs. Dimensional Views of Personality Disorders Overview DSM-IV and DSM-IV-TR Personality Disorder Clusters Cluster A Odd or eccentric cluster (e.g., paranoid, schizoid) Cluster B Dramatic, emotional, erratic cluster (e.g., antisocial, borderline) Cluster C Fearful or anxious cluster (e.g., avoidant, obsessive-compulsive) 1

2 Facts and Statistics Prevalence of Personality Disorders Affect about 0.5% to 2.5% of the general population Rates are higher in inpatient and outpatient settings Origins and Course of Personality Disorders Thought to begin in childhood Tend to run a chronic course if untreated Facts and Statistics Co-Morbidity Rates are High Gender Distribution and Gender Bias in Diagnosis Gender bias exists in the diagnosis of personality disorders Such bias may be a result of criterion and/or assessment gender bias Cluster A: Paranoid PD Clinical Features Pervasive and unjustified mistrust and suspicion The Causes Biological and psychological contributions are unclear May result from early learning that people and the world is a dangerous place 2

3 Cluster A: Paranoid PD Treatment Options Few seek professional help on their own Treatment focuses on development of trust Cognitive therapy to counter negativistic thinking Lack good outcome studies showing that treatment is efficacious Warning Signs of Paranoid Personality Disorder An unmistakable sign of paranoia is continual mistrust Feel as though one needs to be constantly on their guard Tendency to view the world as a threatening place Expect trickery and doubt the loyalty of others Being hypervigilant for signs of threat Vigilance for any slight against them Show a tendency to be defensive and antagonistic Inability to accept blame and mild criticism Tendency to be highly critical of others Often argumentative and uncompromising Appear cold and aloof socially Often avoid intimacy with other people Cluster A: Schizoid PD Overview and Clinical Features Pervasive pattern of detachment from social relationships Very limited range of emotions in interpersonal situations The Causes Etiology is unclear Preference for social isolation in schizoid personality resembles autism 3

4 Cluster A: Schizoid PD Treatment Options Few seek professional help on their own Focus on the value of interpersonal relationships, empathy, and social skills Treatment prognosis is generally poor Lack good outcome studies showing that treatment is efficacious Warning Signs of Schizoid Personality Disorder No desire for social relationships Lack of ability to form close social relationships Often single and unmarried, with little interest in sex or intimacy Preference for solitary activities Limited range of emotions, particularly in social settings (e.g., coldness, detachment, or flatness) Often appear indifferent to compliments and criticisms Find little or no joy in activities or in life Cluster A: Schizotypal Clinical Features Behavior and dress is odd or unusual Socially isolated and may be highly suspicious of others Magical thinking, ideas of reference, and illusions Risk for developing schizophrenia is high The Causes A phenotype of a schizophrenia genotype? Left hemisphere and more generalized brain deficits 4

5 Cluster A: Schizotypal Treatment Options Main focus is on developing social skills Treatment also addresses comorbid depression Medical treatment is similar to that used for schizophrenia Treatment prognosis is generally poor Warning Signs of Schizotypal Personality Disorder Discomfort with close interpersonal relationships (as opposed to a lack of interest) Eccentric behavior (e.g., mumbling; odd dress) Having frequent feelings or illusions Often misinterpreting casual incidents as having particular or unusual meaning for themselves Belief in paranormal experiences, telekinesis, telepathy, etc. Suspicious and paranoid thoughts Express little emotion - flat in social situations Cluster B: Antisocial PD Clinical Features Failure to comply with social norms and violation of the rights of others Irresponsible, impulsive, and deceitful Lack a conscience, empathy, and remorse Many have early histories of behavioral problems, including conduct disorder Many come from families with inconsistent parental discipline and support Families often have histories of criminal and violent behavior 5

6 One of the nation s most notorious serial killers, Jeffrey Dahmer was born and raised in Bath Township, Ohio, a middle-class suburb of Akron. Much has been made of his childhood tendencies - including cases of cruelty to animals - but to outward appearances, at least, he seemed to be a normal child. As an adult he was always gainfully employed and was perceived as quiet and polite by co-workers. At the time of his arrest he had been working at a chocolate factory in Milwaukee and living alone in a small one-bedroom apartment. Dahmer's home was searched on July 22, 1991, after a young man fled his apartment and flagged down a police car. An investigation revealed that the apartment contained the remains of 11 young men, most of them black, Hispanic, or Asian. The bodies had been dismembered, and Dahmer confessed that he had cooked and eaten some of the remains. Asked why he committed such heinous acts, Dahmer told police that he killed because he was "lonely" and did not want his victims to leave him. He explained that he would meet potential victims in bars, shopping malls, or adult bookstores, and invite them back to his apartment where, in exchange for money or beer, he would photograph them naked. He would then drug the beer and, once the victim was unconscious, strangle and dismember the body. Dahmer's victims ranged in age from 14 to 33. On February 15, 1992, Dahmer was found guilty on 15 murder counts in Wisconsin. He was subsequently convicted of another killing in his Ohio hometown. Charges linking him to other murders were dropped for lack of evidence. He was sent to prison in Wisconsin with 15 mandatory life sentences to serve. The first year of his sentence, Dahmer was isolated from the general prison on population for his own protection. In 1994 he was sent to a maximum security facility in Portage and was allowed some contact with the other inmates. He died after a brutal bludgeoning attack on November 28, 1994, by a fellow inmate who claimed God had instructed him to murder Jeffrey Dahmer. Even after Dahmer's death, legal battles continue over his estate. Several families of his victims sued him and were awarded millions of dollars in restitution. Those families have since been trying to gain control of the contents of Dahmer's apartment, including a 55-gallon vat he used to decompose bodies and the refrigerator where he stored his victims' hearts. Warning signs of Antisocial Personality Disorder Defiance and disregard for social norms or the rights of other people Regularly performing illegal acts that are grounds for arrest Show little empathy for others Lack remorse for persons they have hurt Tendency to be self-absorbed Often appear superficial Show difficulties in fulfilling responsibilities and commitments Habitually lying or being manipulative Use of aliases and conning people for personal profit or pleasure Frequent physical aggression and conflict with other people Having had serious behavioral problems in childhood Blaming others or offering rationalizations for antisocial behavior Being impulsive Problems with the legal system Name that personality disorder 6

7 Psychopathy Psychopathy incorporates affective/ personality traits to a greater degree Most psychopaths meet criteria for ASPD, but most individuals with ASPD are NOT psychopaths Psychopathy Hare Psychopathology Checklist (personality profile of the psychopath) Glibness/superficial charm Grandiose sense of self-worth Need for stimulation/proneness to boredom Pathological lying Conning/manipulative Lack of remorse of guilt- callous and lacking empathy Shallow affect Parasitic lifestyle Poor behavior controls Promiscuous sexual behavior Early behavior problems Lack of realistic, long-term plans Impulsivity and irresponsibility Lifetime course of criminal behavior in psychopaths and nonpsychopaths 7

8 Early Behavior in ASPD Many have early histories of behavioral problems, including conduct disorder Many come from families with inconsistent parental discipline and support Families often have histories of criminal and violent behavior Neurobiological Contributions to ASPD Prevailing Neurobiological Theories Underarousal hypothesis Cortical arousal is too low Cortical immaturity hypothesis Cerebral cortex is not fully developed Fearlessness hypothesis Psychopaths fail to respond with fear to danger cues Treatment of ASPD Treatment Few seek treatment on their own Antisocial behavior is predictive of poor prognosis, even in children Emphasis is placed on prevention and rehabilitation Often incarceration is the only viable alternative 8

9 Cluster B: Borderline PD Clinical Features Unstable moods and relationships Impulsivity, fear of abandonment, coupled with a very poor selfimage Self-mutilation and suicidal gestures Most common personality disorder in psychiatric settings High comorbidity The Causes Runs in families - genetics? Early trauma and abuse Cluster B: Borderline PD Treatment Options Few good treatment outcome studies Antidepressant medications provide some short-term relief Dialectical behavior therapy is the most promising psychosocial approach Warning signs of Borderline Personality Disorder Frantic efforts to avoid real or imagined abandonment. A pattern of unstable and intense interpersonal relationships: alternating between extremes of idealization and devaluation. Unstable self-image or sense of self Impulsivity in areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) Affective instability and reactivity (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) Chronic feelings of emptiness Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) Transient (brief) stress-related paranoid ideation or severe dissociative symptoms 9

10 Cluster B: Histrionic PD Clinical Features Overly dramatic, sensational, and sexually provocative Need to be the center of attention Perceived as shallow The Causes Unknown Female variant of antisocial personality? Cluster B: Histrionic PD Treatment Options Few good treatment outcome studies Treatment focuses on attention seeking and long-term negative consequences Targets may also include problematic interpersonal behaviors Little evidence that treatment is effective Cluster B: Narcissistic PD Clinical Features Exaggerated and unreasonable sense of selfimportance Preoccupation with receiving attention Lack empathy Highly sensitive to criticism Envious and arrogant The Causes Early failure to learn empathy as a child Sociological view A product of the me generation? 10

11 Cluster B: Narcissistic PD Treatment Options Extremely limited treatment research Treatment focuses on grandiosity, lack of empathy, unrealistic thinking Treatment may also address co-occurring depression Little evidence that treatment is effective Warning Signs of Narcissistic Personality Disorder Frequent requests for admiration and empathy Arrogance Exaggerates talents or abilities Excessive fantasies of unlimited success, brilliance, beauty, etc. Will only associate with high-status individuals (stuck up) Attitude of entitlement Exploits others to achieve goals Lacks empathy (it s all about them) Envious of others or believes others are envious of them Cluster C: Avoidant PD Overview and Clinical Features Extreme sensitivity to the opinions of others Highly avoidant of most interpersonal relationships Are interpersonally anxious and fearful of rejection The Causes Numerous factors have been proposed Early development A difficult temperament produces early rejection 11

12 Cluster C: Avoidant PD Treatment Options Several well-controlled treatment outcome studies exist Treatment is similar to that used for social phobia Treatment targets include social skills and anxiety Cluster C: Dependent PD Clinical Features Excessive reliance on others to make major and minor life decisions Fear of abandonment Clingy and submissive The Causes Still largely unclear Early disruptions in learning independence Cluster C: Dependent PD Treatment Options Research on treatment efficacy is lacking Therapy typically progresses gradually Treatment targets include skills that foster independence 12

13 Clinical Features Cluster C: Obsessive- Compulsive PD Excessive and rigid fixation on doing things the right way Highly perfectionistic, orderly, and emotionally shallow Obsessions and compulsions are rare The Causes Are largely unknown Cluster C: Obsessive- Compulsive PD Treatment Options Data supporting treatment are limited Treatment may address fears related to the need for orderliness Other targets include rumination, procrastination, and feelings of inadequacy Summary of Personality Disorders Personality Disorders Long-standing, ingrained ways of thinking, feeling, and behaving Disagreement Exists Over How to Categorize Personality Disorders Categorical vs. dimensional, or some combination of both 13

14 Summary of Personality Disorders DSM-IV and DSM-IV-TR Includes 10 Personality Disorder Personality disorders fall in one of three clusters Cluster A, B, or C The Causes of Personality Disorders Are Difficult to Pinpoint Treatment of Personality Disorders Is Often Difficult 14