Personality Disorders: Recognition, Diagnosis, Treatment & Survival Chatman Neely
Welcome
Phase One: Recognition Chronic and Persistent Pattern of relating to self and others: look for suffering!!!
Characteristics that appear to be common in people with personality disorders: Repetitive, inflexible, and maladaptive responses to stress that are often self-defeating
Characteristics Problems in interpersonal relationships and at work Generally in touch with reality Annoying or attention-seeking behavior that may result in rejection by others, including mental health professionals Limited ability to see that they have problems and thus may have to be coerced into seeking intervention
Given what is known about the etiology of some of the personality disorders, it is important that assessment includes information about the following areas: 1) History of intimate relationships 2) History of abuse, rape, or other trauma 3) Family losses through death, divorce, or abandonment 4) Head or other bodily injury or birth complications 5) Family history of mental disorders, especially schizophrenia, depression, antisocial or sever personality disorder, or of substance abuse 6) School and work history 7) History of psychiatric hospitalizations and suicide attempts 8) An evaluation of areas of successful functioning
Phase Two: Diagnosis We are innately curious of others?
Clinical Features of Personality Disorders Enduring pattern of behavior that is pervasive, inflexible, stable, and of long duration. Little evidence of prevalence; estimate that about 13% of the population will meet the criteria for PD at some time in their life PD are coded on Axis II of the DSM-IV TR
Difficulties Doing Research on Personality Disorders Difficulty diagnosing PD Diagnostic criteria not sharply defined Diagnosis relies on inferred traits or consistent patterns of behavior rather than on more objective behavioral standards Diagnostic reliability and validity is low Diagnostic categories are not mutually exclusive Competing dimensional views; five-factor model has become the most influential model of normal personality
Difficulties Doing Research on Personality Disorders Difficulties in Studying the Causes of Personality Disorder High levels of comorbidity among disorders Very little prospective research on disorders Temperamental characteristics are possible biological factors Possible psychological factors maladaptive habits/cognitive styles that may originate from disturbed parent-child attachment relationships, parental psychopathology, ineffective parenting practices, and early emotional/physical/sexual abuse Possible sociocultural factors: social stressors, societal changes, cultural values
Two chickens one nest? Why?
Cluster A Personality Disorders Paranoid Personality Disorder Symptoms: suspiciousness, rigidity, hypersensitivity, and argumentativeness Being constantly on-guard for attacks from others Schizoid Personality Disorder Symptoms: inability to form social relationships and an indifference toward developing them Causal factors: Maladaptive underlying schemas w/ individual as self-sufficient loner and a view of others as intrusive Schizotypal Personality Disorder Extreme introversion, sensitivity, and eccentricity are the central features Oddities of thought, perception, and speech are also present and similar to schizophrenia Causal factors: believed to be moderately heritable genetic & biological assoc. w/ schizophrenia
Cluster B Personality Disorders Histrionic Personality Disorder Excessive attention-seeking, emotionality, and self-dramatization Stormy interpersonal relationships Self-centered, vain, and overly concerned about approval Narcissistic Personality Disorder An exaggerated sense of self-importance leading to a sense of entitlement, lack of empathy, and need for attention More prevalent in men than women Fragile self-esteem underlies grandiosity May be hypercritical and retaliatory Antisocial Personality Disorder (ASPD) Violating rights of others without remorse is a key characteristic May exhibit intelligence and charm Common features include impulsivity, irritability, and aggression Must have symptoms of Conduct Disorder before age 15
It takes a little noise!
Borderline Personality Disorder Symptoms: Impulsivity, anger, instability, and unpredictability Failure to complete process of forming stable self-identity History of stormy, intense relationships Highly unstable mood Impulsive self-destructive behavior (gambling, binge eating, sub. Abuse, wreckless driving) Suicide attempts usually seen as manipulative
Borderline Personality Disorder 70-80% report analgesia (absence of the experience of pain in the presence of a theoretically painful stimulus) 75% experience relatively short or transient psychotic-like symptoms Comorbidity with other Axis I disorders Mood disorders, anxiety disorders, substance abuse, eating disorders; overlap in symptomatology w/ depression w/ other personality disorders (histrionic, dependent, antisocial, schizotypal)
Borderline Personality Disorder Causal Factors: Genetics: Partially heritable personality traits such as impulsivity and affective instability Biological: Lowered functioning of neurotransmitter serotonin may be linked w/ impulsivity-aggression Disturbances in regulation of noradrenergic transmitters may explain hypersensitivity to environmental changes Psychosocial (negative, even traumatic childhood events) Paris s Diathesis-Stress Model: high levels of impulsivity and affective instability combined with psychological risk such as trauma, loss, or parental failure (See figure 10.1 for a diagram on the multidimensional Diathesis Stress Model of Borderline Personality Disorder)
Cluster C Personality Disorders Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder
Cluster C Personality Disorders Avoidant Personality Disorder Fear rejection and show extreme social inhibition, introversion, and hypersensitivity Desire affection and are lonely; desire interpersonal contact but avoid it out of fear of rejection Dependent Personality Disorder Central Symptoms: Extreme dependency and panic when alone Lack of self-confidence and exhibits clingy and submissive behavior Allow others to make decisions Indiscriminate selection of mate May accept abuse to remain in a relationship Obsessive-Compulsive Personality Disorder perfectionism : Rigidity, stubbornness, and a lack of warmth Dysfunctional in that they cannot finish tasks and become overly involved in detail excessive concern with maintaining order and control Mental and interpersonal control is maintained Repeatedly check work for mistakes, Leisure activities are sacrificed
General Socio-Cultural Causal Factors Possible factors are poorly defined Less variance across cultures than within Change in culture s priorities and activities may influence the development of personality disorder Narcissistic Personality Disorder more common in Western cultures Histrionic less common in Asians and more common in Hispanics Borderline more common in Hispanic Americans than African Americans or Caucasian Americans Schizotypal Personality Disorder is more common in African Americans than Caucasian Americans
Phase Three: Treatment What We have learned! Learn to respond not react Structure + consistency = control/safety/growth Know thy self Listen with eyes and ears Behavior is language
Treatment & Outcomes Generally, PD are difficult to treat PD represent relatively enduring, pervasive, and inflexible patterns of behavior Different possible goals of therapy Many people with PD only come to therapy at the request of someone else Many individuals with PD (especially Cluster A or B) will have difficulty forming a therapeutic relationship
Treatment & Outcomes Adapting Therapeutic Techniques to Specific Personality Disorders May need to be careful not to encourage dependence Acting-out behavior may need to be constrained Specific therapeutic techniques are central part of the cognitive approach to personality disorders Techniques include: monitoring automatic thoughts, challenging faulty logic, assigning behavioral tasks to challenge dysfunctional assumptions and beliefs
Treatment & Outcomes Treating Borderline Personality Disorder Biological Tx Controversial medication increases suicide risk SSRIs for treating rapid mood shifts, anger, anxiety Low doses of antipsychotic drugs Mood-stabilizing drugs to reduce irritability, suicidality, and impulsive aggressive behavior
Treatment & Outcomes Treating Borderline Personality Disorder Psychosocial Tx Traditional Tx is psychodynamic Primary goal: strengthening weak ego Focus on defense mechanisms of splitting Linehan s Dialectical Behavior Therapy Promising new approach Form of CBT which is problem-focused & based on clear hierarchy of 5 goals:» Decreasing suicidal & other self-harming behavior» Decreasing behaviors that interfere with therapy» Decreasing escapist behaviors that interfere w/ stable lifestyle» Increasing behavioral skills to regulate emotions, to increase interpersonal skills and increase tolerance of distress» Other goals the patient chooses
Treatment & Outcomes Treating Other Personality Disorders Other Cluster A and B disorders Antipsychotic medications have modest success Antidepressants from the SSRI category may be useful No systemic studies exist for paranoid or schizoid disorder Cluster C disorders Active & confrontational short-term therapy shows improvements Significant gains w/ CBT Antidepressants and MAO inhibitors have been used
A Developmental Perspective Personality disorders Begins in early childhood Oppositional Defiant Disorder Early onset before 6 Conduct disorder by 9 Children who develop conduct disorder in adolescence do not typically develop ASPD Attention Deficit Hyperactivity Disorder (ADHD) When ADHD occurs w/ CD, high likelihood of ASPD and even psychopathy Lynam refers to these children as fledgling psychopaths Other Psychosocial & Socio-Cultural contextual variables contribute: Parents own antisocial behaviors, divorce, poverty, crowded inner-city neighborhoods, parental stress, porr & ineffective parenting skills
A Developmental Perspective Socio-Cultural Causal Factors and Psychopathy Disorder appears in various cultures Inuit of Northern Alaska, Yorubas of Nigeria Socialization forces have impact on expression of aggressive impulses Distinguishing between individualistic and collectivist societies
Treatments & Outcomes Traditional psychotherapeutic approaches are not effective CBT Targets: Increasing self-control, self-critical thinking, & social perspective taking; victim awareness; anger management; changing antisocial attitudes; curing drug addiction Interventions require a controlled situation Even best programs who only modest improvements; psychopathy more difficult to treat than ASPD Many antisocial personalities show improvements as they age Achieve insight into self-defeating actions Cumulative effect of social conditioning Only ASPD changes with age no psychopathy Prevention would seem to be more effective
Unresolved Issues: Axis II of DSM-IV TR Moving towards a Dimensional System of Classification Axis II Diagnoses Are Often Unreliable Personality processes are dimensional in nature Arbitrary decisions are used to define the degree of a trait Diagnoses are not based upon mutually exclusive criteria Clearer Sets of Classification Rules Need to Be Formulated Rules need to become exhaustive & incorporate nonoverlapping behaviors Process may be beyond the current capacities of researchers Dimensional approach has been proposed, but there is no clear evidence about which system is best
Phase Four: Surviving: Knowing the individual personality pattern of relating is essential The disordered person stress leads to a survival-based pattern of distraction called: Drama Personality disordered persons are usually reacting to others via the following roles: Rescuer Victim Precursor
Rescuer: Drama is driven by ulterior motives Apparent Motive: I m trying to help Ulterior Motive: I m good (acceptable) Examples???? Helps to position therapist to respond vs. react
Persecutor: Drama is driven by ulterior motives Apparent Motive: I m trying to fix (acceptable) Ulterior Motive: I m right (Powerful) Examples???? Helps to position therapist to respond vs. react
Victim: Drama is driven by ulterior motives Apparent Motive: I m trying to recover Ulterior Motive: I m blameless (safe) Examples???? Helps to position therapist to respond vs. react
Characteristics of Drama Is designed to maintain an existential position rather than to reach a practical goal Is designed to create stimulation, usually confusion and upset Is decided to produce new problems or to intensity problems to maintain existential positions Is survival-bases and resists both exposure and intervention Is designed to get everyone to participate Severity is determined by the intensity of how drama is played out
Type of Intervention used to deal with Personality Disorders is defined by: The way it intervenes in the process of drama The outcome it is designed to produce To know what role they are in and what the hidden agenda are (when possible) Behavior is language! Behavior is language! Behavior is language!
If you don t live it, it won t come out of your horn. --Charlie parker, legendary Jazz musician Supervision is good gate keeping and ethical practice!!!
Rest is possible!