Personality Disorders

Defined by enduring problems with forming a stably positive identity and with sustaining close and constructive relationships
Extreme and inflexible traits, 10 different disorders, highly heterogeneous o Paranoid – chronic tendencies to be mistrustful and suspicious

o Antisocial – patterns of irresponsibility and callous disregard for rights of others o Dependent – overreliance on others

Persistent, pervasive and maladaptive ways in which the traits are expressed  Unstable, positive sense of self

The DSM-5 Approach to Classification
- 10 different personality disorders, in 3 clusters:
- A) Odd/eccentric  paranoid, schizoid, schizotypal, B) Dramatic/erratic  antisocial, borderline, C) Anxious/fearful  avoidant, dependent, obsessive-compulsive  1/10 meet diagnostic criteria

More common among those with a psychological disorder (MDD, anxiety)

People with PD 7x more likely to have anxiety/mood disorder, and 4x as likely to have a substance disorder *especially cluster B
More severe, poorer social functioning and worse treatment outcome when comorbid PDs are present o Doubles the risk of depression Assessment of DSM-5 Personality Disorders
List of criteria and structured interviews for each PD *most clinicians do not used the structured interviews
Low Interrater reliability for schizoid PD
Low agreement rates in diagnoses and often miss diagnoses
Interviews with people who know the patient will improve the accuracy of diagnosis *rarely occurs Problems with the DSM-5 Approach to Personality Disorders  PDs are Not Stable over Time:
- Half patients diagnosed with a PD at one point in time achieved remission after 2 years o 99% remitted 16 years later
- Symptoms most common during adolescence *PDs may not be as enduring, decline in 20s and late life
- Many people still have some symptoms after remission o After remission many problems in functioning still persist
- Risk of relapse still remains high, years after remission *symptoms wax and wane over time  Personality Disorders are Highly Comorbid:
- More than 50% with PD meet diagnosis for another PD
- DSM system may not be ideal for classifying PDs, lack of test-retest stability and high comorbidity
Some PDs are extremely rare (< 2%)
People with PD can vary a good deal from one another in the nature of their personality traits & severity of condition

Alternative DSM-5 Model for Personality Disorders
- Recommend reducing the number of PDs, incorporating personality trait dimensions, and diagnosing PDs on the basis of extreme scores on personality trait dimensions ***Found in appendix of DSM-5
- Includes only 6 of the 10 PDs: schizoid, histrionic, dependent were excluded because they are rare, paranoid was excluded because it overlaps with other PDs
- Diagnosis based on personality traits
- 5 personality trait domains and 25 more specific personality trait facets, rated using self-report *related to 5-factor model
- Diagnosed is person shows persistent and pervasive impairments in self and interpersonal aspects of functioning from early adulthood
- Provides richer detail for diagnosis, individuals diagnosed with same PD can vary lots in personality traits from another
- Personality trait ratings tend to be stable over time, more than PD diagnoses
- Personality trait dimensions are related to many aspects of psychological adjustment  Captures subsyndromal symptoms better
Common Risk Factors Across the Personality Disorders
- Psychoanalytic and behavioural theory placed emphasis on parenting and early developmental influences
- Recent evidence of strong biological component

Children in the Community Study:

Assessed links between childhood adversity and PDs
Assessed 2 aspects of parenting style: aversive parental behaviour and lack of parental affection
Kept track of child maltreatment, assessed with clinical interview for diagnosing PDs o Findings suggested that PDs were strongly related to early adversity o Parenting style also predicted certain PDs  Norwegian Birth Registry – sample of twins:
High heritability estimates for all PDs (.55-.77)

Clinical Description and Etiology of the Odd/Eccentric Cluster
- Similar bizarre thinking/experiences seen in schizophrenia *less severe
Paranoid PD
- Presence of 4+ of the following signs of distrust and suspiciousness from early adulthood across many contexts:
  - 1) Unjustified suspiciousness of being harmed, deceived, or exploited o 2) Unwarranted doubts about the loyalty or trustworthiness of friends or associates o 3) Reluctance to confide in others because of suspiciousness o 4) Tendency to read hidden meanings into the benign actions of others o 5) Bears grudges for perceived wrongs
  - 6) Angry reactions to perceived attacks on character or reputation o 7) Unwarranted suspiciousness of the partner’s fidelity
- Expect to be mistreated/exploited, are very secretive and continually on the lookout for signs of trickery/abuse
- Hostile and angry in response to perceived insults, seen as difficult and critical
- Other symptoms of schizophrenia are not present (hallucinations), less impairment in social/occupational functioning, no cognitive disorganization
- Full-blown delusions are not present
- Co-occurs most often with schizotypal, borderline and avoidant PD
Schizoid PD
- Presence of 4+ of the following signs of aloofness and flat affect from early adulthood across many contexts:
  - 1) Lack of desire for or enjoyment of close relationships o 2) Almost always prefers solitude to companionship o 3) Little interest in sex o 4) Few or no pleasurable activities o 5) Lack of friends
  - 6) Indifference to praise or criticism
  - 7) Flat affect, emotional detachment, or coldness
- Appear dull, bland, aloof, no warm feelings for others
- Rarely experience strong emotions Schizotypal PD
- Presence of 5+ of the following signs of unusual thinking, eccentric behaviour, and interpersonal deficits from early adulthood across many contexts:
  - 1) Ideas of reference
  - 2) Odd beliefs or magical thinking e.g. beliefs in extrasensory perception
    - Unusual perceptions
    - Odd thought and speech

Suspiciousness or paranoia
Inappropriate or restricted affect
Odd or eccentric behaviour or appearanceo 8) Lack of close friends

9) Social anxiety and interpersonal fears that do not diminish with familiarity

Recurrent illusions (inaccurate sensory perceptions), flat/constricted affect, aloof from others
Most do not develop delusions or schizophrenia (some do)
Similar genetic vulnerability as for schizophrenia – enlarged ventricles, less temporal grey matter (also cognitive and neuropsychological deficits)
60% heritable

Clinical Description and Etiology of the Dramatic/Erratic Cluster

Highly inconsistent behaviour, inflated self-esteem, rule breaking behaviour, exaggerated emotional displays
Most well-known

Antisocial PD (APD) and Psychopathy
- 1) Age at least 18
- 2) Evidence of conduct disorder before age 15
- 3) Pervasive pattern of disregard for the rights of others since the age of 15 as sown by at least 3 of the following:
  - Repeated law breaking, deceitfulness/lying, impulsivity, irritability/aggressiveness, reckless disregard for own safety & that of others, irresponsibility as seen in unreliable employment/financial history, lack of remorse
- Used interchangeably with psychopathy by public *antisocial behaviour is important for both, but they differ in important ways  Psychopathy is not included in DSM-5  Antisocial PD:
  - Core feature: pervasive pattern of disregard for the rights of others
  - Presence of conduct disorder, little regard for truth, lack of remorse for misdeeds o Men are 5x more likely to meet criteria, ¾ meet criteria for another disorder *substance abuse is common
  - ¾ convicted felons meet criteria o Poverty of emotion:
    - Negative – lack of shame/remorse/anxiety, doesn’t learn from mistakes  Positive – merely an act to manipulate others, superficially charming  Psychopathy:
  - Predates APD diagnostic criteria o “Mask of Sanity” – Hervey Cleckley
  - Criteria focuses on person’s thoughts and feelings *poverty of emotions (positive and negative)
  - No sense of shame, positive feelings for others is an act o Superficially charming
  - Impossible to learn from mistakes due to lack of anxiety o Impulsive rule-breaking behaviour o Boldness, meanness, and impulsivity
  - Assessed using Psychopathy Checklist-Revised (PCL-R)

Symptoms do not need to show before age 15 *will not obtain high scores on PCL-R if have APD

Etiology

Most research done on those convicted as criminals, use different measures (APD vs. psychopathy)  Interactions of Genes and the Social Environment:
- Role of social environment is key in APD: parenting qualities of negativity, inconsistency and low in warmth
- Poverty and exposure to violence also predict antisocial behaviour o Those with CD, if impoverished, 2x more likely to develop APD
- Polymorphism of MAO-A gene predicts psychopathy in males who had experienced childhood abuse or maternal rejection
- Anti-social behaviour is 40-50% heritable
Psychological Risk: Insensitivity to Threat and to Others’ Emotions:
- Psychopaths are unable to learn from experience, immune to anxiety that keeps us from breaking the law/lying
- Deficits in experience of fear and threat, lower than normal levels of skin conductance o Deficits in developing conditioned fear responses *no increased amygdala activity for CS o Even more unresponsive to threat when trying to obtain a reward
- Inattentiveness to threats when pursing a goal – deficits in regions of prefrontal cortex involve in attending to negative information during goal pursuit
- Lack of empathy – especially difficult to recognize fear in others

Borderline PD (BPD)

- Presence of 5+ of the following signs of instability in relationships, self-image, and impulsivity from early adulthood across many contexts:
  - Frantic efforts to avoid abandonment
  - Unstable interpersonal relationships in which others are either idealized or devalued o 3) Unstable sense of self
  - Self-damaging, impulsive behaviours in at least two areas, such as spending, sex, substance abuse, reckless driving, and binge eating
  - Recurrent suicidal behaviour, gestures or self-injurious behaviour o 6) Marked mood reactivity o 7) Chronic feelings of emptiness
  - Recurrent bouts of intense or poorly controlled anger
  - Curing stress, a tendency to experience transient paranoid thoughts and dissociative symptoms
- Very common in clinical settings, very hard to treat, associated with recurrent periods of suicidality
- Core features: impulsivity and instability in relationships and mood, emotional reactivity
- Emotions are intense, erratic, shift abruptly *passionate idealization to contemptuous anger
- Overly sensitive to small signs of emotions in others
- No clear/coherent sense of self
- Cannot bear to be alone (fear of abandonment), chronic depression and emptiness
- Psychotic and dissociative symptoms when stressed
- 2/3 engage in self-mutilation
- Likely to have comorbid PTSD, mood disorders, substance related disorders, eating disorders = more likely to last longer

Etiology

Neurobiological Factors:

Highly heritable (60%)

Lower serotonin function – general dysregulation

Increased activation of amygdala to emotional pictures – emotion dysregulation

Deficits in prefrontal cortex – impulsivity

Disrupted connectivity between prefrontal cortex and amygdala  Social Factors: Childhood Abuse in the Context of Genetic Vulnerability:

Parental separation, verbal & emotional abuse during childhood o Tied to high rates of childhood abuse/neglect and high heritability o Childhood abuse doesn’t predict BPD after genetic risk is controlled o Childhood trauma accounts for less than 1% in variance
Genetically driven impulsivity, emotionality and risk-seeking in parents could increase risk of abusing children

Linehan’s Diathesis-Stress Theory:
- BPD develops when people who have difficulty controlling their emotions because of a biological diathesis are raised in a family environment that is invalidating
- Emotional regulation diathesis interactions with experiences of invalidation = BPD development
  - Biological diathesis: Emotional dysregulation in the child  great demands on the family  invalidation by parents through punishing/ignoring  emotional outbursts

by child to which parents attend  emotional dysregulation of child

Histrionic Personality Disorder (HPD)
- Presence of 5+ of the following signs of excessive emotionality and attention seeking from early adulthood across many contexts:
  - 1) Strong need to be the centre of attention o 2) Inappropriate sexually seductive behaviour o 3) Rapidly shifting and shallow expression of emotions o 4) Use of physical appearance to draw attention to self o 5) Speech that is excessively impressionistic and lacking in detail
  - 6) Exaggerated, theatrical emotional expression o 7) Overly suggestible
  - 8) Misreads relationships are more intimate than they are
- Key feature: overly dramatic and attention-seeking behaviour
- Use physical appearance to draw attention to themselves
- Emotionally shallow, overly concerned with physical attractiveness, uncomfortable when not the centre of attention
- Easily influenced by others
Narcissistic Personality Disorder
- Presence of 5+ of the following signs of grandiosity, need for admiration, and lack of empathy from early adulthood across many contexts:
  - 1) Grandiose view of one’s importance
  - 2) Preoccupation with one’s success, brilliance, beauty
  - 3) Belief that one is special and can be understood only by other high-status people o 4) Extreme need for admiration o 5) Strong sense of entitlement o 6) Tendency to exploit others o 7) Lack of empathy o 8) Envious of others
  - 9) Arrogant behaviour or attitudes
- Interpersonal relationships disturbed by lack of empathy, arrogance and envy, self-centeredness

Overly reactive to criticism
Seeks out higher-status partner

Etiology

Parenting:
- Parents who are overly indulgent foster children’s belief that they are special and behavioural expressions of their specialness will be tolerated by others  Self-Psychology:
- Variant of psychodynamic theory (Heinz Kohut) o Characteristics mask low SE (parent & patient)
- In childhood, narcissist valued as a means to increase parent’s own SE
  - Not valued for his/her own self-worth and competencies o Parental emotional coldness & overemphasis on child’s achievement reported by narcissist o Person with NPD projects self-importance, self-absorption, and fantasies of limitless success o Fragile self-esteem  Social-Cognitive Model:
- 1) People with NPD have fragile self-esteem, in part because they are trying to maintain the belief that they are special
- 2) Interpersonal interactions are important to them for bolstering SE rather than for gaining closeness or warmth
- Overestimate attractiveness to others and contributions in group activities o Attribute success to abilities rather than to chance/luck ***cognitive biases
- Show more reactivity when falsely told they have done poorly on an IQ test (also when told they have succeeded)
- Primary goal in interactions is to bolster their own self-esteem brag a lot, denigrate others who perform better
Clinical Description and Etiology of the Anxious/Fearful Cluster
Prone to worry and distress

IIX. Avoidant Personality Disorder

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to criticism as shown by 4+ of the following from early adulthood across many contexts:
- Avoidance of occupational activities that involve significant interpersonal contact, because of fears of criticism or disapproval
- Unwilling to get involved with people unless certain of being liked
- Restrained in intimate relationships because of the fear of being shamed or ridiculed o 4) Preoccupation with being criticized or rejected
- Inhibited in new interpersonal situations because of feelings of inadequacy o 6) Views self as socially inept, unappealing or inferior
- Unusually reluctant to try new activities (taking risks) because they may prove embarrassing
Often co-occurs with social anxiety disorder – similar diagnostic criteria and genetic vulnerability overlaps *maybe a more chronic variant of social anxiety disorder
80% have comorbid major depression, alcohol abuse is also common
Dependent Personality Disorder
- An excessive need to be taken care of, as shown by the presence of at least 5 of the following from early adulthood across many contexts:
  - 1) Difficulty making decisions without excessive advice and reassurance from others
    - Need for others to take responsibility for most major areas of life
    - Difficulty disagreeing with others for fear of losing their support
    - Difficulty doing things on own or starting projects because of lack of self-confidence
    - Doing unpleasant things as a way to obtain the approval and support of otherso 6) Feelings of helplessness when alone because of fears of being unable to care for self o 7) Urgently seeking new relationships when one ends o 8) Preoccupation with fears of having to take care of oneself
  - See themselves as weak, fear being alone
  - Very passive
  - Can do what is necessary to maintain a close relationship
  - Men with higher levels of dependency are at elevated risk of perpetrating domestic violence
  - Likely to develop depression after interpersonal losses, show high suicidality when depressed
  - Elevated risk of developing anxiety disorders and bulimia
  - Overprotective parents may reinforce children for dependency
  - Authoritarian discipline may limit opportunities for children to develop feelings of self-efficacy
Obsessive-Compulsive Personality Disorder
- Intense need for order, perfection, and control as shown by the presence of at least 4 of the following from early adulthood across many contexts:
  - Preoccupation with rules, details, and organization to the extent that the point of an activity is lost
  - Extreme perfectionism interferes with task completion o 3) Excessive devotion to work to the exclusion of leisure and friendships Inflexibility about morals and values o 5) Difficulty discarding worthless items
  - Reluctance to delegate unless others conform to one’s standards o 7) Miserliness
  - Rigidity and stubbornness
- More oriented towards work than pleasure *causes social relationships to suffer, little time for leisure, family, friends
- Difficulty making decisions and allocating time
- Serious, rigid, formal, and inflexible
- Does not include obsessions and compulsions of OCD, often co-occurs with OCD, some overlapping genetic variability
Treatment of Personality Disorders
Many enter treatment for condition other than PD (e.g. substance abuse, anxiety, depression)

General Approaches to the Treatment of PDs

Psychotherapy is the treatment of choice – small but positive effects, often supplemented with medication
Weekly sessions, or day-treatment programs (several hours/day), occupational therapy provided
Psychodynamic theory – childhood problems are at the root of PDs, help patient reconsider those early experiences, become more aware of how they drive current behaviour and reconsider beliefs/responses to early events
Cognitive theory – negative cognitive beliefs are at the heart of PDs, help person become aware of those beliefs and challenge maladaptive cognitions o Explore biases in thinking
- Look for dysfunctional schemas/assumptions the underline person’s thoughts/feelings
Cannot change underlying traits of PD, but can change disorder into a style or more adaptive way of approaching life

Treatment of Schizotypal Disorder and Avoidant Personality Disorder

Antipsychotic drugs (risperidone) for schizotypal, reduces unusual thinking
Avoidant PD responds to same treatments as social anxiety disorder – antidepressant medications and cognitive behavioural treatment o Help person challenge negative beliefs about social interactions, teach behavioural strategies for dealing with social situations, exposure treatment
Psychopathy – psychotherapy, either CBT or psychodynamic

Treatment of Borderline Personality Disorder

***Difficult to treat
Show interpersonal problems in therapeutic relationship
Client finds it difficult to trust others, idealize and vilify the therapist
Difficult to tell if call at 2:00 from patient is call for help or a manipulative gesture to test the therapist
Medications – anti-depressants, mood stabilizers
Hospitalization is often necessary to protect against suicide
Many therapist consult with others due to high stress of treatment
Metallization based therapy – fail to think about their own and other’s feelings
Schema-focused cognitive therapy – identify maladaptive assumptions that underlie cognitions
Dialectical behaviour therapy – combines client-centered empathy and acceptance with cognitive behavioural problem solving, emotion-regulation techniques and social skills training o Constant tension between any phenomenon and its opposite is resolved by creating a new phenomenon (the synthesis) *term dialectical used on 2 main ways:
- 1) Seemingly opposite strategies that the therapist must use when treating BPD – accepting them as they are and yet helping them change
- 2) The patient’s realization that splitting the world into good and bad is not necessary; instead one can achieve a synthesis of these apparent opposites
4 stages:
- 1) Dangerously impulsive behaviours are addressed with the goal of promoting greater control
- 2) Learning to modulate the extreme emotionality – learn to tolerate emotional distress
- 3) Improving relationships and self-esteem
- 4) Designed to promote connectedness and happiness
- Learn more effective and socially acceptable ways to handle day-to-day problems