Personality Disorders

Personality Disorders: 

Personality Disorders I. Background

A. Definition: 

A. Definition Personality disorder = 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 that cause significant functional impairment or subjective distress

B. DSM-IV General criteria for personality disorder: 

B. DSM-IV General criteria for personality disorder Enduring pattern of inner experience and behavior that deviates markedly from cultural expectations. Manifested in two or more of the following areas: Cognition Affectivity Interpersonal functioning Impulse control

B. General criteria (cont.): 

B. General criteria (cont.) B. Pattern is inflexible and pervasive across a broad range of personal and social situations C. Pattern leads to clinically significant impairment or distress D. Pattern is stable and of long duration and onset can be traced to adolescence or early childhood

B. General criteria (cont.): 

B. General criteria (cont.) E. Pattern not better accounted for as a manifestation of another disorder F. Not due to substance or GMC (e.g., head trauma)

B. General criteria (cont.): 

B. General criteria (cont.) Person must meet the general criteria before a specific PD is diagnosed Coded on Axis II

C. Other Features: 

C. Other Features Lack insight into PD (seek treatment for Axis I problem or relationship problems) PD symptoms are ego syntonic = feels like a normal part of oneself Most have interpersonal problems Can be difficult to diagnose in initial session Intractable, difficult to treat; can affect treatment of other disorders

D. Cluster Organization in DSM-IV: 

D. Cluster Organization in DSM-IV PDs classified within clusters defined by common features Cluster A main feature is odd or eccentric in nature 3 PDs in this cluster: Paranoid PD – distrust and suspiciousness Schizoid PD – detachment from social relationships (does not want them) Schizotypal PD – social deficits and perceptual distortions or eccentricities

D. Clusters (cont.): 

D. Clusters (cont.) 2) Cluster B Main feature is dramatic, emotional, or erratic 4 PDs in this cluster: Antisocial PD – disregard for social norms and rights of others Borderline PD – instability in relationships, self-image, and mood; impulsivity Histrionic PD – excessive emotionality and attention seeking Narcissistic PD – grandiosity, need for admiration, self-centered

D. Clusters (cont.): 

D. Clusters (cont.) 3) Cluster C Main feature involves anxiety or fearfulness 3 PDs in this cluster: Dependent PD – submissive, need to be taken care of Avoidant PD – social inhibition and inadequacy Obssessive-compulsive PD – orderliness, perfectionism, need to control things

E. Categorical System: 

E. Categorical System DSM-IV is a categorical classification system Personality traits viewed as dimensional constructs Push toward dimensional approach to classifying PDs PD research lags behind Axis I research  PDs are least reliable diagnoses  problems for their systematic study

Personality Disorders: 

Personality Disorders II. Antisocial Personality Disorder (ASPD)

A. Background: 

A. Background ASPD diagnosis stems from Cleckley’s description of psychopathy: Superficial charm Absence of delusions and irrational thinking Absence of 'nervousness' Unreliability Untruthfulness and insincerity Lack of remorse or shame Inadequately motivated antisocial behavior Poor judgment and failure to learn by experience

Psychopathy (cont.): 

Psychopathy (cont.) Pathological egocentricity and incapacity for love General poverty in major affective reactions Specific loss of insight Unresponsiveness in general interpersonal relations Fantastic and uninviting behavior with drink Suicide rarely carried out Sex life impersonal, trivial, and poorly integrated Failure to follow any life plan

A. Background (cont.): 

A. Background (cont.) ASPD definition based on Cleckley’s view appeared in DSM-II Psychopathy is now a separate construct with an antisocial (ASPD-like) component Lee Robins’ work in mid-1960’s formed basis of current ASPD criteria Found that most antisocial adults were antisocial in childhood Most antisocial children are not antisocial as adults

A. Background (cont.): 

A. Background (cont.) ASPD vs. criminality 'criminal' is a legal term denoting conviction for breaking a law: Not all people with ASPD are criminals (or in jails) Not all people in jail or considered criminal have ASPD Not all people with ASPD are psychopaths

Slide17: 

B. Criteria and features of ASPD: 

B. Criteria and features of ASPD Case of George DSM-IV criteria (p. 433) A. Pattern of disregard for and violation of the rights of others occurring since age 15 as indicated by 3 or more: (1) failure to conform to social norms (2) repeated lying/conning (3) impulsivity or failure to plan ahead

1. Criteria (cont.): 

1. Criteria (cont.) (4) irritability and aggressiveness (5) reckless disregard for safety (6) consistent irresponsibility (7) lack of remorse B. Individual is at least 18 years old C. Evidence of Conduct Disorder before age 15 D. Occurrence of antisocial behavior not exclusively during course of schizophrenia or a manic episode

B. Criteria and features of ASPD (cont.): 

B. Criteria and features of ASPD (cont.) 2. Course and statistics - prevalence is 3% in men; lower in women - sex difference is probably real, but may be inflated by clinician bias - onset in childhood (by definition) - CD portion may start as early as age 3-5

2. Statistics and course (cont.): 

2. Statistics and course (cont.) Course of all PDs is chronic, but overt antisocial behavior seems to age out after 40 - could still show ASPD features (e.g., lying; poor work habits)

B. Criteria and features of ASPD (cont.): 

B. Criteria and features of ASPD (cont.) 3. Causal influences - twin, family, and adoption data show strong genetic influence - CD also appears to have shared environment influence - poor socialization due to low fearfulness may account for some cases

C. Treatment: 

C. Treatment Most don’t seek treatment for ASPD (usually substance abuse) No treatment shown to be efficacious More likely to end up in jail than in treatment Focus is on prevention – target antisocial children

Summary: 

Summary PDs are enduring, maladaptive patterns of relating to the world and to others General criteria for PD, then specific PD DSM-IV arranges PDs in 3 clusters according to shared characteristics Lack of insight – usually do not seek treatment for the PD; PD can impact treatment of other disorders ASPD