The Nature of Personality Disorders • Enduring patterns of perceiving, Chapter 12 relating to, and thinking about the Personality world and oneself Disorders • Manifest across many life areas • Are inflexible and maladaptive, and cause either significant impairment or distress to self or others • Dimensional vs. Categorical – Problem of degree vs. Problem of kind • DSM-IV • Cluster A – Categorical View “Odd” or “Eccentric” – Axis II Paranoid – Ten Types Schizoid • DSM-IV Clusters Schizotypal Cluster A: “Odd / Eccentric” Cluster B: “Dramatic / Emotional / Erratic” Cluster C: “Anxious / Fearful” • Causes • Paranoid Personality Disorder – Still unclear – Pervasive unjustified distrust – Biological vulnerability – Excessively suspicious – Distorted thoughts – Tend not to confide in others – Roots of these perceptions are in early upbringing – Think others want to harm them – Cultural factors – Meaningful relationships are very difficult • Treatment because of the profound mistrust – Unlikely to initiate treatment – Obviously hostile toward others – Trigger for seeking therapy is crisis in one’s life or – Appear tense & ready to pounce when they anxiety or depression think they’ve been slighted – Difficulty establishing trust in treatment – Very sensitive to criticism – Use CT to address mistaken assumptions – Excessive need for autonomy – No evidence that treatment works! 1 • Schizoid Personality Disorder • Causes and Treatment – Extreme social detachment (loner) – Possibly a biological dysfunction similar to that – They neither desire nor enjoy closeness with found in autism others, including romantic relationships – They rarely request treatment except in response to a – Limited range of emotions in interpersonal crisis situations – Treatment teaches value of social relationships, & involves education about emotions, empathy – Lack emotional expressiveness training, social skills training, & role playing – Appear aloof, cold, indifferent – Treatment prospects are poor – Many are homeless – Extreme social deficiencies • Causes • Schizotypal Personality Disorder – Also socially isolated – Viewed by some as one phenotype of a – BUT behavior is more unusual schizophrenia genotype – Often considered odd or bizarre because of how • Treatment they relate to other people, think & behave & even – 30-50% of the people seeking treatment for this dress also have MDD – They tend to be suspicious & have odd beliefs – Limited research into treatment • Ideas of reference – Teach social skills to help reduce their isolation • Magical thinking from & suspicion of others • Illusions – Medical treatment similar to that for people with schizophrenia Antisocial Personality Disorder • Long histories of Cluster B –Violating cultural norms –Violating rights of others “Dramatic, Emotional, Erratic” –Impulsivity & aggressiveness –Antisocial –Lack of remorse –Substance abuse is common (83%) –Borderline • Long–term outcome often is poor –Histrionic • Many met the criteria for conduct disorder –Narcissistic during childhood • Antisocial personality disorder, psychopathy & criminality 2 Causes • Psychological & Social Influences • Genetic and Developmental Influences – Once they set their sights on a reward goal, – Family, twin, & adoption studies all suggest a genetic they’re less likely to be deterred despite influence – There’s a gene–environment interaction signs that the goal is no longer achievable • Neurobiological Influences – Gerald Patterson – Under–arousal Hypothesis • Coercive family process – Fearlessness Hypothesis • Developmental Influences – Jeffrey Gray’s model of brain functioning – Rate of antisocial behavior declines • Individuals with Antisocial PD may have an imbalance between the reward system (REW) & markedly around age 40 the behavioral inhibition system (BIS), with REW >>> BIS Borderline Personality Disorder • Treatment • Unstable & intense relationships – Most do not seek treatment • Unstable self-image – Can be very manipulative with their • Unstable moods therapists • Impulsive behavior – Poor prognosis – Most common treatment strategy for • Causes children involves parent training – Runs in families – Focus on prevention – Connection with mood disorders – Contribution of early abuse, especially sexual & physical abuse • Treatment Histrionic Personality Disorder • Overly dramatic – Few Controlled Studies • Emphasis on appearance – Medications • Seductive & provocative • Antidepressants and Lithium • Center of attention – Marcia Linehan’s Dialectical Behavior Therapy (DBT) • Seek reassurance & approval • Multifactorial • Tend to be impulsive & have difficulty delaying – Teaches problem solving gratification – Teaches identification & regulation of emotions • Impressionistic style; vague speech – Social skills training • Causes – Re–experience prior traumatic events to help – Little research extinguish associated fear – Ancient Greeks & hysteria – Relationship with Antisocial PD 3 Narcissistic Personality Disorder • Treatment • Grandiose – Again few controlled studies • Require & expect special attention – Modify attention seeking behavior • Requires admiration – Focus on changing relationship styles • Little sensitivity for others or empathy – Shown more appropriate behaviors • Exploits others for their own interests • Frequently depressed because they often fail to live up to their own expectations • Causes – Lack of early experiences with empathy / altruism >Cluster C – A function of the “me generation” • Treatment studies are limited “Anxious or Fearful” – Therapy focuses on grandiosity, hypersensitivity to evaluation, & lack of empathy toward others Avoidant – CT aims to replace their fantasies with a focus on attainable day–to–day pleasurable experiences Dependent – Relaxation training to help them face & accept criticism Obsessive-Compulsive – Focus on feelings of others – Treatment for depression Avoidant Personality Disorder • Causes • Because they are hypersensitive to – May be born with a difficult early temperament others’ opinions • Treatment – They avoid social relationships – Several well controlled studies • Because of extreme low self-esteem – Target anxiety and social skills – Treatment similar to social phobia High fear of rejection, – • Systematic Desensitization – They become very dependent on those few • Behavioral Rehearsal they feel comfortable with – Modest improvements with fear of • Take few risks negative evaluation, social avoidance & • Socially inhibited & anxious distress • Different from Schizoid PD 4 Dependent Personality Disorder Obsessive-Compulsive PD • Excessive reliance on others • Fixation on doing things “the right way” • Fear abandonment & rejection • Submissive, timid & passive • Preoccupation with • Cling to relationships –Orderliness & perfectionism –Control • Causes –Details & rules – Disruption in early attachment due to neglect, rejection, or early death • Rigid and stubborn, leading to poor interpersonal – Because early bonding is interrupted, they’re relationships constantly anxious they’ll lose people close to them • Very work–oriented • Very limited research into treatment • Only distantly related to OCD effectiveness • Causes Personality Disorders Under Study – Weak genetic contribution • Depressive personality disorder – May require parental reinforcement of conformity & neatness – Self–criticism, dejection, judgmental stance toward others, & a tendency to feel guilt • Few controlled treatment studies – It may be a PD distinct from dysthymic disorder – Address fears underlying need for orderliness • Negativistic personality disorder – Relaxation and distraction techniques to – Passive aggression in which people adopt a redirect the compulsive thoughts negativistic attitude to resist routine demands & expectations – May be a subtype of Narcissistic PD 5.