Personality and clinical issues

Personality DisordersTrait approachesEvaluations

Overview

• Personality Disorders• DSM-IV approaches• Trait approaches

– Five factor model– Evaluation and arguments

What is a mental disorder?

1. Clinically significant behavioural or psychological syndrome orpattern that occurs in an individual and that is associated withpresent distress or disability or with a significant increasedrisk of suffering, death, pain, disability or an important loss offreedom

2. Must not merely be an expected or culturally sanctionedresponse to a particular event.

3. Must currently be considered a manifestation of abehavioural, psychological or biological dysfunction in theindividual.

4. Behaviour and conflicts between individual and society arenot disorders unless the it is symptom of dysfunction

5. Does not classify people - classifies disordersDSM-IV

Personality Disorders (PD)

“Personality traits - enduring patterns of perceiving,relating to and thinking about the environment andoneself that are exhibited across a wide range ofsocial and personal contexts” DSM-IV

When these traits are inflexible, maladaptive andcause functional impairment and/or distress = PD

Personality Disorders

Co-morbidity commonEnduring pattern of inner experience and behaviour that:• Deviates markedly from expectations of prevailing culture.

Manifests within two or more of: cognitions, affectivity,interpersonal functioning and impulse control

A. Is inflexible and pervasive across contextsB. Leads to clinically significant distress or impairment in social,

occupational or other areasC. Is stable and can be traced back to adolescence or beforeD. Is not better accounted for by another disorderE. Is not due to physiological effects of substance or general

medical condition

Personality Disorders

Coded on Axis II1. Paranoid2. Schizoid3. Schizotypal4. Antisocial Personality Disorder5. Borderline6. Histrionic7. Narcissistic8. Avoidant9. Dependent10. Obsessive-Compulsive

Cluster A (odd, eccentric)

Cluster B (dramatic, emotional)

Cluster C (fearful, anxious)

Paranoid PD

Prevalence:• 0.5-2.5% general population,• 2-10% outpatient mental health• 10-30% inpatient mental health

• Increased prevalence if family Schizophrenia and Delusional

• NOT to be confused with members of groups for whom thereis a real issue of persecution (minorities, refugees, etc)

• Symptoms apparent from childhood and adolescence

Paranoid PD

Diagnostic criteriaA Pervasive distrust and suspicion of others, across contexts.

Show 4 (or more) of the following:i) Suspects others are harming, deceiving or plotting (no basis)ii) Preoccupied with doubts about trustworthiness of friendsiii) Reluctant to confide in others (due to above)iv) Reads hidden demeaning/threatening meanings into remarksv) Persistently bears grudges (lack of forgiveness)vi) Perceives attacks and reacts quickly and angrilyvii) Recurrent suspicions about fidelity in relationshipsB Does not occur exclusively during a Psychotic disorder or due

to medication

Schizoid PD

Prevalence:• Uncommon in clinical settings

• Increased prevalence if family Schizophrenia and Schizotypal

• Distinguished from Psychotic disorders, ASD, Avoidant, OCD• Not to be confused with those who have defensive

interpersonal styles (e.g. those moved to a strange new area)

• Symptoms apparent from childhood and adolescence:solitariness and poor peer relations (prone to victimisation)

Schizoid PD

Diagnostic criteriaA Pervasive detachment from social relationships. Restricted

emotional expression. Show 4 (or more) of the following:i) Neither enjoys or seeks close relationshipsii) Chooses solitary activitiesiii) Little interest in sexual relationshipsiv) Takes pleasure in v. few activitiesv) Lacks close confidants (1st degree relatives excluded)vi) Indifferent to praise / criticism of othersvii) Emotional coldness, detachment, flattened affectB Does not occur exclusively during a Psychotic disorder or due

to medication

Schizotypal PD

Prevalence:• 3% general population

• Increased prevalence if 1st degree biological Schizophrenia

• Distinguished from Psychotic disorders, Schizoid, Avoidant,ASD, Language disorders

• Not to be confused with those who have religious beliefscharacterised by rituals (Voodoo, speaking in tongues,magical thinking)

• Stable life course. Very few develop Schizophrenia

Schizotypal PDDiagnostic criteriaA Acute pervasive discomfort with social relationships. Cognitive and

perceptual distortions. Eccentric behaviour. Show 4 (or more) of:i) Ideas of reference (not delusions)ii) Odd beliefs outside norms - bizarre preoccupations / fantasiesiii) Perceptual illusions (including bodily illusions)iv) Odd thinking and speech (e.g. I’m not talkable today)v) Suspicious / paranoidvi) Inappropriate / constricted affectvii) Peculiar behavioursviii) Lack of confidants (except 1st degree relatives)ix) Social anxiety which does not diminish with familiarityB Does not occur exclusively during a Psychotic disorder, Pervasive

Developmental Disorder or due to medication

Antisocial PDPrevalence:• 3% males: 1% females (community samples)• 3-30% clinical samples• Higher in drug treatment and forensic settings

• Increased prevalence if family Antisocial PD, substance abuse.Nurture also plays part in familial relationships

• Distinguished from Substance-Related Disorder, Narcissistic PD,Histrionic, Borderline, Paranoid

• Higher in lower SES - maybe due to middle class judgements ofacceptable behaviours. May be under diagnosed in females due toemphasis on physical aggression

• Symptoms apparent from childhood and adolescence tend todiminish across lifespan

Antisocial PDDiagnostic criteriaA Pervasive disregard of rights of others since 15yrs. Show 3 (or

more) of the following:i) Lack of conformity to social norms. Repeated behaviours grounds

for arrestii) Lying, aliases, conning for profit or pleasureiii) Impulsivity, failure to planiv) Irritability, aggressiveness, frequent fightsv) Reckless disregard for others’ and own safetyvi) Irresponsibility (failure to maintain work, relationships, obligations)vii) Lack of remorse for actionsB Over 18yrs oldC Conduct Disorder prior to 15yrsD Not during Schizophrenia or Mania

Borderline PDPrevalence:• 2% general population• 10% outpatient mental health• 20% inpatient mental health• 30-60% of PD clinical populations

• Increased prevalence if 1st degree biological, Substance Disorders,Antisocial PD, Mood Disorders

• Distinguished from Histrionic PD, Schizotypal, Paranoid, Nacissistic,Antisocial, Dependent

• Not to be confused with adolescent settling into identity /relationships

• Symptoms most evident in early adulthood. Relative stability in 30s

Borderline PDDiagnostic criteriaA Pervasive instability of interpersonal relationships, self-image, affect.

Marked impulsivity. Show 5 (or more) of the following:

i) Frantic efforts to avoid abandonment (real / imagined)ii) Extremes of idealization and devaluation in relationshipsiii) Identity disturbanceiv) Impulsivity in 2 or more areas (e.g. sex, spending, binging, drinking)v) Recurrent suicidal gestures, threats, self-harmvi) Marked reactivity of mood (short lived)vii) Chronic feelings of emptinessviii) Inappropriate angerix) Transient, stress-related paranoia / severe dissociative symptoms

Histrionic PD

Prevalence:• 2-3% general population• 10-15% inpatient and outpatient mental health

• Distinguished from Borderline, ASPD, Narcissistic, Dependent

• Not to be confused with cultural norms of emotionalexpressiveness

• Evident from early adulthood

Histrionic PD

Diagnostic criteriaA Pervasive excessive emotionality and attention seeking

expression. Show 5 (or more) of the following:i) Uncomfortable if not centre of attentionii) Interactions often inappropriately sexual or provocativeiii) Rapidly shifting and shallow emotional expressioniv) Gains attention via physical appearancev) Speech impressionistic and lacking in detailvi) Self-dramatization, theatrical expression of emotionvii) Suggestableviii) Considers relationships to be more intimate than they are

Narcissistic PD

Prevalence:• <1% general population• 2-16% in clinical population (most male)

• Distinguished from Histrionic, ASPD, Borderline, OCD,Schizoid, Schizotypal. Grandiose beliefs not due to Delusions.

• Not to be confused with adolescent self absorption

• Symptoms apparent from early adulthood

Narcissistic PD

Diagnostic criteriaA Pervasive grandiosity, need for admiration, lack of empathy.

Show 5 (or more) of the following:i) Grandiosity without commensurate achievementsii) Preoccupied with fantasies of unlimited success, poweriii) So special, few (high status) people could understand themiv) Requires excessive admirationv) Sense of entitlementvi) Interpersonally exploitativevii) Lacks empathyviii) Envious of others, or believes others envy themix) Arrogant / haughty behaviours and attitudes

Avoidant PD

Prevalence:• 0.5-1% general population• 10% outpatient mental health

• Distinguished from Social Phobia, Panic with Agoraphobia,Dependent, Schizoid or Schizotypal, Paranoid

• Not to be confused with expected difficulties due toimmigration, and childhood shyness

• Evident from early childhood and does not dissipate with age

Avoidant PD

Diagnostic criteriaA Pervasive social inhibition, inadequacy, hypersensitive to

negative evaluation. Show 4 (or more) of the following:i) Avoids jobs with interpersonal contact due to fear of

disapproval and rejectionii) Will only get involved with people if certain to be likediii) Restraint in relationships in case of being ridiculediv) Preoccupied with being rejected in social situationsv) Views self as socially inept, inferiorvi) Reluctant to take risks or try something new in case of

embarrassment and failure

Dependent PD

Prevalence:• Extremely common in mental health clinics

• Distinguished from Axis I, Borderline, Histrionic, Avoidant

• Not to be confused with cultural norms of dependency inclose relationships

• Evident from early adulthood

Dependent PDDiagnostic criteriaA Pervasive need to be taken care of. Submissive and clingy

behaviour. Show 5 (or more) of the following:i) Difficulty making everyday decisions without advice and

reassurance from othersii) Needs others to assume responsibilityiii) Difficulty expressing disagreement because of fear of loss of supportiv) Difficulty initiating projects on own (lack of self-confidence)v) Goes to lengths to gain nurturance and support (e.g. volunteering to

do things which are unpleasant)vi) Uncomfortable when alone because of exaggerate fears of being

unable to look after selfvii) Urgently seeks another relationship when one endsviii) Unrealistically preoccupied with fears of being left to care for self

Obsessive-Compulsive PD

Prevalence:• 1% general population• 3-10% clinical mental health• Twice as common in males

• Distinguished from ASPD, Narcissistic, Schizoid

• Not to be confused with cultural norms of work ethics

• Evident from early adulthood.

Obsessive-Compulsive PDDiagnostic criteriaA Pervasive preoccupation with orderliness, perfectionism and control

at expense of flexibility. Show 5 (or more) of:

i) Preoccupied with details, rules, lists. Big picture lost.ii) Perfectionism interferes with completioniii) Excessively devoted to work to exclusion of leisure and friendshipsiv) Over-conscientious and inflexible about morality / ethicsv) Unable to discard items even if have no valuevi) Reluctant to delegate unless submit exactly to their instructionsvii) Miserly form of spending to self and others (cash is to be hoarded

for future catastrophes)viii) Rigidity and stubborness

PD links with normal personality traits

N linked with most psychiatric conditions (Costa & McCrae, 1992)E - associated with histrionic (+ve) & Schizoid (-ve) (Wiggins & Pincus,

1989)O - can influence the type of therapy a patient will respond toA - influence rapport between patient and therapist (Cost & McCrae 1992)C - linked to ASPD (-ve), OCD (+ve) (Lyons et al, 1990)

P linked on continuum with Psychoticism through Psychopathy toSchizophrenia (Eysenck)

PD links with normal personality traits(Costa & McCrae, 1992)

10.8

13.9

14.0

M

6.7

7.7

6.4

SD C

-.37.26.38Antisocial

-.36.26.67Borderline

-.53.43Paranoia

AOEN

OCD links with Five-Factor Model(Rector et al., 2002)

OCD should be related to higher COCD and Big 5 may also be related to Depression

OCD = 98 & matched Major Depression = 98• Patients had high N and low E & C, average A and O compared to

control statistics• OCD had higher E, A, C than MD group• MD group had higher levels of N

When depression severity was controlled across patients:• OCD had higher E & A• MD had higher N

OCD links with Five-Factor Model(Rector et al., 2002)

• OCD findings with no difference in C after controlling for depressionseverity is counter intuitive

• May be due to their exceptionally high standards - and so items arebeing responded to not via norms of others, but of self.

BUT

• Did not assess Axis II co-morbidity

• Cross sectional design

PDs with Five-Factor Model(Costa, McCrae, 1990)

Community population, N = 192 males (27-90), 105 females (19-87)274 had SR data on NEO-PI60 had spouse ratings112 had peer ratings (from 1-4 friends and neighbours)

Given MMPI (based on DSM-III) and NEO-PI (self and other ratings)

PDs with Five-Factor Model(Costa, McCrae, 1990)

*(-)*(Peer)

(Spouse)

*(-)***(-)***Paranoid (SR)

(Peer)

*(Spouse)

*(-)***(-)***Schizotypal (SR)

*****(-)(Peer)

****(-)(Spouse)

**(-)******(-)**Schizoid (SR)

CAOENCLUSTER A

PDs with Five-Factor Model(Costa, McCrae, 1990)

*(-)*(Peer)

*(-)(Spouse)

*(-)***(-)***Borderline (SR)

***(-)(Peer)

*(-)*(-)(Spouse)

***(-)***(-)***Antisocial (SR)

*(Peer)

***(Spouse)

**(-)******(-)Narcissistic (SR)

***(Peer)

**(-)***(Spouse)

***(-)******(-)Histrionic (SR)

CAOENCLUSTER B

PDs with Five-Factor Model(Costa, McCrae, 1990)

(Peer)

(Spouse)

*(-)**(-)***Compulsive (SR)

***(Peer)

(Spouse)

***(-)******(-)***Dependent (SR)

*(-)(Peer)

**(-)(Spouse)

***(-)***Avoidant (SR)

CAOENCLUSTER C

Can the Five-Factor Model be used inClinical Assessment?

Ben-Porath & Waller (1992)Any additional measure needs to:1. Do all the job of existing measures if replacement, or2. Do additional functions to existing measures if supplement.

Content of assessment important - but also manner of interaction withtherapist / assessment

What does a Clinical Assessment need to do?

Ben-Porath & Waller (1992)1. Identification of symptoms and differential diagnosis2. Current adjustment and stable personality3. Treatment implications (related to forensic and legal issues)

Can the Big 5 do this?John (1990): Definitive labels not yet achieved for Big 5Briggs (1989): “The five (plus or minus two) have yet to be defined by

consensus with any degree of specificity” (p.248)

Some aspects not dealt with by Big 5 (e.g. autonomy, traditional values,maturity)

What does a Clinical Assessment need to do?

Ben-Porath & Waller (1992)1. Protocol validityBig 5 doesn’t give info on how client is cooperating• Costa & McCrae (C&R) (1992) say S.R. valid even when people

aren’t removed on basis of question about engagement inassessment

• BP&W(1992) Still may not give info on single client

2. Depression, impulsivity and anxiety all load onto N• Tellegen (1985):

Depression = low Positive Emotionality (E),Anxiety = High negative Emotionality (N),Impulsivity = low Control (C)

Costa & McCrae’s reply

1. Don’t consider Big 5 as stand alone

2. Don’t believe protocol validity checks work. When look at MMPIagainst MMPI (observer ratings), protocol validity controls make thevalidity worse

3. Scales are different at facet level to domain.

4. Anxiety can be part of depression (panic attacks)Impulsivity (of considered as inability to resist urges and cravings),is similar to inability to tolerate tension and frustration = N

Conclusions

1. “Normal” personality traits can inform personality disorders

2. Assumption that measures made for community samples can beused for clinical populations is point for debate

3. Is personality personality disorder a continuum or separate?