the personality disorders troubling, mysterious, untreatable?

The Personality Disorders

Troubling, mysterious, untreatable?

Over-arching characteristics

• The 3 P’s

• Pervasive – their problems cut across settings• Persistent – difficulties don’t go away or wax

and wane, last for decades• Pathological – behaviors are destructive and

maladaptive

More characteristics

• Tremendous problems with relationships hot and then ice-cold don’t last long few, if any, friends

• Identity issues – don’t form a stable, positive sense of self

Worse yet

• Lots of them• Notoriously hard to treat• Great burden on society crime family issues general chaos

Classification – DSM5

• Recognizes 10 types divided into three clusters

• Odd/eccentric – Schizoid, Schizotypal, Paranoid

• Erratic/emotional/dramatic – Histrionic, Antisocial, Borderline, Narcissistic

• Fearful/anxious – Avoidant, Obsessive-compulsive, Dependent

Comorbidity

• Many have other disorders – 50%!• The presence of a pd has a great influence on

symptoms, social functioning and treatment options

• More severe symptoms• More frequent in treatment settings

Reliability

• Since DSMIII commenced listing specific behavioral criteria, interrater reliability has greatly improved, typically >.8

• At least if structured interviews are used• Exception – schizotypal • Gender expectations

Self reports as basis?

• Huge reliability concern• By definition, pd involves an unstable self-view• Can they accurately describe their behaviors?• Another perspective is crucial, though rarely

obtained

An alternative DSM5 model

• Described in appendix to DSM5• Reduces disorders• Heavy reliance on the Big 5 personality traits• Provides more detail• Stability • Better predictions• Aids research

Odd/Eccentric Cluster

• Characterized by weird, bizarre behaviors

• Somewhat similar to schiz, but less severe

• Paranoid• Schizoid• Schizotypal• Lots of comorbidity between disorders

Paranoid

• Suspicion • Great effect on all types of relationships• Expectation of betrayal• Attend to and exaggerate threats & ill will• Hostility

• Not as severe or as profound as Schiz – lack hallucinations & full-blown delusions

Schizoid

• Don’t want or maintain relationships• Lifeless, bland• Little joy or fun• No interest in sex• Indifferent to other people, no warm feelings

for others

Schizotypal – “Schiz lite”

• Strange, unusual thoughts and behaviors• Magical thinking – think they can read minds• Ideas of reference – everything is about them• Illusions – strange, impossible sensory

perceptions• Strange appearance• Flat or out of place affect• Paranoia• Limited social contacts

Cause?

• Highly heritable • Beyond that, much uncertainty

• Schizotypal – high genetic overlap w/ schiz• Also share same cognitive and neuro

functioning issues w/ Schiz, just milder• Find enlarged ventricles and decreased grey

matter like schiz

Dramatic/erratic • Extremely variable behavior• Excessive, unrealistic self-esteem• Emotional outbursts• Rule-breaking• Antisocial – no care or concern for others• Histrionic – drama kings and queens• Borderline – rollercoaster relations, fragile self

image • Narcissistic – I’m perfect, you’re snot

Antisocial vs. Psychopathy

• Related but distinct

• Antisocial w/in DSM, Psychopathy not

• Both involve flagrant disregard for rules/ laws

Antisocial

• Long-standing pattern of behavior flouting the rights of others

• Aggressive, impulsive, callous• DSM5 requires Conduct Disorder diagnosis• All sorts of nasty behaviors – fighting, stealing,

lying, never planning ahead, impulsivity, failing to repay debts, temper outbursts

• No remorse

Demographics

• More men than women• Some seem to outgrow• More severe among young• ¾ comorbid• Substance abuse most common• ¾ of convicted felons meet criteria

Psychopathy

• Came before antisocial • Cleckly (1976)’s classic – The Mask of Sanity• Focused on thoughts and feelings (or lack of)• Lack emotions, good or bad• No sense of shame• Any exhibited emotion just an act• No plan, just acting on whim or impulse

Differences in DSM 5

• DSM 5 requires onset before 15, many psychopaths didn’t

• Antisocial often (80%) score low on Psychopathy Checklist

Causes

• Lots of research and theories• Two limitations though, 1) findings include both psychopaths and

antisocials = despite differences in diagnoses 2) samples drawn from convicts., some

escape criminal penalties

Genetic factors

• Follows biological children of APDs and substance abuse

• Heritability estimates range from 40-50%• More aggression, more heritability• More thorough (reliable) studies, higher

heritability• These run parallel with substance abuse• But very difficult to disentangle genetic, familial

& behavioral influences

Social factors

• Initial socialization from family key to building respect for others

• Parenting red flags - high negativity, low warmth, inconsistency

• Especially crucial if there is genetic risk• Also, poverty and exposure to violence predict

even w/out genetic risk

Nothing scares them

• Seem unable to profit from experience, even punishment

• Don’t fear arrest, prison, social stigma• The opposite of anxiety disorders, don’t

develop conditioned fear responses• Amygdala doesn’t get activated by stimuli

which should trigger CRs• CC fail

Can’t resist

• Impulsivity predicts• If they are pursuing something they want,

they don’t respond to consequences• However, if they are forced to pause before

responding, they do show learning

They just don’t feel others pain

• Focus on lack of empathy – being able to walk in another’s shoes

• Can’t even recognize other’s fear• Don’t respond to victimization scenes• Lack of arousal of ventromedial prefrontal

cortex in brain-imaging studies

Borderline

• Wild, inconsistent relationships• Rollercoaster moods• Rapidly changing, searingly hot to freezing

cold• Typical behaviors – promiscuity, gambling,

over-spending, substance abuse

Who am I?

• Fail to develop a clear and coherent sense of self

• Basic aspects of identity can change instantaneously

• Career plans, hobbies, values, loyalties can shift from one moment to the next

• Correspondingly, great fear of abandonment, rejection, emptiness

Self-harm, even suicide

• Many engage in self-destructive behaviors• 2/3’s engage in self-mutilation at some point

• 15% attempt and 7.5 % succeed in taking life

• But these tendencies tend to decrease as they mature

Duration, comorbidity• Thankfully, many lose the diagnosis over 10-15

years, most by 40

• Many suffer from: 1) other pds 2) mood disorders 3) substance abuse• More conditions, longer duration

The many causes of Borderline

• Neurobiological factors high, 60% heritability lower serotonin function hyper amygdala reactivity explains erratic

emotions poor function of prefrontal cortex explains

impulsivity also poor control of amygdala

Social factors – child abuse

• Compared to other pds, Borderlines show more parental separation, verbal and emotional abuse

• Similar to Dissociative Identity Disorder• On a continuum DID?

Diathesis- Stress model

• If you have genetic difficulties in controlling your emotions (diathesis) and are raised in an invalidating environment (stress), you are likely to develop Borderline

• Invaladating – no one pays attention to you or credits your expression of emotion

• Abuse is even worse

Dynamics of DS

• Interactive effect• Some children are difficult and demanding

from the start• Children punish or ignore emotional outbursts• Child suppresses emotions• Child boils over, drawing attention

(reinforcement)• Ongoing and escalating

Histrionic

• Excessive need for attention • Overly dramatic behavior• Provocative dress• Seductive, theatrical behavior• Emotional volatility• Easily persuaded• Strange, shallow language• Exaggerated intimacy in relationships

Cause

• Psychodynamic theory poses a father’s seductive behavior as cause for daughter’s actions

• Parents ambivalent views towards sex cause child to approach but then withdraw

• unverified

Narcissistic

• Grandiose, unjustified opinion of achievements and talents

• Demand attention and admiration• So special, only the truly gifted can

understand them• Entitled, exploitative• Arrogant, envious• No empathy

Causes of Narcissisitic

• Often comorbid with Borderline• Two distinct theories• Self-psychology – studies find parental

coldness & excessive praise• Parents set this up by exaggerating child’s

abilities to bolster their own self-esteem• Child feels shame with any failure

Social-cognitive model

• Two basic premises 1)Narcissists desperately seek to prove their

specialness due to precarious self-esteem, and

2) dealings with other people serve to bolster self-esteem, not warmth or fun

Support for social-cognitive model

• In controlled settings, they exaggerate attractiveness and achievement

• They falsely attribute success to special abilities rather than good fortune

• Hyper sensitive to feedback because they need constant praise

• Thirst to prove their specialness, rather than get close to people alienates others

The Anxious/Fearful Cluster

• Preoccupied and functionally impaired by worry and distress

• Avoidant – so terrified of social humiliation, they keep away from others

• Dependent – need someone else for everything

• Obsessive-Compulsive – rigid, inflexible, demanding perfection

Avoidant

• Afraid of criticism, rejection and negativity, so they avoid social contact

• Especially jobs or situations which will expose them to such

• Very restrained face-to-face• Deep seated conviction that they are

worthless and incompetent

Social Anxiety, & other connections

• Often found together• On a continuum, with Avoidant just more

severe?• Plenty of overlap w/ symptoms• Both similar to taijin kyofusho• Often found with MDD (80%!), borderline, and

schizotypal pds• And, of course, alcohol abuse

Cause?

• No one knows• Victims don’t want to discuss it• Fair heritability - ~30%• Maybe, through childhood modeling, they

associated any social contact with humiliation and ridicule

Dependent

• Desperate need for someone to take care of them and make decisions for them

• No self-confidence• Grave fear of being alone• Willing to sacrifice anything for support• When one “guardian” leaves, another must be

found

Other aspects

• DSM might be wrong in requiring helpless passivity – can work to keep relationships

• Found more frequently in eastern cultures like India and Japan where some passivity is expected

• Found w/ many of PDs, mood and anxiety mds• Bulimia also

Cause of Dependent?

• Parenting – authoritarian style – which prevents self efficacy, might be responsible

• Also, maybe it arises from an attachment failure, infant didn’t get enough affection and attention

Obsessive-Compulsive

• Wrapped up completely in details, rules, schedules, etc. to the point of impairing performance

• Trouble with decisions and time-management• No fun, all work• “Control freaks”• Troubled relationships• Inflexible morally

Distinguishing from OCD

• Not prey to obsessions and compulsions• Can appear together • But more likely found with Avoidant

Obsessive – compulsive cause?

• Not much research• Twin studies produced differing heritability

estimates• Some genetic overlap with OCD found• Especially with traits like Perfectionism

Treatment for PD

• Many get into treatment itself for other conditions like mood disorders or substance abuse

• Treaters should always consider since presence of pd predicts more difficult treatment

General Treatments

• Surprisingly pds respond to treatment, with a 52% recovery rate within 15 months

• But lack of control group limits optimism• Typically, several hours a day of

psychotherapy, and attention to social and occupational skills

• Sometimes in groups, other times solo• Can run for months

Specific Treatments

• Schizotypal – treated similarly to schiz with resperodone, effectively manages strange thinking

• Avoidant – mix of antidepress and cognitive behavioral therapy. Social skills training can help with fear of criticism. Similar, but more severe than social anxiety d.

Effective cure for psychopathy?

• Meta-analysis (42 studies) suggests there is hope

• Psychoanalytic therapy helps w/ relationships, experiencing remorse/empathy, reducing lying, holding a job, and completing probation

• Cognitive-Behavioral helped also• Therapy must be intense – 4x weekly• But are they just playing us?

Treating Borderline

• Very difficult to treat• Relationship issues rear up in treatment• Rollercoaster course 1)BDPs idealize then despise therapists 2) demand trust, then lie 3) demand extra, but give nothing 4) plus, great feat of suicide • Therapists need great support & feedback

Do meds help?

• Tried to calm moods and impulsivity• Some success re anger and depression• Lithium helps with irritability and suicide

• Much more research is necessary

Dialectical Behavior Therapy

• Linehan pioneered approach combining empathy/acceptance w/ Cog/Behav strategies

• Cog/Behav techniques: 1) problem solving, 2) emotion-regulation, and 3) social skills training• Clients are pushed towards self-acceptance

tempered with a more reasonable world-view

4 Stages of Dialectical Behav Therapy

• 1) take on dangerous, impulsive behaviors to gain control

• 2) learning to handle emotional upsets• 3) improving relationships & self-esteem• 4) promote connectedness and happiness• Follow-up studies revealed improvement vs.

controls but ongoing problems with happiness