personality disorders: an enduring (long-standing) pattern in two or more of the following areas: 1)...

PERSONALITY DISORDERS:

An enduring (long-standing) pattern in two or more of the following areas: 1) Cognition (thoughts) - ways of interpreting and perceiving events2) Affectivity (emotions) - range, intensity, lability, & appropriateness3) Interpersonal functioning (behavior)4) Impulse control (behavior)

Personality Traits vs. Disorders

Deviation from social & cultural norms – consider contribution of situational & cultural context

Inflexibility – rigid patterns of behaviors & responses

Pervasive – present in a variety of contexts

Clinically significant distress – for self or others

Impairment in functioning – highly maladaptive

Stable & long-lasting - onset by early adulthood, long-term pattern vs. occasional

CLUSTER A PERSONALITY DISORDERS

Characterized by:Odd behavior, reactions, emotionsEccentric thoughts & behaviors – e.g. illusory or magical thinking, inappropriate social interactionsIsolative behavior – social withdrawalSuspiciousness – paranoia

Includes:Paranoid Personality DisorderSchizoid Personality DisorderSchizotypal Personality DisorderMay represent mild variations of Schizophrenia, but reality testing is intact

PARANOID PERSONALITY DISORDER

A. A pervasive pattern of distrusting, being suspicious of, and attributing malevolent intention to others

B. Pattern of behavior is not due to Schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, the effects of a substance, or a general medical condition

PARANOID PERSONALITY DISORDERIndicated by 4 or more of the following 7:1. Assuming others will exploit, harm, or deceive them2. Continually doubting the loyalty or trustworthiness of

friends or associates3. Reluctance to confide in others because fear info will

be used against them4. Reading hidden demeaning or threatening meanings

into benign remarks or events5. Persistently bearing grudges6. Often believing they have been attacked or slighted

and are quick to react angrily or with counterattack7. Continually suspecting spouse or sexual partner of

being unfaithful

PARANOID PERSONALITY DISORDER

What it looks like:

Chronically suspicious of others

Distrusting of others

Assuming the worst intention

Not open

Continually doubting loyalty of others

Unforgiving

Hold grudges

PARANOID PERSONALITY DISORDERFacts & Figures: Prevalence – 0.5-2.5% in general population Gender – more common in males Onset – often first apparent in childhood and

adolescence Cultural Factors – need for caution in diagnosing

members of minority, ethnic, immigrant, refugee groupsTreatment Considerations: Importance of developing trust & a solid therapeutic

alliance Cognitive therapy to counter mistaken assumptions and

negative beliefs about others No evidence that therapy is very successful

SCHIZOID PERSONALITY DISORDER

A.Characterized by a pervasive pattern of:

-detachment from social relationships

-restricted range of emotional expression in interpersonal settings

B. Pattern of behavior is not due to schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder.


Indicated by 4 or more of the following 7:1. Neither desiring nor enjoying close relationships,

including being part of a family2. Almost always choosing solitary activities3. Having little, if any, interest in sexual

experiences/relationships4. Taking pleasure in few, if any, activities5. Lacking close friends or confidants6. Indifference to praise or criticism7. Emotional coldness, detachment, or flatness


What it looks like:Emotionally cold & distantGreat difficulty forming relationshipsSocial isolation – lonerRestricted affect – lack of emotional expressivenessLack of interest in people, relationships, & most activities

SCHIZOID PERSONALITY DISORDERFacts & Figures: Prevalence – uncommon; <1% Gender – slightly more common and

impairing in males Onset – often first apparent in childhood and

adolescence Cultural – need for caution in diagnosing

people from different cultural backgrounds, environments, or immigrants

SCHIZOID PERSONALITY DISORDERContributing factors: Childhood shyness Genetics Parenting: neglectful & cold parenting; intrusive

mother; absent father Lower density of dopamine receptors Traumatic experiences

Treatment: Modeling healthy relationship skills & emotional

expression Empathy training – teaching the person how to identify,

express, & respond to emotion Social skills training, including role playing Building a support network

SCHIZOTYPAL PERSONALITY DISORDER

A. A pervasive pattern of social and interpersonal deficits marked by:-acute discomfort with close relationships -a reduced capacity for close relationships-cognitive or perceptual distortions -eccentric behaviors

B. Pattern is not due to schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder

SCHIZOTYPAL PERSONALITY DISORDERIndicated by 5 or more of the following 9:1. Ideas of reference2. Odd beliefs or magical thinking3. Unusual perceptual experiences4. Odd thinking & speech5. Suspiciousness or paranoid ideation6. Inappropriate or constricted affect 7. Odd, eccentric or peculiar behavior or

appearance 8. Lack of close friends or confidants9. Excessive social anxiety that does not diminish

with familiarity and tends to be associated with paranoid fears


What it looks like:Social impairment & isolationSocial discomfort & anxietyVariety of odd beliefs & cognitionsUnusual perceptions & perceptual experiencesOdd speech & presentationEccentric & peculiar behaviorInappropriate or blunted affect


Facts & Figures: Prevalence – 3-5% of general population Gender – slightly more common in males Onset – often first apparent in childhood and

adolescence Course – chronic; some go on to develop

Schizophrenia Cultural – need to consider cultural context

when evaluating symptoms


Contributing Factors: Biological and genetic factors have been

emphasized – Schizotypal PD as a milder variant of schizophrenia

Treatment Considerations: Psychotropic medication –

antidepressants, antipsychotics Cognitive-behavioral therapy Social skills training

Cluster A Scenario

An individual receives an invitation to attend the birthday party of a supervisor at work. This supervisor is not well known to the individual, in fact, they have only spoken on a couple of occasions.

Paranoid Personality Disorder

Cognitions include:This person reached their position through dishonesty or fraud – they are not to be trusted.My colleagues are out to get me – it will not be safe to be in an unfamiliar setting with them.My job security is being threatened.

Behaviors include:Approaching the supervisor to research these suspicions in a hostile and accusatory mannerFinding an excuse to not attend the birthday partyIncreased irritability in the workplaceHypervigilance for “suspicious” behavior from colleagues

Schizoid Personality Disorder

Cognitions Include:

Not wanting to go to the party

I would rather be alone.

This party won’t be enjoyable.

Behaviors include:

Not attending the party

Telling the supervisor she won’t attend in a cold, detached way

Schizotypal Personality Disorder

Cognitions Include:

I was meant to go to this birthday party because something supernatural will occur

I wonder why the supervisor chose me?

Will I be prepared to handle what is to come?

Behaviors Include:Wearing an unusual ceremonial costume to the party Remaining detached from others at the party Speaking to others in an elaborate way

CLUSTER B PERSONALITY DISORDERS

Characteristics:DramaticEmotional Erratic behaviorImpulsivenessReduced capacity for empathyUnstable emotions & relationships

Includes:Antisocial Personality DisorderBorderline Personality DisorderHistrionic Personality DisorderNarcissistic Personality Disorder

ANTISOCIAL PERSONALITY DISORDER

A. Pervasive pattern of disregard for and violation of the basic rights of others

B. Beginning in childhood or early adolescence (must have evidence of Conduct Disorder prior to 15 years)

C. Continuing into adulthood (must be at least 18 years)

D. Occurrence of antisocial behavior is not exclusively during a course or Schizophrenia or Mania

ANTISOCIAL PERSONALITY DISORDERIndicated by 3 or more of the following 7:1. Failure to conform to social norms and laws, e.g.

repeatedly performing acts that are grounds for arrest2. Deceitfulness & manipulation, e.g. repeated lying, using

aliases, or conning others for personal profit or pleasure3. Impulsivity or failure to plan ahead4. Irritability and aggressiveness, e.g. repeated physical

fights or assaults5. Reckless disregard for safety of self or others6. Consistently & extremely irresponsible, e.g. repeated

failure to sustain consistent work or honor financial obligations

7. Lack of remorse, e.g. being indifferent to or rationalizing having hurt, mistreated, or stolen from another

ANTISOCIAL PERSONALITY DISORDERWhat you see:

Aggressiveness Superficial charmSelf-centeredBore easily, high need for stimulation, sensation-seeking, thrill-seekingLie easilyConning, manipulativeRelationships of “utility”Lack of remorse – little or no guilt about the harm they cause othersLack of empathy – may seem cold & insensitiveEnjoy testing, provoking, pushing, “playing with” othersCriminal behavior – feel rules don’t apply to them

ANTISOCIAL PERSONALITY DISORDER

Facts & Figures: Prevalence: 3% males; <1% females Gender: more common in males SES: associated with low SES & urban

settings; important to consider the social and economic context for behaviors

Course: chronic, but symptoms tend to lessen or remit by 4th decade of life

Antisocial Personality DisorderContributing Factors:

Strong biological roots: Genetic influence Low levels of 5HT Low arousability Excessive theta waves Poor impulse control Fearlessness

Environmental factors: Parenting: harsh, inconsistent, neglectful, uninvolved, abusive Chronic stress, trauma

Treatment:Psychotherapy is not very effective; often court-mandatedLithium & SSRI’s may help control impulsive, aggressive behaviors

BORDERLINE PERSONALITY DISORDERA pervasive pattern of marked impulsivity and

unstable relationships, self image, and emotions

Indicated by 5 or more of the following 9: 1. Frantic efforts to avoid real or imagined

abandonment2. A pattern of unstable and intense interpersonal

relationships – shifts from extreme idealization to devaluation

3. Identity disturbance – sudden & dramatic shifts in self image, e.g. goals, values, career plans & aspirations, sexual identity, types of friends

BORDERLINE PERSONALITY DISORDER4. Impulsive behavior that is potentially self-damaging,

e.g. spending, sex, substance abuse, reckless driving, binge eating

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

6. Affective instability due to highly reactive mood, e.g. episodes of dysphoria, anxiety, panic, irritability, anger, despair

7. Chronic feelings of emptiness8. Inappropriate, intense anger or difficulty controlling

anger; e.g. frequent temper, biting sarcasm, enduring bitterness, verbal outbursts, recurrent fights

9. Transient, stress-related paranoia or dissociative symptoms, such as depersonalization

BORDERLINE PERSONALITY DISORDERWhat it looks like:

Unstable mood & emotions – lack control over emotionsUnstable self-conceptUnstable interpersonal relationshipsPoor impulse controlSelf-destructive Good at splitting Vacillating between extremely positive & negative evaluations of self & others

BORDERLINE PERSONALITY DISORDERFacts & Figures: Prevalence: 1-3% of general population Gender: 75% female Completed suicide rate: 6-10% Course:

greater instability, impairment, and suicide risk in adolescence & young adulthood

symptoms gradually wane with advancing age by 30’s & 40’s, most attain greater stability in

relationships and vocational functioning

BORDERLINE PERSONALITY DISORDER

Contributing Factors:Biological factors – low levels of serotoninFamily history of mood disordersEnvironmental factors – invalidating &

neglectful parenting; history of abuse; traumaTreatment:Drug therapies – SSRI’s for dysphoria; mood

stabilizers for mood instability Long-term therapyDialectical Behavior TherapyTrauma work

HISTRIONIC PERSONALITY DISORDER

A pervasive pattern of excessive emotionality and attention-seeking behavior

Indicated by 5 or more of the following 8:

1. Feels uncomfortable or unappreciated when not the center of attention

2. Inappropriately seductive or provocative behavior

3. Displays rapidly shifting and shallow emotions

HISTRIONIC PERSONALITY DISORDER4. Consistently uses physical appearance to

draw attention to self5. Have strong opinions & impressions, but

can’t back up with facts, details, examples, evidence

6. Is overly dramatic, theatrical and emotionally expressive

7. Is suggestible, i.e. easily influenced by others, fads, or circumstances

8. Considers relationships to be more intimate than they actually are


What it looks like:Flamboyant self expression & presentationOver-blown, overly dramatic emotional rxnsNeedy & solicitous of othersRequire excessive approval & reassuranceFrequently dependentImpressionistic & superficialOverly concerned with appearanceSeductive & charming


Facts & Figures: Prevalence: 2-3% in general population Gender: diagnosed more frequently in women;

prevalence may be equal for males & females Sex role stereotypes influence the behavioral

expression of the disorder Aging presents special difficulties Course: chronic, but sx may improve with ageContributing Factors: Unmet needs for attention & success

NARCISSISTIC PERSONALITY DISORDER

Pervasive pattern of grandiosity in fantasy or behavior, need for admiration, and lack of empathy

Indicated by 5 or more of the following 9:1. Grandiose sense of self importance, e.g.

overestimating one’s abilities, exaggerating one’s accomplishments, underestimating/devaluing others.

2. Fantasies about unlimited success, power, brilliance, beauty, or love.

3. Belief that one is special, superior, or unique.


4. Need for excessive admiration and/or constant attention

5. Sense of entitlement, i.e. expecting especially favorable treatment or automatic compliance from others

6. Conscious or unwitting exploitation of others7. Lack of empathy for others; e.g. insensitivity,

emotional coldness, lack of interest in others8. Envying others; believing others envy them9. Arrogant, haughty, patronizing, snobby, or disdainful

behaviors or attitudes


What it looks like:Self-enhancing, self-aggrandizingSelf-centered, self-absorbedReadily dismiss opinions of othersNeed to feel specialLove to receive special treatmentCan become rageful & attacking in response to perceived threat


Facts & Figures: Prevalence: <1% in general

population Gender: up to 75% male Age: narcissistic traits are particularly

common in adolescents Course: the aging process presents

special difficulties; may improve over time

NARCISSISTIC PERSONALITY DISORDERCauses: Parental factors: failure in modeling empathy; rejecting,

abandoning, or cold; capricious, unreliable; treating the child as an extension of themselves; overvaluation; lack of genuine, sincere affection

Treatment: Usually seek treatment at insistence of family member or

as a result of a major life crisis Coping skills to improve ability to accept criticism &

rejection and to help person develop a more realistic view of their abilities and talents

Empathy building Addressing depression & other underlying problems that

may exist

Cluster B Scenario

An individual sees someone they occasionally date out at the movies with another date.

Antisocial Personality Disorder

Cognitions Include:Thoughts about what could be done to ensure that they are the one selected for the date next time – it is, after all, a dog eat dog world.

Behaviors Include:Socially unacceptable or unlawful behavior to interrupt the date (calling in a bomb threat to the movie theatre)Starting rumors about the person who their romantic interest was on a date with, or about the romantic interest themselves.

Borderline Personality Disorder

Cognitions Include:She must hate me now.I am worthless.I will never have a relationship.My life is over.I was in love with her.

Behaviors Include:An emotional outburstSelf injurious behaviorCalling attention to himself impulsively in the moment

Histrionic Personality Disorder

Cognitions Include:I can’t stand that person (either the romantic interest or the date).Didn’t someone tell me he was promiscuous?We were in love.

Behaviors Include:A dramatic outburstSexually seductive behaviorExcessive emotional response that is prolonged and involves many people

Narcissistic Personality Disorder

Cognitions Include:A brief thought of being rejectedThoughts of being superior to the other dateThoughts that the date would be envious if they knew who she was

Behaviors Include:Loudly discussing accomplishments in the movie theatre so the romantic interest and date are sure to hearShowing how well known they are by greeting every acquaintance in the movie theaterApproaching the romantic interest and asking them to call or actually starting up a conversation

Cluster C Personality Disorders

Characterized by:

Anxious behavior

Chronic fears

Perfectionism

Constant self-doubt

Includes:Avoidant Personality DisorderDependent Personality DisorderObsessive- Compulsive Personality Disorder

AVOIDANT PERSONALITY DISORDER

A pervasive pattern of social inhibition, feeling inadequate, and hypersensitivity to negative evaluation

Indicated by 4 or more of the following 7:1. Avoid work or school activities involving significant

interpersonal contact because fear disapproval, criticism, or rejection

2. Resist getting involved with people without assurance that they will be liked and accepted without criticism

3. Are restrained in intimate relationships because fear being shamed or ridiculed


Continued:

4. Are preoccupied with being criticized or rejected in social situations (confirmatory bias)

5. Inhibited in new interpersonal situations due to feeling inadequate & having low self-esteem

6. See self as socially inept, unappealing, or inferior to others

7. Unusual reluctance to take personal risks or engage in any new activities because these may prove embarrassing


What it looks like:Feel inadequateLow self-esteemSocially incompetentWorry about being criticizedAvoid situations, activities, relationships, and people where there is any potential for them to be criticized, rejected, ridiculed, embarrassed, or disapproved of

AVOIDANT PERSONALITY DISORDERFacts & Figures: Prevalence: 0.5%-1.0% in general population Gender: equally frequent for men & women Course: avoidant/shy behavior often starts in infancy or

childhood & increases during adolescence & early adulthood Prognosis: modest improvements with treatment Need for caution with: (1) different cultural/ethnic groups; (2)

immigrants; (3) children & adolescentsCausal Factors: Parental rejection Sensitive temperamentTreatment: Behavioral interventions – systematic desensitization,

behavioral rehearsal, social skills & assertiveness training

DEPENDENT PERSONALITY DISORDER

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation.

Indicated by 5 or more of the following 8:1. Difficulty making everyday decisions without an

excessive amount of advice and reassurance from others.

2. Allow others to assume responsibility for major areas of his/her life.

3. Difficulty expressing disagreement with others because they fear losing support or approval.


4. Difficulty initiating projects or doing things on own because lack self confidence

5. Go to excessive lengths to obtain nurturance and support from others, e.g. volunteering to do things that are unpleasant

6. Feel uncomfortable or helpless when alone due to exaggerated fears of being unable to take care of self

7. Urgently seek another relationship as a source of care and support when a close relationship ends; become quickly & indiscriminately attached to people

8. Preoccupied with fears of being left to take care of self


What it looks like:Worry about being abandonedLack self-confidenceSubmissive, clingy, needyUrgency, desperation with relationship-seekingNeed for others to assume responsibility for themRely on others for almost everything:To take care of themTo do things for themTo make decisions for themTo support and nurture them

DEPENDENT PERSONALITY DISORDERFacts & Figures: Prevalence: 2%; one of the most frequently reported

personality disorders in mental health clinics Age & cultural factors need to be considered Gender: diagnosed more frequently in females; may be

equally prevalent for men & womenCauses: Disruption in early bonding/attachment due to early

death of a parent or neglect or rejection by caregiversTreatment: Long-term psychotherapy Assertiveness training, self-esteem work, skills building

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

A pervasive pattern of preoccupation with orderliness, perfectionism, and control, at the expense of flexibility, openness, and efficiency

Indicated by 4 or more of the following 8:1. So preoccupied with procedures, details, lists,

order, and schedules that the major point of the activity is lost.

2. Perfectionism interferes with task completion and causes significant dysfunction and distress.

3. Excessive devotion to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).


4. Excessively conscientious, scrupulous, and inflexible about matters of morality, ethics or values (not accounted for by cultural or religious identification)

5. Inability to discard worn-out or worthless objects, even when they have no sentimental value

6. Reluctance to delegate tasks or work to others unless they submit to exactly their way of doing things

7. Overly miserly and stingy with money: hoard money for future catastrophes

8. Rigidity and stubbornness


What it looks like:Controlling – have to have control over everything in their lifeBelieve they have to be perfect to be accepted by othersFollow rigid routines & become anxious when routines are disruptedOrderlyLose the forest for the treesInefficient at completing tasksWorkaholics – unable to delegateRigid morals & valuesPack ratsRigid and stubbornOverly frugal and stingy with money


Facts & Figures: Prevalence: 1-4% of community samples Gender: diagnosed twice as often among males Special considerations: individual’s reference groupTreatment Considerations: May seek Tx due to depression or slipping productivity Don’t like the loss of control inherent in therapy – tend to

counter by providing a detailed, orderly account of Sx & issues

Therapist needs to avoid competing with client to direct the session

Antidepressants may be helpful for underlying anxiety & depression

Cluster C Scenario

This individual is going to meet her boyfriend’s parents in another city for the first time.

Avoidant Personality Disorder

Cognitions Include:

Is it possible to get out of this?

They won’t approve of me.

They might be mean to me.

How could they ever like me?

Behaviors Include:Speaking very little around the familyAvoiding the situation altogetherTaking excessive measures to ensure that she is approved of (bringing luxurious gifts)

Dependent Personality Disorder

Cognitions Include:

What will I wear, do, say? (Followed by asking her boyfriend for input about this.)

I have to make sure they like me.

Behaviors Include:

Volunteering to babysit all the children while the adults go out to dinner

Sticking by her boyfriend’s side the entire time

Agreeing to everything the family suggests and with all the opinions they offer

Obsessive-Compulsive Personality Disorder

Cognitions Include:Everyone here is doing everything wrong. Distress about having to delegate work tasks while away, and about the dogsitter’s ability to perform tasks (or the babysitter’s…)

Behaviors Include:Planning out activities to fill the entire trip.Making extensive lists of things to bring but not packing until the last minute.Exhibiting a great deal of distress when conforming to others’ ways of doing things or being stubborn and ensuring that things are done her way.

Theories of Personality Disorders:

Family dynamics – growing up in a dysfunctional, abusive, invalidating, overprotective, controlling, or uncaring environment; poor parenting; parent-child relationship

Genetic Influences

Biological/biochemical Influences

Trauma & other significant experiences

Continuum model – personality disorders represent extreme variations of normal personality traits

Treatment for Personality DisordersLong-term supportive, structured psychotherapyDialectical Behavior Therapy (DBT) – accepting & validating client, setting limits, skills trainingCognitive Behavioral Therapy (CBT) – challenging maladaptive thoughts, beliefs, schemas; skills training; behavioral experimentationPsychodynamic/Object Relations Therapy – emphasis on transference, the effect of past relationships on the present, raising insightRelational/Interpersonal Therapy – using the therapeutic relationship and other significant relationships to foster growth, change, and healing

personality disorders: an enduring (long-standing) pattern in two or more of the following areas: 1)...

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