Personality Disorders

Definition = maladaptive ways of interacting

• *Rigid

• *Pervasive

• Common

• Ego syntonic

-> don’t seek tx

-> less motivated to change

“Medical Students’ Disease”

• Continuum of characteristics

• Disorder = greater degree & impairment

Course

• Originate in childhood & persists

Sex Differences

1.Histrionic, dependent = women

2.Current research: Either > in males or equal

• Males = Paranoid, Schizoid, Schizotypal, Antisocial, Narcissistic, Obsessive-compulsive

• Equal = Histrionic, Avoidant, Dependent

• Females = Borderline

Sex Bias: Ford & Widiger

• Histrionic/Antisocial case histories:

male diagnosed Antisocial PD

female diagnosed Histrionic PD

• Simple gender differences … bias

• But Histrionic PD may brand stereotypic women as mentally ill

• Categories vs. Dimensions– Currently, categories– Possible move to dimensions– Reduces stigma– Reflects actual clients

Cluster A: Odd, eccentric

Paranoid PD

= Excessively suspicious/mistrustful

Causes• Slight genetic evidence of link to schizophrenia• Cognitive errors• Parental teaching• Certain groups more susceptible

Treatment

• Only seek for crisis

• Therapist provides trust

(cognitive therapy for errors)

• No clear evidence of change

Schizoid PD

• Solitary, uninterested in others

• Not from fear

• But some are sensitive

• Extreme social deficiencies

• No unusual/bizarre thoughts

Causes - unknown

• Isolation resembles autism

-> maybe shared biological mechanism

Treatment

• Help develop interest in relationships

• Little optimism

Schizotypal PD

• Social isolation + unusual behaviors & thoughts

• Not full-blown hallucinations, but “as if”

Causes - little known

• Genetic link to schizophrenia

• Probable environmental stressors

Treatment

• Social skills to improve relationships

• Help adjust to solitary life

• Antipsychotics (but side effects)

Cluster B: Dramatic, emotional

Antisocial PD

• Disregard for social norms

• No remorse

• Substance abuse/sensation-seeking

• Age 18

Causesa) Genetic influence on nonviolent criminalityb) Neurobiology: NOT brain damage

i. Low cortical arousal- stimulation-seeking behaviors- slower brain waves/heart rateii. Fearlessness hypothesis- higher threshold for fear & worse atdetecting danger cuesiii. Inhibition vs. reward systems: weakinhibition & strong reward (BAS vs. BIS)

c) Aggression learned at home

- parents reward kid’s aggression

- inconsistent discipline

- low SES

Treatment

• Behavior dies down by age 40

• But difficult to treat

• Manipulate therapist

• Few positive outcomes

• Focus: childhood prevention via parent training

Borderline PD

*No sense of self• Instability in relationships -> fear abandonment• All-or-none thinking• Unstable moods• Poor self-image (“empty”)• Impulsive

Causes

• Possible genetics – mood disorders

• Childhood trauma

• Psychodynamic: Abandonment fears

poor separation/individuation from mom

Treatment

• Extremely difficult

• But: Linehan — help dev. identity

• Support/constancy, coping, identify & regulate emotions

• Medication (for depression & anxiety)

- poor compliance, abuse meds

Histrionic PD

• Dramatic, self-centered, shallow

• Singers, actors

Causes

• Learn appearance & performance-> attention

Treatment

• Focus on problematic relationships

• Reward for appropriate & fine for inappropriate/attention-getting behavior

Narcissistic PD

• Grandiose, exaggerated sense of own importance

• Preoccupation with gaining attention

• Lack sensitivity/compassion, exploit others

Causes

• Inadequate admiration from parents

• Damaged sense of self

• Grandiosity = façade

• Current society (“me,” instant gratification)

-> increases prevalence

Treatment: Cognitive

i. Replace grandiose fantasies

- attainable daily pleasures

ii. Coping with criticism

iii. Understand others’ feelings

iv. Treat depression

Cluster C: Anxious, fearful

Avoidant PD

• Extreme sensitivity to rejection

• Actively avoid relationships

• Low opinion of self

Causes

• May be more “difficult” infants

-> inadequate early unconditional positive regard

-> alienated & unworthy

Treatment - many good studies

• Behavioral therapy for anxiety & social skills problems

• Systematic desensitization for specific situations

Dependent PD

• Excessive reliance on others for everyday decisions

• Abandonment fears

• Submissive/agreeable to avoid rejection

Causes

• Childhood assertiveness punished

• Parental overprotection

• Early parental loss/rejection -> abandonment fears

Treatment - little research

• Appear to be ideal therapy clients

-> danger of over-dependence on therapist

• Develop independence & responsibility

Obsessive-Compulsive PD

• Preoccupation with the “right way”

• Inflexible, perfectionistic, rigid

• Relationships often poor

• Only distantly related to OCD

Causes

• Possible genetic basis, but weak

• Strong parental discipline & over-control

• No real understanding of causes

Treatment - little research

• Attack fears underlying perfectionism

• Deal with possible anxiety regarding inadequacy

• Relaxation/distraction

For all PDs, therapy involves

• Insight into how they affect other people & are perceived

• Insight into how their behavior causes them problems

Ethical Issues

Therapy with Personality Disorders

• Very resistant to treatment

• Rarely seek treatment on own

-> When is treatment justifiable?

Adopting a Potential Sociopath

• Strong genetic basis for APD/sociopathy

=> Should adoptive parents be told if child is offspring of sociopath?

=> Is revealing this information to prospective parents fair to the child?

Interpersonal Psychotherapy

Rationale

• General style of interacting

• Most are flexible

• In people with personality disorders, style is rigid & pervasive

• Goal of interpersonal psychotherapy

= help people be more flexible

Therapy

• Pull from usual part of circle to opposite

• Act in complementary manner to goal behavior

• Meta-communicate