Introduction to the Personality Disorders

Basic Concept of a Personality Disorder


Personality disorders (PDs) tend to be pervasive, life long disorders. People with PDs carry with them destructive patterns of thinking, feeling, and behaving as their way of being and interacting with the world and others. In order to be classified as a personality disorder the personality traits must be inflexible, be maladaptive and cause functional impairment or subjective distress. Onset begins in adolescence or early adulthood and is generally stable over time. They tend to be incredibly difficult to treat, in no small part because people with personality disorders often do not view themselves as actually having a problem, and they tend to frame reality in terms of their needs and perceptions, and are unable to understand the perspectives of others. For instance, most people with Narcissistic personality disorder are actually convinced they are as wonderful as they profess themselves to be. Similarly, people who suffer from schizophrenia see no problem with the fact that they do not like people, this to them is not a disorder, only a character trait. A person with antisocial personality disorder might resist treatment because they see the psychologist as trying to gain dominance over them, viewing it as if the psychologist is trying to change them to be submissive, weak and pathetic like the way they view the psychologist has. On the other hand they may even think that the psychologist really is trying to help, but is simply confused about the harsh and cruel nature of reality. Another reason for why they are difficult to treat include their limited ability to receive, accept, or benefit from corrective feedback. Another difficulty during treatment is the strong counter-transference clinicians have while working with them.

People with PDs are also often fully mentally functional. Though their views of reality may be distorted or odd, this is not due to impairment in mental function. Many people at the top of corporations, for example the CEOs of Enron, could easily be diagnosed with antisocial PD. In this way, the PDs tend to be seen somewhat differently than the other 'mental disorders' instead is seen as a deficit. Those with PDs, it is quite literally a change in the nature of the cognition, rather than a reduction in the potency thereof, and due to this, treatment can be difficult. It is also different from those with mood disorders where the person is usually not as resistant to treatment. People with PD often have strong wills and ideas, and the intelligence to back up what they experience and rationalize it.

Also due to these traits, people do not often bring themselves in for treatment for personality disorders. People with personality disorders tend to be either court-ordered to attend therapy, as is often the case with antisocial personality disorder or borderline personality disorder. Those who are treated may be pushed into it by family and friends, which is the case more often in paranoid personality disorder or dependent personality disorder. This is very different from the anxiety or mood disorders, where the person quite often attends therapy in order to see an increase in the quality of their life. There are also very few, if any PDs that seem to respond well to pharmaceutical treatment in fact, there does not seem to be many treatments at all that seem to work well for this spectrum of disorders and each person suffering from them is not the same as the next. Prevalence rates for PD is about 10-15% of the general population, along with 50% in clinical settings and 50% in the inmate population meet the criteria for ASPD, Antisocial Personality Disorder.

The presence of other mental disorders, such as mood, anxiety, and psychotic disorders can worsen the course and severity of Personality Disorders. People with any one of the 10 Personality Disorders are at an increased likelihood of being diagnosed with another Personality Disorder. In clinical practice, clients will often have more than one PD and might have features of many (Substance Abuse and Mental Health Services Administration (SAMHSA), 2009).

Finally, the PDs are broken up into 3 clusters, named simply Cluster A, B and C. Cluster A focuses on the odd or eccentric disorders, cluster B focuses on the dramatic, emotional and erratic disorders and Cluster C focuses on the anxious and fearful disorders. The clusters are defined as follows:

Cluster A
Paranoid, Schizotypal, and Schiziod Personality Disorders
This cluster includes the "odd" or eccentric" disorders. Those who suffer from the Cluster A disorders may act socially detached, suspicious, and distrustful. These disorders are the closest PDs to the stereotypical psychiatric disorders: the psychotic disorders. With cluster A we see very odd behaviors, and a distinct separation from reality. However, this is not occurring on a sensory level as can be seen in the psychotic disorders. The schism (meaning break or gap, from which schizophrenia, schizotypal and schizoid got their name) from reality occurs on a cognitive level. In each of the Cluster A disorders, the nature of the separation is different. In Paranoia, where the person experiences delusions and is a generalized separation, the nature of the world itself (the fact that it is incredibly unlikely anyone cares enough to do anything to the paranoid person) is at a distance from the sufferer.

In Schizoid PD, the person is isolated from both enjoyment, and sociability. In Schizophrenia, the chasm, or breach, that must be crossed is to reality itself. Understanding of the rules of nature, or of social rules seems to be very difficult, but unlike in Schizoid PD, the desire to interact is there, and unlike Paranoid PD, people suffering from Schizophrenia do not have the anxieties or fears of the world or people in it.

Schizoid vs Schizotypal Personality Disorders
  • The major reason for the distinction is the relationship between schizotypal personality and schizophrenia.
  • There is a much higher prevalence of schizophrenia among first degree relatives of patients with schizotypal personality than among relatives of people with any other personality disorder.
  • Thinking is more distorted and closer to psychosis in schizotypal personality than in schizoid personality
  • Patients with schizoid personality disorder are more likely to seek therapy
  • Patients with schizotypal personality disorder are less likely to seek therapy, but are more likely to find a group of eccentrics who have similar beliefs.

Cluster B
Histrionic, Narcissistic, Antisocial, and Borderline Personality Disorder.

This cluster includes disorders where the individual is viewed as being overly emotional or erratic in his or her behavior. The individual's behavior tends to be impulsive, may be dramatic, and may have antisocial features. People who suffer from Narcissism for example tend to have excessive amounts of vanity, fascination with themselves, above and beyond egocentrism. Antisocial personality disorder sufferers have an unusual disregard for others, including others rights and feelings. They may show no remorse for their actions, such as, hurting others and stealing. Unfortunately it is difficult to diagnose due to substance abuse is some situations. Borderline Personality Disorder is called such because it is close to being considered a psychiatric disorder. This disorder is characterized by extreme mood swings, impulsiveness and aggression.

Characteristics of People with Antisocial and Borderline Personality Disorders (SAMHSA, 2009)
Characteristic
Antisocial
Borderline
Affect
Angry intimidation
Angry self-harm
World View
If you don't do what I want, you'll be sorry
I deserve it all
They're the ones with the problem
I've got to get you before you get me
I don't deserve to exist
Help me, help me, but you can't
Presenting Problem
Legal difficulties
polysubstance abuse
dependence
parasitic relationships
Self-harm
impulsive behavior
episodic polysubstance abuse
hot-and-cold relationships
Social Functioning
Episodic achievement
Gross dysfunctioning
Motivation
Self-esteem
Safety
Defenses
rationalization
projection
splitting
projection


















Cluster C
Avoidant, Dependent, and Obsessive-Compulsive Personality Disorder.

This cluster includes the disorders where the individual appears anxious or fearful. In this specific instance, these disorders resemble Anxiety Disorders, which make it harder to differentially diagnose. These disorders are pretty much self explanatory in there title. Avoidant is just that, a tendency to avoid intimacy or interaction with others. Dependent is dependent on others and Obsessive-compulsive disorder, where the person repeats the same everyday activities repeatedly, has lack of openness and flexibility in their everyday functions and relationships. Fortunately this is highly treatable but not easily done, these people tend to dislike describing the events and situations that occur in their lives.

Some Statistics Regarding Personality Disorders
  • Personality disorders affect about 15 million adults in the United States. Approximately 10 to 13 percent of the U.S. population meets the diagnostic criteria for a personality disorder at some point in his or her life. These disorders, however, have the highest rate of misdiagnosis than any other categories. Personality disorders present themselves as being a maladaptive presence, meaning they develop highly unsuitably adaptive symptoms in the lives of those affected. Most people can live relatively normal lives with mild personality disorders, however in times of extreme stress, symptoms can increase and become disruptive in everyday activities.
  • The DSM-IV-TR defines a personality disorder as "...an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment... The clinician should assess the stability of personality traits over time and across different situations."
  • Personality disorders are usually only diagnosed for person's over the age 18. There is the exception that if the individual shows symptoms for at least, or above, 1 year then they can be diagnosed. As noted below, however, minors cannot be diagnosed with antisocial personality disorder.
  • 35% of admissions to a methadone maintenance program have a Personality Disorder (SAMHSA, 2009).

General diagnostic criteria for a Personality Disorder according to the DSM-IV-TR
  • An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:
    1. cognition (the ways of perceiving and interpreting self, other people, and events)
    2. affectivity (the range, intensity, ability, and appropriateness of emotional response)
    3. interpersonal functioning
    4. impulse control
  • The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
  • The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The pattern is stable and continues for long durations, and its onset can be traced back to as far as adolescence or early adulthood.
  • The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
  • The enduring pattern is not due to the direct physiological effects of a substance (e.g., drug abuse, medication) or a general medical condition (e.g., head trauma).

DSM-V Changes
  • The work group recommends a major re-conceptualization of personality psychopathology with core impairments in personality functioning, pathological personality traits, and prominent pathological personality types. Personality disorders are diagnosed when core impairments and pathological traits are severe and other criteria are met. The criteria are as follows:
    • 5 identified severity levels of personality functioning
    • 5 personality disorder types, each defined by core PD components and a subset of:
      • 6 broad, higher order personality trait domains, with 4-10 lower order, more specific trait facets comprising each, for a total of 37 specific trait facets
    • a new general definition of personality disorder based on severe or extreme deficits in core components of personality functioning and elevated pathological traits
  • New general definition
    • Adaptive failure is manifested in one or both of the following area
      • Impaired sense of self-identity as evidence by one or more of the following:
        1. Identity integration. Poorly integrated sense of self or identity (e.g., limited sense of personal unity and continuity; experiences shifting self-states; believes that the self presented to the world is a false appearance)
        2. Integrity of self-concept. Impoverished and poorly differentiated sense of self or identity (e.g., difficulty identifying and describing self attributes; sense of inner emptiness; poorly defined interpersonal boundaries; definition of the self changes with social context)
        3. Self-directedness. Low self-directedness (e.g., unable to set and attain satisfying and rewarding personal goals; lacks direction, meaning, and purpose in life)
      • Failure to develop effective interpersonal functioning as manifested by one or more of the following:
        1. Empathy. Impaired empathic and reflective capacity (e.g., finds it difficult to understand the mental states of others)
        2. Intimacy. Impaired capacity for close relationships (e.g., unable to establish or maintain closeness and intimacy; inability to function as an effective attachment figure; inability to establish and maintain relationships)
        3. Cooperativeness. Failure to develop the capacity for pro-social behavior (e.g., failure to develop the capacity for socially typical moral behavior; absence of altruism, the sense of unselfish concern).
        4. Complexity and integration of representations of others. Poorly integrated representations of others (e.g., forms separate and poorly related images of significant others)
    • Adaptive failure:
      • is associated with extreme levels of one or more personality traits.
      • is relatively stable across time and consistent across situations with an onset that can be traced back to adolescence.
      • is not solely explained as a manifestation or consequence of another mental disorder
      • is not solely due to the direct physiological effects of a substance (e.g., drug abuse, medication) or a general medical condition (e.g., severe head trauma)

(American Psychiatric Association (APA), 2010)

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301.0 Paranoid Personality Disorder


Definition and Associated Features

  • Paranoid personality disorder (PPD) is characterized by an extreme level of distrust and suspicion of others; unjustified feelings of suspicion and mistrust of others, hyper sensitivity, expectation - without justification -that will be damaged and exploited by others and a tendency to find hidden meanings messages and comments that are in reality harmless behaviors as degrading or threatening. People with PPD often interpret even friendly gestures as manipulative or malevolent. They are often difficult to get along with, as they can be confrontational and aggressive; therefore, they generally lack close relationships with other people because they are constantly waiting for negative outcomes such as betrayal. As a result of others reacting negatively to their hostility, their negative expectations are often confirmed; for example, they may suspect that their neighbor takes the garbage out early in the morning just to bother them.
  • People who suffer with PPD do not only suspect strangers, but people they know as well, they believe those they know are planning to harm or exploit them without evidence to support their suspicions. If a person with PPD does form a close relationship, the relationship is often accompanied by jealousy and controlling tendencies. These individuals typically do not have psychotic features, that is, they are in clear contact with reality and usually do not experience hallucinations. They may also have less cognitive disorganization, therefore they are able to function socially in the work environment, although somewhat effectively as the rest of society.
  • When people with PPD suspect exploitation, harm, or deceit, it is almost always associated with friends or close partners because these are the people they are near the most. For example: They may suspect their spouse or partner is involved in an affair. This is where loyalty and trust issues come in, They are reluctant to give out any information that will hurt them or be used to put them down in any way, so they tend to keep secrets from those who are close to them because of a paranoid idea they will be harmed in the process.
  • Since they have trouble with trusting others, people with PPD have an excessive sense of self-sufficiency and autonomy. They are often rigid, unable to collaborate, and often have difficulty accepting criticism and instead blame others for their shortcomings. They may frequently be involved in legal disputes because of their tendency to counterattack in response to perceived threats. Sometimes PPD may appear antecedent of Delusional Disorder or Schizophrenia. Those with PPD may develop Major Depressive Disorder, and Substance Abuse or Dependence is frequent.
  • Individuals who have PPD typically do not have psychotic features, that is, they are clearly in contact with reality, and they usually do not have hallucinations. However, they may experience brief psychotic episodes in response to stress. The important thing to remember is that these individuals do not have Schizophrenia, Paranoid Type because they do not have hallucinations, and their cognitive disorganization, typical of the Schizophrenias, is not present. In addition, they are able to function socially and in the workplace, although their functioning is affected by this disorder. These individuals are always guarded and alert for attacks from other people in areas of employment, social areas and home life.




















DSM-IV-TR Criteria
  • Defined as stated above. This can begin by early adulthood and present in a variety of contexts, as indicated by four (or more) of the items listed below.
    1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
    2. Preoccupied with unjustified doubts about the loyalty or trustworthiness of friends, family or associates.
    3. Reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
    4. Reads hidden demeaning or threatening meanings into benign remarks or events.
    5. Persistently bears grudges, because they are unforgiving of insults, injuries, or practical jokes.
    6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
    7. Has recurrent suspicions, without justification, regarding fidelity of spouse or partner.
  • Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, or another Psychotic Disorder and is not due to the direct physiological effect of a general medical condition.
    • NOTE: If criteria are met prior to the onset of Schizophrenia, add "Pre-morbid," e.g., "Paranoid Personality Disorder (Pre-morbid)".

Child vs. Adult Presentation
  • According to the DSM-IV-TR, there are a few exceptions noting personality disorders are not generally diagnosed in individuals under the age 18. If the symptoms or behaviors, sometimes called features, have been present for at least 1 year, then the individual can be diagnosed with a personality disorder if he or she is less than 18 years of age.
  • Signs of Paranoid personality disorder can be seen in childhood, seen as having poor relationships, not doing well in school, odd thoughts, social anxiety, solitariness, hypersensitivity, and they may seen as "odd" or "eccentric" by others and as a result may attract teasing by other children.

Gender Differences in Presentation of Disorders

  • Paranoid Personality Disorder affects more males than females and contains a few co-morbid disorders. Co-morbidity often occurs with Schizophrenia, Avoidant, and Borderline Personality Disorders.
  • Females are generally more associated with the disorders of Borderline, Histrionic, and Dependent.
  • Males are generally more associated with the disorders of Paranoid, Schizophrenia, and Antisocial.
  • Diagnosis for males and females are also different even if both present the same symptoms.
  • Females are also more apt to seek help than males because they are more willing to acknowledge the symptoms, acknowledge the need for help, and are more influenced by their social group to seek help.

Cultural Differences in Presentation
  • Most of the disorders listed and reviewed are Caucasian based. However for different cultural groups, symptoms and treatment may not be the same.
  • Some behaviors influenced by culture or life circumstances may be mistaken for Paranoia. Members of minority groups, immigrants, refugees, or those of different ethnic backgrounds may be guarded or defensive because of unfamiliarity or perceived as neglect by the majority society. These behaviors may produce anger in those who deal with these individuals, thus setting up a mutual mistrust, which would not be Paranoid Personality Disorder.

Epidemiology
  • The lifetime prevalence of Paranoid Personality Disorder is 0.5% to 2.5% of the general population. An increased prevalence of Paranoid Personality Disorder has a biological connection to relatives of chronic sufferers of schizophrenia and patients with persecutory delusional disorders, which is the presence of persistent delusions.
  • The prevalence rate for inpatient psychiatric hospitals is 10%-30%. Anywhere from 2% to 10% of patients in an outpatient treatment facility are also affected.
  • One study has found that 44% of those in treatment for alcoholism have Paranoid Personality Disorder, while other studies have only found it to be around 13.2% (SAMHSA, 2009).

Etiology
  • The cause of Paranoid Personality Disorder is unknown, although there are some theories that it may be due to negative childhood experiences in a threatening domestic atmosphere or caretakers having PPD
    • In their childhood there was no way of predicting or escaping their environment; therefore, they develop paranoid ways of thinking in order to cope with the stressful situations.
  • In addition, the incidence of PPD appears to be increased in families with a member who suffer from Schizophrenia.
    • Having a familial factor means that they are more likely to get the disorder because it was in the family genetics, thus having a higher chance of developing the disorder rather than someone whose family has a no known genetic disorders.
  • The developmental path of PPD predominantly involves environmental responses of criticism, blame, and hostility. Studies have linked this diagnosis to caregivers who treated the individual with PPD in a sadistic, degrading, or humiliating manner, imposing the belief that he or she was fundamentally bad. A process that restricts the individual's ability to trust, leads to an anxious withdraw from interactions that are later compensated for with rage and peremptory behaviors seeking to protect the individual from impending harm.
  • Promotes belief that hateful criticism or abuse may result from interpersonal interactions. Leads to withdrawal from such interactions that may later be compensated for with rage.
  • According to the Encyclopedia of Mental Disorders, other possible interpersonal causes have been proposed. For example, some therapists believe that the behavior that characterizes PPD might be learned and might be traced back to childhood experiences. According to this view, children who are exposed to adult anger and rage with no way to predict the outbursts and no way to escape or control them develop paranoid ways of thinking in an effort to cope with the stress. PPD would emerge when this type of thinking becomes part of the individual's personality as adulthood approaches.
  • Studies of identical (or monozygotic) and fraternal (or dizygotic) twins suggest that genetic factors may also play an important role in causing the disorder. Twin studies indicate that genes contribute to the development of childhood personality disorders, including PPD. Furthermore, estimates of the degree of genetic contribution to the development of childhood personality disorders are similar to estimates of the genetic contribution to adult versions of the disorders.

Medications:
  • While individual supportive psychotherapy is the treatment of choice for PPD, medications are sometimes used on a limited basis to treat related symptoms. If, for example, the patient is very anxious, anti-anxiety drugs may be prescribed. In addition, during periods of extreme agitation and high stress that produce delusional states, the patient may be given low doses of antipsychotic medications.
  • Some clinicians have suggested that low doses of neuroleptics should be used in this group of patients; however, medications are not normally part of long-term treatment for PPD. One reason is that no medication has been proven to relieve effectively the long-term symptoms of the disorder, although the selective serotonin reuptake inhibitors such as fluoxetine (Prozac) have been reported to make patients less angry, irritable and suspicious. Antidepressants may even make symptoms worse.
  • A second reason is that people with PPD are suspicious of medications.They fear that others might try to control them through the use of drugs. It can therefore be very difficult to persuade them to take medications unless the potential for relief from another threat, such as extreme anxiety, makes the medications seem relatively appealing. The best use of medication may be for specific complaints, when the patient trusts the therapist enough to ask for relief from particular symptoms.

Prognosis
  • Paranoid personality disorder is often a chronic, lifelong condition; the long-term prognosis is usually not encouraging. Feelings of paranoia, however, can be controlled to a degree with successful therapy. Unfortunately, many patients suffer the major symptoms of the disorder throughout their lives.

Prevention
  • With little or no understanding of the cause of PPD, it is not possible to prevent the disorder.

Empirically Supported Treatments
  • Because those with PPD are very suspicious and untrustworthy of others, they are generally not likely to seek therapy on their own. Often, the legal system or the family of the person suffering from this disorder gets involved and encourages the person to seek treatment. However, it is extremely difficult to begin treatment with the person, as the therapist has to gain the trust of the patient.
  • The most successful form of treatment for this disorder is psychotherapy, which can be used to help the patient control his paranoid thoughts. Medications are sometimes used to treat related symptoms, such as anxiety or delusional states that some people with PPD suffer when under stress.
  • Some clinicians suggest that low doses of neuroleptics should be used for short-term treatment of PPD. Antidepressants such as Prozac have been reported to make symptoms of PPD worse and people with PPD are often suspicious of medication and believe that others might try to control them through drugs. Although psychotherapy and medication can temporarily control symptoms of PPD, most patients experience the symptoms of PPD for their entire life and require consistent therapy in order to manage their paranoia.

Psychotherapy

  • According to the Encyclopedia of Mental Disorders, the primary approach to treatment for such personality disorders as PPD is psychotherapy . The problem is that patients with PPD do not readily offer therapists the trust that is needed for successful treatment. As a result, it has been difficult to gather data that would indicate what kind of psychotherapy would work best. Therapists face the challenge of developing rapport with someone who is, by the nature of his personality disorder, distrustful and suspicious; someone who often sees malicious intent in the innocuous actions and statements of others. The patient may actively resist or refuse to cooperate with others who are trying to help.
  • Mental health workers treating patients with PPD must guard against any show of hostility on their part in response to hostility from the patient, which is a common occurrence in people with this disorder. Instead, clinicians are advised to develop trust by persistently demonstrating a nonjudgmental attitude and a professional desire to assist the patient.
  • It is usually up to the therapist alone to overcome a patient's resistance. Group therapy that includes family members or other psychiatric patients, not surprisingly, isn't useful in the treatment of PPD due to the mistrust people with PPD feel towards others. This characteristic also explains why there are no significant self-help groups dedicated to recovery from this disorder. It has been suggested, however, that some people with PPD might join cults or extremist groups whose members might share their suspicions.
  • To gain the trust of PPD patients, therapists must be careful to hide as little as possible from their patients. This transparency should include note taking; details of administrative tasks concerning the patient; correspondence; and medications. Any indication of what the patient would consider "deception" or covert operation can, and often does, lead the patient to drop out of treatment. Patients with paranoid tendencies often don't have a well-developed sense of humor; those who must interact with people with PPD probably should not make jokes in their presence. Attempts at humor may seem like ridicule to people who feel so easily threatened.
  • With some patients, the most attainable goal may be to help them to learn to analyze their problems in dealing with other people. This approach amounts to supportive therapy and is preferable to psychotherapeutic approaches that attempt to analyze the patient's motivations and possible sources of paranoid traits. Asking about a patient's past can undermine the treatment of PPD patients. Concentrating on the specific issues that are troubling the patient with PPD is usually the wisest course.
  • With time and a skilled therapist, the patient with PPD who remains in therapy may develop a measure of trust. But as the patient reveals more of his paranoid thoughts, the clinician will continue to face the difficult task of balancing the need for objectivity about the paranoid ideas and the maintenance of a good rapport with the patient. The therapist thus walks a tightrope with this type of patient. If the therapist is not straightforward enough, the patient may feel deceived. If the therapist challenges paranoid thoughts too directly, the patient will be threatened and probably drop out of treatment.

Portrayed in Popular Culture
  • George from Seinfeld
    • He is characterized by irrational suspicions and mistrust of others
  • Cornelius Fudge from Harry Potter
    • He irrationally fears that Albus Dumbledore, and just about anybody, is trying to overthrow him as the Minister of Magic

DSM-V Changes

(APA, 2010)

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301.20 Schizoid Personality Disorder

















DSM-IV-TR criteria
  • A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
    1. neither desires nor enjoys close relationships, including being part of a family
    2. almost always chooses solitary activities
    3. has little, if any, interest in having sexual experiences with another person
    4. takes pleasures in few, if any, activities
    5. lacks close friends or confidants other than first-degree relatives
    6. appears indifferent to the praise or criticism of others
    7. shows emotional coldness, detachment, or flattened affectivity
  • Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to the direct physiological effects of a general medical condition.
  • NOTE: If criteria are met prior to the onset of Schizophrenia, add "Pre-morbid," e.g., "Schizoid Personality Disorder (Pre-morbid)."

Associated Features
  • Individuals with Schizoid Personality Disorder (SPD) have little to no contact with the outside world. They have no desire to have social relationships, and when they do have them they do not enjoy them. This is a reason that they have few to no friends and to others these individuals seem to be cold and distant, often displaying a stoic expression. They are rarely able to express their emotion and often fail to have warm feelings for anyone. They have little to no interest in sexual activity and have very few things in their lives that give them pleasure. They tend to be loners and pursue activities and occupations where they do not have to interact with people.
  • There is highest Co-morbidity for Schizotypal, Avoidant, and Paranoid Personality Disorders. Thus, is it most likely that another Cluster A disorder will occur with SPD. Anhedonia is often expressed, that is a an inability to experience pleasure and joy in activities and life. People that suffer from SPD tend to show long-standing patterns of behaviors that are abnormal to their environmental norms. They may experience brief psychotic episodes resulting from stress. SPD may appear as a precursor to Delusional Disorder or Schizophrenia, and those with SPD may develop Major Depressive Disorder.
  • The person may have a stoic look most of the day and not respond to any comments or jokes; they just keep to their self and do what they want to do alone. They are somewhat shy of others, not knowing what is going to happen next.

Child vs. Adult Presentation
  • Typically, the onset of SPD is in early adulthood or late adolescence were the symptoms can be seen. These would include performing badly in school, self-isolation, and bad relationships with their peers.
  • The symptoms that are needed for diagnosing SPD need to be shown by early adulthood. The earlier this is found, the better, because it will be more difficult to treat once the person gets older.
  • One issue that is known is the similarity between SPD, autism and Asperger's disorder. It is important to know that the personality traits of SPD are inflexible and cause impairment in functioning

Gender and Cultural Differences in Presentation
  • More males are affected by Schizoid PD than females. The disorder is uncommon in clinical settings because individuals with SPD do not perceive themselves as distressed and, therefore, are not inclined to seek out treatment. They see themselves as normal, but not when they interact with others; they do not know what to expect from other people they have not met because they are socially inclined to be quiet and conserved of mysterious people.
  • SPD may be more prevalent in individuals with schizophrenic or schizotypal relatives.
  • Those from a variety of cultural backgrounds may sometimes exhibit defensive behavior and styles which may be mistaken as schizoid.
  • Immigrants are sometimes mistaken as cold, hostile, or indifferent.

Epidemiology
  • Schizoid Personality disorder has a prevalence rates in the general population between 1% and 3% and prevalence in an outpatient psychiatric setting around 1%. There is some familial patterns but none that are very significant in general settings.
  • This is the least diagnosed personality disorder in the general population, and is uncommon in clinical settings.
  • The diagnosis is based on a clinical interview to assess symptomatic behavior. Other assessment tools that are helpful in diagnosing Schizoid Personality Disorder include:
    • Minnesota Multiphasic Personality Inventory (MMPI-2)
    • Millon Clinical Multiaxial Inventory (MCMI-II)
    • Rorschach Psychodiagnostic Test
    • Thematic Apperception Test (TAT)
Etiology
  • SPD shares many commonalities of depression, Avoidant Personality Disorder and Asperger’s syndrome and can be difficult to distinguish from the others because of some of the same symptoms and behaviors that are displayed in the other disorders.
  • Family life seems to be the underlying cause of Schizoid PD. These families are reserved emotionally, have impersonal communication, and are very formal. The parents often did not give very much attention to the person while they were growing up. This occurring in the first year of their lives, seems to have an impact on their lack of wanting to form close relationships because these children did not learn the necessary skills needed to form and maintain close relationships.
  • Schizoid Personality Disorder may have increased prevalence in the relatives of those with Schizophrenia and Schizotypal Personality Disorder.

Empirically Supported Treatments
  • Individuals with Schizoid PD do not usually seek out treatment because they generally do not feel as if they are in need of help, like some of the other disorders; they think they are pretty normal individuals with normal lives but need an intervention by a friend to reveal that the behavior is problematic. When they realize, for the few who do seek treatment, there are medications that treat only the negative symptoms, similar to those persons with schizophrenia.
  • Psychodynamically oriented therapies:
    • A psychodynamic approach would typically not be the first choice of treatment due to the patient's poor ability to explore his or her thoughts, emotions, and behavior. When this treatment is used, it usually centers around building a therapeutic relationship with the patient that can act as a model for use in other relationships.
  • Cognitive-behavioral therapy:
    • Attempting to cognitively restructure the patient's thoughts can enhance self-insight. Constructive ways of accomplishing this would include concrete assignments such as keeping daily records of problematic behaviors or thoughts. Another helpful method can be teaching social skills through role-playing. This might enable individuals to become more conscious of communication cues given by others and sensitize them to others' needs.
  • Group therapy:
    • may provide the patient with a socializing experience that exposes them to feedback from others in a safe, controlled environment. It can also provide a means of learning and practicing social skills in which they are deficient. Since the patient usually avoids social contact, timing of group therapy is of particular importance. It is best to develop first a therapeutic relationship between therapist and patient before starting a group therapy treatment.
  • Family and marital therapy:
    • It is unlikely that a person with schizoid personality disorder will seek family therapy or marital therapy. If pursued, it is usually on the initiative of the spouse or other family member. Many people with this disorder do not marry and end up living with and are dependent upon first-degree family members. In this case, therapy may be recommended for family members to educate them on aspects of change or ways to facilitate communication. Marital therapy (also called couples therapy ) may focus on helping the couple to become more involved in each other's lives or improve communication patterns (minddisorders.com).

Medications
  • Some patients with this disorder show signs of anxiety and depression which may prompt the use of medication to counteract these symptoms. In general, there is to date no definitive medication that is used to treat schizoid symptoms.

Prognosis
  • Since a person with schizoid personality disorder seeks to be isolated from others, which includes those who might provide treatment, there is only a slight chance that most patients will seek help on their own initiative. Those who do may stop treatment prematurely because of their difficulty maintaining a relationship with the professional or their lack of motivation for change.
  • If the degree of social impairment is mild, treatment might succeed if its focus is on maintenance of relationships related to the patient's employment. The patient's need to support him- or herself financially can act as a higher incentive for pursuit of treatment outcomes.
  • Once treatment ends, it is highly likely the patient will relapse into a lifestyle of social isolation similar to that before treatment.

Prevention
  • Since schizoid personality disorder originates in the patient's family of origin, the only known preventative measure is a nurturing, emotionally stimulating and expressive care-taking environment

Portrayed in Popular Culture
  • Mr. Freeze from Batman
    • Due to a long-time search for a cure for his wife's malady, he is an emotionless machine.
  • Severus Snape from Harry Potter
    • He rarely expresses emotions and usually stays in his office or in the Potions chamber away from the company of others

DSM-V Changes
(APA, 2010)

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301.22 Schizotypal Personality Disorder


















DSM-IV-TR criteria
  • A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
    1. ideas of reference (excluding delusions of reference)
    2. odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstition, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations)
    3. unusual perceptual experiences, including bodily illusions
    4. odd thinking and speech (e.g., vague, circumstantial, metaphorical, over elaborate, or stereotyped)
    5. suspicious or paranoid idealization
    6. inappropriate or constricted affect
    7. behavior or appearance that is odd, eccentric, or peculiar
    8. lack of close friends or confidants other than first-degree relatives
    9. excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self
  • Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder.
  • NOTE: If criteria are met prior to the onset of Schizophrenia, add "Pre-morbid," e.g., "Schizotypal Personality Disorder (Pre-morbid)."

Associated Features
  • The speech of individuals with this disorder is affected in such a manner that it may be distinguished by unclear and unusual usages. Language is impaired by different contexts and syntax, or the arrangement of words and how they are used, in other words the grammer. Schizotypal behavior is often linked to individuals with Schizophrenia. They tend to appear emotionless, showing flat or constricted affect in interpersonal situations.
  • Schizotypal PD is difficult to accurately diagnose because it is highly co-morbid with several personality disorders, such as: Narcissistic, Borderline, Avoidant, Paranoid, and Schizoid PD. Individuals with this disorder may experience brief psychotic episodes in response to stress. They often seek treatment for anxiety, depression, or other dysphoric symptoms rather than for the actual disorder.
  • The schizotypal individual has unusual thought patterns that end up disrupting their ability to communicate clearly with others. In addition, his or her ties to reality are impacted but not completely severed as in Schizophrenia. Because of this, many of these individuals are not able to realize their potential and are unable to lead truly productive lives.
  • Symptoms pointing to Brief Psychotic Disorder, Schizophreniform Disorder, Delusional Disorder, or Schizophrenia may develop in clinical settings. Over half may have a Major Depressive Episode.

Child vs. Adult Presentation
  • Schizotypal Personality Disorder may be first apparent in childhood and adolescence with solitude-seeking behavior, poor peer relationships, social anxiety, underachievement in academics, hypersensitivity, odd thoughts and speech, and bizarre fantasies.
  • As adults, presentation is similar but probably less severe such as less solitary activities because of boredom onset, and peer relationships are essential to advance in a life, such as with careers, friends and family.

Gender and Cultural Differences in Presentation
  • Generally more males are affected by Schizotypal Personality Disorder than females. Presentation in different cultural aspects do favor males as more Schizotypal affected than females probably because of a tendency for females to relate or talk to others enabling them to make relationships easier.
  • Females are more social and emotional than males in general, and they have the tendency to communicate more information to other people and to be more open about their feelings and emotions. Males tend to be more closed off and only share private information to those they trust the most.
  • Some distortions must be evaluated within the individuals cultural context, as some cultural characteristics may be mistaken as schizotypal.

Epidemiology
  • The prevalence of Schizotypal Personality Disorder is approximately 3% of the general population and is believed to occur slightly more often in males.
  • Approximately less than 1% in an outpatient clinical sample.
  • The course is rather stable, and only a small portion go on to develop Schizophrenia or another Psychotic Disorder.
  • Schizotypal Personality Disorder is generally stable across an individual's life.
  • Schizotypal Personality Disorder appears to occur more frequently in individuals who have an immediate family member with schizophrenia .

Etiology
  • There is a chance that genetic factors contribute to the cause of Schizotypal Personality Disorder. Familial patterns are not major here but can be more likely to contract the disorder if it is prevelant in the family genetics.
  • Environmental factors are less likely to contribute to this disorder than interpersonal factors because of interactions with people are social activities and may involve suspicion of others, odd beliefs and weird thinking, unusual perceptions or distortions of reality.
  • Oddities in children with STPD are reinforced when they are shunned and rejected by others, thus increasing their social anxiety and suspicion.
  • An alternative pathogenic hypothesis suggests that the child was severely abused, limited in autonomy development and peer interactions while caregivers modeled illogical formulations of reality, leading the adult with STPD to claim an unusual ability of knowing or controlling events combined with paranoid withdrawal from others.
  • Other hypotheses suggest that the infant's needs were met, but without sufficient emotional intimacy or warmth. Which hindered subsequent childhood development by punitive criticism, fragmented communications, and humiliation by peers.
  • The diagnosis of schizotypal personality disorder is based on a clinical interview to assess symptomatic behavior. Other assessment tools helpful in confirming the diagnosis of schizotypal personality disorder include:
    • Minnesota Multiphasic Personality Inventory (MMPI-2)
    • Millon Clinical Multiaxial Inventory (MCMI-II)
    • Rorschach Psychodiagnostic Test
    • Thematic Apperception Test (TAT)

Empirically Supported Treatments
  • Individuals with Schizotypal Personality Disorder are generally difficult to treat, as they are not comfortable with forming new relationships and interacting with others (ie. psychologists). They want to keep to themselves and not develop new close friends, or even have communication on a regular basis with family members. They would rather stay inside all day and be alone.
  • For individuals that have a little bit of higher functioning compared to other Schizotypal individuals, there are various treatment options. Provided these individuals see that they have a problem and seek treatment. One option is psychodynamic oriented therapies. This helps the individual build trusting relationships. Therapies include:
  • Psychodynamically oriented therapies
    • A psychodynamic approach would typically seek to build a therapeutically trusting relationship that attempts to counter the mistrust most people with this disorder intrinsically hold. The hope is that some degree of attachment in a therapeutic relationship could be generalized to other relationships. Offering interpretations about the patient's behavior will not typically be helpful. More highly functioning schizotypals who have some capacity for empathy and emotional warmth tend to have better outcomes in psychodynamic approaches to treatment.
  • Cognitive-behavioral therapy:
    • Cognitive approaches will most likely focus on attempting to identify and alter the content of the schizotypal's thoughts. Distortions that occur in both perception and thought processes would be addressed. An important foundation for this work would be the establishment of a trusting therapeutic relationship. This would relax some of the social anxiety felt in most interpersonal relationships and allow for some exploration of the thought processes. Constructive ways of accomplishing this might include communication skills training, the use of videotape feedback to help the affected person perceive his or her behavior and appearance objectively, and practical suggestions about personal hygiene, employment, among others.
  • Interpersonal therapy:
    • Treatment using an interpersonal approach would allow the individual with schizotypal personality disorder to remain relationally distant while he or she "warms up" to the therapist. Gradually the therapist would hope to engage the patient after becoming "safe" through lack of coercion. The goal would be to develop trust in order to help the patient gain insight into the distorted and magical thinking that dominates. New self-talk can be introduced to help orient the individual to reality-based experience. The therapist can mirror this objectivity to the patient.
  • Group therapy:
    • may provide the patient with a socializing experience that exposes them to feedback from others in a safe, controlled environment. It is typically recommended only for schizotypals who do not display severe eccentric or paranoid behavior. Most group members would be uncomfortable with these behavioral displays and it would likely prove destructive to the group dynamic.
  • Family and marital therapy:
    • It is unlikely that a person with schizoid personality disorder will seek family or marital therapy. Many schizoid types do not marry and end up living with and being dependent upon first-degree family members. If they do marry they often have problems centered on insensitivity to their partner's feelings or behavior. Marital therapy ( couples therapy ) may focus on helping the couple to become more involved in each other's lives or improve communication patterns.

Medications
  • According to the Encyclopedia of MD, there is considerable research on the use of medications for the treatment of schizotypal personality disorder due to its close symptomatic relationship with schizophrenia. Among the most helpful medications are the antipsychotics that have been shown to control symptoms such as illusions and phobic anxiety, among others. Amoxapine (trade name Asendin), is a tricyclic antidepressant with antipsychotic properties, and has been effective in improving schizophrenic-like and depressive symptoms in schizotypal patients. Other antidepressants such as fluoxetine (Prozac) have also been used successfully to reduce symptoms of anxiety, paranoid thinking, and depression.

Prognosis
  • The prognosis for the individual with schizotypal personality disorder is poor due to the ingrained nature of the coping mechanisms already in place. Schizotypals who depend heavily on family members or others are likely to regress into a state of apathy and further isolation. While some measurable gains can be made with mildly affected individuals, most are not able to alter their ingrained ways of perceiving or interpreting reality. When combined with poor social support structure, most will not enter any type of treatment.

Prevention
  • Since schizotypal personality disorder originates in the patient's family of origin, the only known preventative measure is a nurturing, emotionally stimulating and expressive caretaking environment.

Portrayed in Popular Culture
  • Kramer from Seinfeld
    • He is characterized by odd behavior and thinking
  • Luna Lovegood and Sybill Trelawny from Harry Potter
    • They are both very eccentric with odd appearances and awkward in social settings

DSM-V Changes
  • Be reformulated as the Schizotypal Type
  • Individuals who match this personality disorder type have social deficits, marked by discomfort with and reduced capacity for interpersonal relationships; eccentricities of appearance and behavior, and cognitive and perceptual distortions.
  • They have few close friends or relationships.
  • They are anxious in social situations (even when they have the time to become familiar with the situation), feel like outcasts or outsiders, find it difficult to feel connected to others, and are suspicious of others’ motivations, including their spouse, colleagues, and friends.
  • Individuals with this type are eccentric, odd, or peculiar in appearance or manner (e.g., grooming, hygiene, posture, and/or eye contact are strange or unusual).
  • Their speech may be vague, circumstantial, metaphorical, over-elaborate, impoverished, overly concrete, or stereotyped. Individuals with this type experience a limited or constricted range of emotions, and are inhibited in their expression of emotions.
  • They may appear detached and indifferent to other’s reactions, despite internal distress at being “set apart.”
  • Odd beliefs influence their behavior, such as beliefs in superstition, clairvoyance, or telepathy.
  • Their perception of reality can become further impaired, often under stress, when reasoning and perceptual processes become odd and idiosyncratic (e.g., they may make seemingly arbitrary inferences, or see hidden messages or special meanings in ordinary events) or quasi-psychotic, with symptoms such as pseudo-hallucinations, sensory illusions, over-valued ideas, mild paranoid ideation, or transient psychotic episodes.
  • Individuals with this personality disorder type are, however, able to “reality test” psychotic-like symptoms and can intellectually acknowledge that they are products of their own minds.
  • Instructions
(APA, 2010)

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301.7 Antisocial Personality Disorder

























DSM-IV-TR criteria
  • There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:
    1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are groups for arrest
    2. deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
    3. impulsive behavior or failure to plan ahead
    4. irritability and aggressiveness, as indicated by repeated physical fights or assaults
    5. reckless disregard for safety of self or others
    6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
    7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
  • The individual is at least age 18 years.
  • There is evidence of Conduct Disorder with onset before age 15 years.
  • The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

Associated Features
  • Most essential diagnostic feature of ASPD is the pervasive disregard for and violation of the rights of others (SAMHSA, 2009).
  • They appear deficient in their ability to experience shared or reciprocal emotions such as guilt or love (SAMHSA, 2009).
  • They have a disdain for society's rules. They know right from wrong, but they simply do not care (SAMHSA, 2009).
  • Antisocial Personality Disorder (ASPD) is considered to be a chronic illness in which an individual's manner of thinking, perceiving situations, and empathizing with others is deemed morally wrong in his or her society.
  • Antisocial Personality disorder is also sometimes called psychopathy or sociopathic personality disorder. Normally, an individual suffering from Antisocial Personality Disorder will display a pattern of lying, stealing, running away from home, and having difficulty upholding the law. They also tend to have problems with the abuse of illicit drugs and alcohol.
    • The fearlessness hypothesis states they psychopaths have a higher fear threshold, or the frightening things for most people, like a burning building, or gunshots, have little effect on these individuals. It is possible there is no association with certain stimuli or cues with punishment or danger, such as an alarm going off.
    • Psychopaths do not show normal anxiety reactions when anticipating a punishment response and they were slow at learning how to stop responding when punishment was inevitable.
    • They were unable to avoid punishment because they have problems learning how to properly respond to anxiety-producing situations. Impulsive behaviors are unrestrained because the individuals do not successfully avoid punishment.
    • These inhibited responses that can be learned in the face of cues that signal upcoming punishment or also known as passive avoidance earning, and appears to be deficient in psychopaths and in individuals with ASPD.
  • A behavioral activation stem may, at the least, be normal, and at the most, be overactive in avoiding the punishment by any means necessary. Psychopaths are persistent in situations where failure is likely, so they set sites on a goal and very little if anything will stop him or her from attaining their goal.
  • The majority of people who have a substance use disorder in conjuncture with ASPD are not sociopathic except as a result of their addiction.
  • Most people that are diagnosed with ASPD are not true psychopaths.
  • Individuals with ASPD violate the rights of others through deceit or aggression.
    • They will lie repeatedly or will con other people for profit or pleasure.
    • They are impulsive and lack the ability to plan ahead.
    • Their behavior will generally be irresponsible, they will often be irritable, and they will often get into physical fights.
    • An important criterion is that they will be indifferent to having hurt or mistreated another person, or they will rationalize this behavior.
  • They are also unable to hold down a steady job and will often renege on financial commitments or steal from others.

Substance Use Among People with ASPD
  • They use substances in a polydrug pattern, meaning more than one drug at a time, involving alcohol, marijuana, heroin, cocaine, and methamphetamine.
  • The illicit drug culture can correspond with their view of the world as fast-paced and dramatic, which helps to support their need for a heightened self-image.
  • (SAMHSA, 2009)

Child vs. Adult Presentation
  • The disorder cannot be diagnosed until the age of 18, but symptoms must be present before the age of fifteen and diagnosed as Conduct Disorder. Studies show that 60% of all children who suffer from Conduct Disorder will later develop ASPD. It is when Conduct Disorder is left undiagnosed and untreated that it is most likely to develop into ASPD.
  • The rates of ASPD are much higher for young adults than for older adults.
  • A well known notion about ASPD is that these disorders begin early on in a child's life. The greater the number of antisocial behaviors the child demonstrates, the more likely that child will develop ASPD later on in life. This is the single best predictor of developing ASPD or psychopathy. Conduct disorder is closely related in behaviors, such as theft, truancy, and school discipline problems.

Gender and Cultural Differences in Presentation
  • Men are more likely than women to be diagnosed with ASPD. Studies show that about 3% of males and about 1% of females receive this diagnosis.
    • Women are more likely to be misdiagnosed as Borderline Personality Disorder (SAMHSA, 2009).
    • Determining the type and extent of antisocial symptoms for women is not easy, but it is important due to the high prevalence of neglectful parenting in women with substance use disorders and ASPD (SAMHSA, 2009).
  • Studies also show that in clinical settings, the prevalence rate of ASPD ranges anywhere from 3 to 30 percent of the clinical population, with an increased prevalence with substance abuse facilities and prisons.
  • ASPD rates are much higher among young adults than older adults.
  • Culture seems to play a large role in the prevalence rates of Antisocial Personality Disorder.
    • For example, in Taiwan the prevalence rate is 0.14% while in Canada it is 3.7%. The only reasonable explanation for the lower rate in Taiwan is that the Taiwanese report antisocial behaviors more often than other countries.
    • In contrast, Taiwan has a lower prevalence rate than the countries surrounding it. Studies show that rates in Hong Kong and South Korea are similar to those in the U.S. and Europe; studies also show that the countries with high rates in ASPD also have high rates in other disorders with which there is typically co-morbidity. This disorder is more common among individuals with a relatively low socioeconomic status within their culture.

Epidemiology
  • 3% of males and about 1% of females in community samples show Antisocial Personality Disorder. Clinical settings can have between a 3% to 30% prevalence rate depending on the characteristics of the populations being sampled.
  • Higher rates are seen with substance abuse treatment settings and forensic or prison setting. In the male prison populations, 20% or more have Antisocial PD (SAMHSA, 2009).
  • Most recent epidemiology studies put prevalence rates in the general population between 1% and 4%, and prevalence in an outpatient psychiatric setting at around 3% to 4%.
  • The course is chronic, but the disorder may become less evident or remit with age, especially about age 40. This remission tends to be particularly evident regarding criminal behavior, though there is likely a decrease in the full spectrum of behavior.
  • 10 to 20% of homeless women, and 20 to 25% of homeless men receive diagnosis of Antisocial PD (SAMHSA, 2009).
  • 34.7% of alcoholics, 27% of heroin addicts, 30.4% of cocaine addicts have Antisocial Personality Disorder
    • The percentage is in the mid 40s for those addicted to 2 of the 3 drugs listed above.
    • 59.8% of those addicted to all 3 of the drugs have Antisocial Personality Disorder
    • (SAMHSA, 2009)

Etiology
  • Little is known about the causes of Antisocial Personality Disorder. There are several factors which complicate detecting the cause.
    • First, most individuals with this disorder do not perceive any fault within themselves and, therefore, will not seek out clinical assistance.
    • Another reason is because many of the disorders dealing with personality are similar to one another, making it difficult to differentiate one disorder from another.
  • There seems to be a strong genetic link to ASPD development and criminality.
  • Although researchers aren’t entirely sure, they do believe that genetics have something to do with the development of Antisocial Personality Disorder.
    • Even though some researchers believe that genetics has some to do with a person developing ASPD, they mainly believe that a person’s environment is the main cause.
    • One perspective looks at the parents for answers. Studies have shown that parents who passively give in to their children's whims and do not take disciplinary action can aid in the development of antisocial personalities. Their children may perceive their parents behavior as uncaring and will continue to behave poorly because they have not been conditioned to behave otherwise.
  • They often exhibit signs of antisocial behavior from 15 to 18 years of age, such as unlawful behavior, deceitfulness, consistent irresponsibility, and lack of remorse.
    • Evidence of similar behaviors even before the age of 15.
    • When antisocial behavior occurs without any signs of it during adolescence, the DSM-IV diagnosis is Adult Antisocial Behavior.
  • A history of childhood abuse, including harsh and neglectful care giving, is believed to result in the adult individual with ASPD neglecting others' needs and feelings.
  • Some suggest that individuals with ASPD exhibited difficult temperaments in childhood, eliciting hostile reactions in caregivers and reinforcing withdrawal from others.
  • Developmental examinations of ASPD suggest that children who are repeatedly rejected by their normative peer group and who are more involved in deviant peer groups are more likely to develop ASPD.
  • Also, the under-arousal hypothesis is given credit in that it states that individuals with personality disorders, in general, including ASPD have low levels of arousal in their brain's cortex and is one reason why these individuals exhibit antisocial behaviors.
  • More research has been conducted on ASPD than any other Personality Disorder.
  • Environmental factors help to influence the development of psychopathy, criminal behavior and other conditions.
  • The fearlessness hypothesis states they psychopaths have a higher fear threshold, or the frightening things for most people, like a burning building, or gunshots, have little effect on these individuals. It is possible there is no association with certain stimuli or cues with punishment or danger, such as an alarm going off.
  • Psychopaths do not show normal anxiety reactions when anticipating a punishment response and they were slow at learning how to stop responding when punishment was inevitable.
  • Inability to avoid punishment because of problems learning how to properly respond to anxiety-producing situations.
  • Impulsive behaviors are unrestrained because the individuals do not successfully avoid punishment.
  • These inhibited responses that can be learned in the face of cues that signal upcoming punishment or also known as passive avoidance learning, and appears to be deficient in psychopaths and in individuals with ASPD.

Empirically supported treatments
  • There is currently no permanent treatment for Antisocial Personality Disorder.
  • As stated above, individuals with ASPD rarely see themselves as having a problem and are not motivated to enter treatment willingly.
  • Many therapists do not see significant improvement throughout the course of counseling, as the patients tend to be manipulative and uncooperative.
  • The patients have also been known to fake improvement in order to end their treatment.
  • Even if treatment is successful for a patient, relapse is very likely to occur shortly after treatment sessions have ceased.
  • ASPD is still not completely understood, so the use of medications is not yet a safe treatment option.
  • Also, since ASPD is resistant to treatment; suicide, alcoholism, vagrancy, and social isolation are very common among these patients.
  • Antisocial personality disorder is highly unresponsive to any form of treatment, in part because persons with APD rarely seek treatment voluntarily. If they do seek help, it is usually in an attempt to find relief from depression or other forms of emotional distress. Although there are medications that are effective in treating some of the symptoms of the disorder, noncompliance with medication regimens or abuse of the drugs prevents the widespread use of these medications.
  • The most successful treatment programs for APD are long-term structured residential settings in which the patient systematically earns privileges as he or she modifies behavior. In other words, if a person diagnosed with APD is placed in an environment in which they cannot victimize others, their behavior may improve. It is unlikely, however, that they would maintain good behavior if they left the disciplined environment.
  • If some form of individual psychotherapy is provided along with behavior modification techniques, the therapist's primary task is to establish a relationship with the patient, who has usually had very few healthy relationships in his or her life and is unable to trust others. The patient should be given the opportunity to establish positive relationships with as many people as possible and be encouraged to join self-help groups or prosocial reform organizations.
  • Unfortunately, these approaches are rarely if ever effective. Many persons with APD use therapy sessions to learn how to turn "the system" to their advantage. Their pervasive pattern of manipulation and deceit extends to all aspects of their life, including therapy. Generally, their behavior must be controlled in a setting where they know they have no chance of getting around the rules.

Counseling Tips for Clients with Antisocial Personality Disorders (SAMHSA, 2009)
Corral:
  • Coordinate treatment
  • Communicate with other providers
  • Make contracts with clients
Confront:
  • Be direct and firm
  • Identify antisocial thinking
  • Conduct random substance testing
Consequences:
  • Make clients responsible for their behavior
  • Record violations of rules
  • Allow clients to experience consequences of their behavior
  • Designate positive consequences for pro-social behavior


Prognosis
  • APD usually follows a chronic and unremitting course from childhood or early adolescence into adult life. The impulsiveness that characterizes the disorder often leads to a jail sentence or an early death through accident, homicide or suicide . There is some evidence that the worst behaviors that define APD diminish by midlife; the more overtly aggressive symptoms of the disorder occur less frequently in older patients. This improvement is especially true of criminal behavior but may apply to other antisocial acts as well.

Prevention
  • Measures intended to prevent antisocial personality disorder must begin with interventions in early childhood, before youths are at risk for developing conduct disorder. Preventive strategies include education for parenthood and other programs intended to lower the incidence of child abuse; Big Brother/Big Sister and similar mentoring programs to provide children at risk with adult role models of responsible and prosocial behavior; and further research into the genetic factors involved in APD.

ASPD and Brain Structures
  • There is a subtle structural deficit in the prefrontal cortex of uninstitutionalized antisocial, violent persons with psychopathic-like behavior who live in community settings
  • There is a much less observable volume reductions specific to the prefrontal gray matter that is associated with APD
    • APD had a 11% reduction in prefrontal gray matter when compared to a control group, a 13.9% reduction when compared to a substance-dependent group, and a 14% reduction when compared to a psychiatric control group
  • APD also have reduced autonomic activity during social stressors
    • Those with APD who also had reduced prefrontal gray matter volume also had lower skin conductance activity during social stressors
  • Prefrontal cortex is part of a neural circuit that plays a central role in fear conditioning and stress responsivity
    • Poor conditioning is theorized to be associated with poor development of the conscience, and those who are less autonomically responsive to aversive stimuli such as social criticism during childhood would be less susceptible to socializing punishments, and hence become predisposed to antisocial behavior
    • Antisocial groups show poor fear conditioning
  • Prefrontal cortex is involved in the regulation of arousal, and deficits in autonomic and central nervous system arousal in antisocial persons have been viewed as facilitating a stimulation-seeking, antisocial behavioral response to compensate for such under arousal
  • Patients with prefrontal damage fail to give anticipatory autonomic response to choice options that are risky, and make bad choices even when they are aware of the more advantageous response option
    • Inability to reason and decide advantageously in risky situations is likely to contribute to the impulsivity, rule breaking, and reckless, irresponsible behavior that make up 4 of the 7 traits of APD
  • Previous research has shown that patients with major damage to the prefrontal cortex show dysregulation of cognition, emotion, and behavior, which predisposes to antisociality
  • Those who are antisocial have visually imperceptible but meaningful and significant reductions in prefrontal gray matter volume in addition to psycho-physiological deficits in emotion reacitivity
  • It is unlikely that only one brain mechanism is compromised in APD
    • Functional imaging has indicated multiple cortical and subcortical deficits in violent offenders
  • Limitations
    • It is possible that it is only those substance abusers who also have APD who show the prefrontal deficit since substance abusers have been shown to have lower than normal prefrontal gray matter volumes
    • No study of gray matter volume loss in schizophrenia has controlled for crime and violence
    • Only men were assessed, so cannot be generalized to women
    • Only an association has been shown, not any causality
    • Does not delineate which subregion of the prefrontal cortex is particularly reduced in volume
      • It is predicted that the orbitofrontal region would be the most impaired and the dorsolateral region relatively spared
(Raine, Lencz, Bihrle, LaCasse, & Colletti, 2000)

Portrayed in Popular Culture
  • The Silence of the Lambs (1991)
  • American Psycho (2000)
  • The Joker from Batman
    • Anarchy is his guiding philosophy
  • Lord Voldemort from Harry Potter
    • He is a classic model of a conduct disorder case developing into Antisocial Personality Disorder


DSM-V Changes
  • Reformulated as the Antisocial/Psychopathic Type
  • Individuals who match this personality disorder type are arrogant and self-centered, and feel privileged and entitled. They have a grandiose, exaggerated sense of self-importance and they are primarily motivated by self-serving goals.
  • They seek power over others and will manipulate, exploit, deceive, con, or otherwise take advantage of others, in order to inflict harm or to achieve their goals.
  • They are callous and have little empathy for others’ needs or feelings unless they coincide with their own. They show disregard for the rights, property, or safety of others and experience little or no remorse or guilt if they cause any harm or injury to others.
  • They may act aggressively or sadistically toward others in pursuit of their personal agendas and appear to derive pleasure or satisfaction from humiliating, demeaning dominating, or hurting others.
  • They also have the capacity for superficial charm and ingratiation when it suits their purposes.
  • They profess and demonstrate minimal investment in conventional moral principles and they tend to disavow responsibility for their actions and to blame others for their own failures and shortcomings.
  • Individuals with this personality type are temperamentally aggressive and have a high threshold for pleasurable excitement. They engage in reckless sensation-seeking behaviors, tend to act impulsively without fear or regard for consequences, and feel immune or invulnerable to adverse outcomes of their actions.
  • Their emotional expression is mostly limited to irritability, anger, and hostility; acknowledgment and articulation of other emotions, such as love or anxiety, are rare.
  • They have little insight into their motivations and are unable to consider alternative interpretations of their experiences.
  • Individuals with this disorder often engage in unlawful and criminal behavior and may abuse alcohol and drugs. Extremely pathological types may also commit acts of physical violence in order to intimidate, dominate, and control others.
  • They may be generally unreliable or irresponsible about work obligations or financial commitments and often have problems with authority figures.
  • Instructions
(APA, 2010)

For More Information, Please Read:
  • Luntz, B.K., & Widom, C.S. (1994). Antisocial personality disorder in abused and neglected children grown up. American Journal of Psychiatry, 151(5), 670-675.

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301.83 Borderline Personality Disorder


Becky describes what it feels like to live with BPD
















DSM-IV-TR criteria
  • A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts. This is indicated by having 5 or more of the following characteristics:
      1. Being frantic to avoid abandonment, either real or imagined
        • NOTE: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
      2. A pattern of intense, unstable interpersonal relationships characterized by alternating between extreme variances of idealization and devaluation
      3. Identity disturbance: markedly and persistently unstable self-image or sense of self
      4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
        • NOTE: Do not include suicidal or self mutilating behavior covered in Criterion 5.
      5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior
      6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
      7. Chronic feelings of emptiness
      8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
      9. Transient, stress-related paranoid ideation or severe dissociative symptoms

Associated features
  • One of the most prominent features is instability in interpersonal relationships, self-image, and affects.
  • Severe instability can be seen in their fluctuating views and feelings about him or herself. They often feel really good about themselves, their progress, and their futures to only have a seemingly minor experience turn their world upside-down with concomitant plunging self-esteem and depressing hopelessness (SAMHSA, 2009).
  • Another prominent feature is marked impulsivity that begins by early adulthood and is present in a variety of contexts.
  • Individuals with BPD will often give up on something just before the goal is attained.
  • It is often difficult to maintain relationships, a job, or educational goals since their basic instability extends to work and school.
  • Psychotic-like symptoms may occur when an individual is under stress. These symptoms include hallucinations, body-image distortions, ideas of reference, and hypnagogic phenomena.
  • They typically don't do well with personal relationships and may feel more comfortable with pets or inanimate objects. If they do have relationships, they are unstable, with reports of how wonderful an individual is one day and then the next expressions of intense anger, disapproval, condemnation, and even hate towards the same person (SAMHSA, 2009).
  • The risk of suicidal, self-mutilating, and/or brief psychotic states increases when they are experiencing an emotional state that they cannot handle (SAMHSA, 2009).
    • The risk for suicide increases when the individual also has a co-occurring Mood or Substance Related Disorder.
    • 10 percent of adults with BPD commit suicide
    • A person with BPD has a suicide rate 400 times greater than the general public
    • 33 percent of youth who commit suicide have features of BPD
    • (Kreger, 2008)
  • Patients suspected of BPD also exhibit symptoms of Depressive mood disorders, addictions to various things from drugs to binge eating, and Anti-Social Behaviors. Other co-morbid disorders include Mood, Substance Related, Eating, Post-Traumatic Stress, Attention Deficit/Hyperactivity, and other Personality Disorders.
  • To the sufferer, BPD is about deep feelings, such as:
    • If others really get to know me, they will find me rejectable and will not be able to love me and will leave me
    • I need to have complete control of my feelings otherwise things go completely wrong
    • I have to adapt my needs to other people's wishes, otherwise they will leave me or attack me
    • I am an evil person and I need to be punished for it
    • Other people are evil and abuse you
    • If someone fails to keep a promise, that person can no longer be trusted
    • If I trust someone, I run a great risk of getting hurt or disappointed
    • If you comply with someones request, you run the risk of losing yourself
    • If you refuse someones request, you run the risk of losing that person
    • I will always be alone
    • I can't manage by myself, I need someone I can fall back on
    • There is no one who really cares about me, who will be available to help me, and whom I can fall back on
    • I don't really know what I want
    • I will never get what I want
    • I'm powerless and vulnerable and I can't protect myself
    • I have no control of myself
    • I can't discipline myself
    • My feelings and opinions are unfounded
    • Other people are not willing or helpful
    • (Facing the Facts, 2009)

BPD Traits Organized by Thoughts, Feelings, and Actions (Kreger, 2008)

DSM Traits
THINKING:
Impaired perception and reasoning
Spitting (extremes of idealization and devaluation)

Brief moments of stress-related paranoia or severe
dissociative symptoms (being very "out of it")
FEELING:
Poorly regulated, highly changeable emotions
Intense, unstable moods and strong reactions to
shifts in the environment. Irritability or anxiety,
usually lasting for a few hours or days. Feelings of
acute hopelessness, despair, and unhappiness

Frantic efforts to avoid real or imagined abandonment

A feeling of emptiness and a lack of identity, which
complicate moods and emotions
ACTING:
Impulsive behaviors
Imulsiveness in at least 2 areas that are potentially
self-damagine (spending, sex, substance abuse,
reckless driving, or binge eating)

Inappropriate, intense anger or difficulty controlling
anger (frequent displays of temper, constant anger,
or recurrent physical fights)

"Pain management" behaviors such as overspending,
aggression toward others suicide, self-harm, substance
abuse, and eating disorders

Impaired Thinking (Kreger, 2008)
Cognitive Distortion
Cognitive Distortions in BPs
FEELINGS EQUAL FACTS:
Emotions color interpretations of people and situations
The BP makes jaw-dropping interpretations, assumptions,
and inferences that may bear little resemblance to reality
JUMPING TO CONCLUSIONS:
Negative interpretation without supporting facts
The BP jumps to conlusions even when past experiences
with the person/situation have been positive.

The BP dismisses contrary supporting facts.
MIND READING:
Assuming others think badly of you
The BP assumes others think she's scum on the garbage
scow of the world
CATASTROPHIZING:
Thinking the worst-case scenario will occur and nothing
can be done to help the situation
The BPs catastrophizing can lead to poor, rash decisions
or dangerous actions, such as self-harm or suicide attempts

Small molehills become Mt. Everest
BLAME:
Holding others totally accountable for negative situations
The BP not only dismisses contrary supporting facts but also
thrashes, mutilates, and pummels them into submission

The BP will not be held accountable for anything
DISCOUNTING THE POSITIVE
In a way similar to splitting, some BPs discount anything
good in themselves and in others
MENTAL FILTER:
Dwelling on criticism of the self while repelling compliments
For the BP, the soaking in is deeper - to the bone instead
of the pores.

Compliments are repelled faster and further away

Lower-Functioning vs High Functioning (Kreger, 2008)

Mostly Lower-Functioning
Conventional BPs
Mostly Higher- Functioning
Invisible BPs
COPING TECHNIQUES
Acting in:
Mostly self-destructive acts such as self-harm
Acting out:
Uncontrolled and impulsive rages, criticism,
and blame. These may result less from a
lack of interpersonal skills than from an
unconcious projection of their own pain
onto others
FUNCTIONING
Low functioning:
BPD and associated conditions make it difficult to live
independently, hold a job, manage finances, and so on.

Families often step in to help
High functioning:
The BP appears normal, even charismatic,
but exhibits BPD traits behind closed doors

Has a career and may be successful
WILLINGNESS TO OBTAIN HELP
Self-harm and suicidal tendencies often bring these
BPs into the mental health system (both as inpatients
and outpatients)

High interest in therapy
A state of denial much like an untreated
alcoholic

The BP disavows responsibility for
relationship difficulties, refuses treatment;
when confronted, he or she accuses others
of having BPD.

May see a therapist if threatened, but rarely
takes it seriously or stays long
CO-OCCURRING (CONCURRENT)
MENTAL HEALTH ISSUES
Mental conditions such as bipolar and eating disorders
require medical intervention and contribute to low
functioning
Concurrent illness most commonly a
substance use disorder or another PD,
especially Narcissistic PD
IMPACT ON FAMILY MEMBERS
The major family focus is on practical issues such as
finding treatment, preventing/reducing BPs self-
destructive behavior, and providing practical and
emotional support.

Parents feel extreme guilt and are emotionally
overwhelmed
Without the diagnosis of an obvious illness
for the BP, family members blame
themselves and try to get their emotional
needs met

They make fruitless efforts to persuade
their BP to get professional help

Major issues include high-conflict divorce
and custody cases


Substance Use Among People with BPD
  • They are often skilled in seeking multiple sources of medication that they favor, such as benzodiazepines.
  • They associate drugs with social interactions and use the same drugs of choice, method of administration, and frequency as the individuals that they interact with.
  • They often use substances in a chaotic and unpredictable pattern.
  • Polydrug use is common and may involve alcohol and other sedative-hypnotics taken for self-medication.
  • A the beginning of a crisis episode, they will often take a drink or use a different drug in order to subside the growing sense of tension or loss of control.
  • They usually have big appetites, and they often experience powerful, emotion-driven needs for something outside of themselves, such as drugs.
  • When they stop using drugs, they are extraordinarily vulnerable to meeting their needs through other compulsive behaviors.
    • Some of these behaviors include:
      • compulsive sexual behavior
      • compulsive gambling
      • compulsive spending/shopping
      • other out of control behaviors that result in negative or even dangerous consequences
(SAMHSA, 2009)


Hitler as an example:
  • The DSM-IV-TR describes Borderline Personality Disorder as a “pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five or more symptoms.
  • The first symptom is frantic efforts to avoid real or imagined abandonment.
  • The second is a pattern of unstable and intense, interpersonal relationships characterized by alternating between extremes of idealization and devaluation. When we look at most of the relationships in Hitler’s life, Gustl, Geli, Eva, they go back and forth between stable and rocky. He somewhat cares, he does not care at all, he is happy with them, he is angry with them, he loves them, he hates them. This back and forth happens quite often throughout all of those relationship.
  • The third symptom is identity disturbance: markedly and persistently unstable self-image or sense of self. At times Hitler thought he was the greatest most prominent person in the world but others he thought of himself as a worthless failure. We can look at the period of trying to be an artist as an example, or the episode with the German film star. These switches between security were often.
  • The fourth is impulsivity in at least two area that are potentially self-damaging.
  • Recurrent suicidal behavior, gestures, threats, or self-mutilating behaviors is the fifth symptom.
  • The sixth symptom is the affective instability due to a marked reactivity of mood such as an intense episodic dysphoria, irritability, or anxiety. Hitler had affective instability quite often. At any given moment Hitler could ‘fly off the handle’ so to speak in fits of rage.
  • The seventh symptom is chronic feelings of emptiness.
  • The eighth is inappropriate intense anger or difficulty controlling anger. Like previously stated, Hitler had anger problem which he could not control. There are accounts in which Hitler has been reported not just yelling but throwing objects in his fits of rage.
  • The ninth and last symptom is transient, stress-related paranoid ideation or sever dissociative symptoms. Hitler was paranoid about a number of things. He was paranoid that people were out to get him. He was paranoid that the Jewish people were responsible for the evil, negative ambiance, and downfall of Germany. He was a hypochondriac who was paranoid that he was sick and had cancer any time something felt wrong or he was around a person he thought to be sick.
  • Hitler displayed five of the nine symptoms. If there were knowledge about psychology in Hitler’s time like there is knowledge now, Hitler may have been diagnosed with Borderline Personality Disorder.
  • (Kershaw, 2008)

Child vs. Adult Presentation
  • It should be noted that the DSM is not currently modified to diagnose patients under 18 with BPD. The generally accepted modifications to diagnosing underage patients are exhibitions of disruptive behavioral problems, and mood and anxiety symptoms. Adolescents and young adults with identity problems may display behaviors that could be mistaken as Borderline Personality Disorder. Such situations are characterized by emotional instability, anxiety-provoking choices, uncertainty, and dilemmas.

Gender and Cultural Differences in Presentation
  • BPD is diagnosed most often in females (about 75%).
  • There have been some studies which suggest that women with BPD are more likely to have eating disorders, as well as histories involving sexual or physical abuse that qualify them for PTSD (Post-Traumatic Stress Disorder).
    • These studies also suggest that men are more likely to abuse substances, and have more defined antisocial personalities.
  • 1 out of every 4 people with BPD are male (Kreger, 2008)
  • We know very little about how BPD expresses itself in men or if treatment programs designed for women are as effective for men (Kreger, 2008)
  • Men won't seek treatment
    • They see it as "unmanly" to acknowledge feelings, especially the vulnerability and abandonment fears associated with BPD
    • (Kreger, 2008)
  • Clinician Bias
    • Anger is interpreted differently depending upon whether it comes from a man or a woman
    • Harder for clincians accurately diagnose the presence of BPD in males
    • (Kreger, 2008)
  • Cultural influences
    • Men are socialized not to expose their fear of abandonment or other emotional vulnerabilties
    • Men are permitted anger
    • (Kreger, 2008)
  • Borderline men and domestic violence
    • Some men use the same outlets as borderline women do, such as making suicide threats
    • A great many of them anexthetize themselves with alcohol and drugs such as cocaine or methamphetamine
    • A subset channel their feelings into their more socially acceptable cousins: rage and aggression
    • Both men and women can express their fear of abandonment as physical aggression
      • Men's level of violence is often more lethal
    • This aggression often results in a misdiagnosis of Antisocial PD or a conduct disorder in adolescents
    • They are often incarcerated
    • (Kreger, 2008)
  • Sexual acting out
    • Men frequently engage in addictive, sexually compulsive behaviors, including:
      • hiring prostitutes
      • having serial affairs
      • going to strip clubs
      • obsessive viewing pornography
      • engaging in voyeurism or exhibitionism
      • compulsive masturbation
      • (Kreger, 2008)

Epidemiology
  • Borderline Personality Disorder affects about 1 to 2 percent of the population
    • Recent research is showing that this number is much higher (Kreger, 2008)
  • It is much more highly represented in the clinical population
    • About 10 percent of outpatients and about 20 percent of inpatients in psychiatric settings are diagnosed with this disorder.
  • About 75 percent of those diagnosed with Borderline Personality Disorder are females.
  • Five times more common in first degree relatives of affected persons
  • The course is decidedly variable. The most common pattern is of chronic instability in early adulthood, with episodes of affective and impulsive dyscontrol and high levels of the use of health resources. Impairment and the risk of suicide are greatest in young adults and decrease with age. the tendency toward intense emotions, impulsivity, and intensity in relationships is often lifelong, though these areas improve with intervention within the first year. Greater stability is often attained during the 30s and 40s.

Etiology
  • The actual cause or root of the disorder is not known.
  • It is commonly believed that because the symptoms are long-lasting, that the symptoms primarily manifest in early adolescence, and may not show negative consequences until early adulthood.
  • People with symptoms may have a history of unstable relationships and sexual/physical abuse or neglect.
  • It also appears that a serotonin deficiency may be involved in the development of Borderline Personality Disorder.
    • This could possibly explain why these individuals engage in self-mutilation and why these individuals are impulsive, especially when it comes to aggressive behavior.
  • Other research has implicated an irregularity of non adrenaline.
    • Research also indicates that dopamine has been implicated in the etiology of Borderline Personality Disorder, which can be related to the fact that some borderline individuals demonstrate psychotic symptoms that are temporary.
  • Research indicates that a complex interaction of environmental and genetic factors likely contributes to the presence of BPD. One environmental factor hypothesized to contribute to BPD has been pathological child experiences leading to trauma as indicated by a co-occurring diagnosis of PTSD.
  • Another suggestion is that BPD is a dysfunction in the emotional regulations system that results from a combination of biological predisposition and environmental factors.
  • There is also considerable research indicating that early childhood abuse such as emotional and verbal abuse maybe implicated in individuals with Borderline Personality Disorder, which account for 90% of individuals with Borderline Personality Disorder.
  • Older people with BPD
    • Experts differ on whether people with BPD "grow out of BPD" when they get into their fifties and above
    • Popular thinking is that they do
    • More research needs to be done on this
    • (Kreger, 2008)

Portrayed in Popular Culture
  • Play Misty for Me (1971)
  • Fatal Attraction (1987)
  • Poison Ivy (1992)
  • The Crush (1993)
  • Girl, Interrupted (1999)
    • It is about a girl diagnosed with borderline personality disorder who is sent to a mental institution.
  • Allein (Germany, 2004)
  • Chloe (2009)
  • Eliane from Seinfeld
    • She has extreme "black and white" thinking. She also has instability in relationships, self-image, identity, and behavior
  • Anakin Skywalker from Star Wars
    • He shows signs of six out of nine criteria
    • He has unstable moods, interpersonal relationships, and behaviors
    • Infantile illusions of omnipotence and dysfunction experiences of self and others
    • Frantic efforts to avoid real or imagined abandonment
    • Shows impulsive behavior and has difficulty controlling his anger
    • Experiences two "dissociative episodes"
      • Exterminated the Tusken people after his mothers death
      • Killed all of the Jedi younglings
    • Has a disturbance in identity when he turns to the dark side and changes his name
    • (Landau, 2010)
  • Catwoman from Batman
    • She is a woman of many moods and traumas
    • Her alter-ego, Selina Kyle, is typical of the impulsivity characterized by Borderline Personalities
  • Moaning Myrtle from Harry Potter
    • Has expressed feelings of loneliness and abandonment mixed with the occasionally warm approach
    • Has very dramatic mood swings

Diagnostic Tests
  • Diagnostic Interview for Borderline Patients (DIB-R)
    • The Diagnostic Interview for Borderline Patients (DIB-R) is the best-known "test" for diagnosing BPD. The DIB is a semi structured clinical interview that takes about 50-90 minutes to administer. The test, developed to be administered by skilled clinicians, consist of 132 questions and observation using 329 summary statements. The test looks at areas of functioning that are associated with borderline personality disorder. The four areas of functioning include Affect (chronic/major depression, helplessness, hopelessness, worthlessness, guilt, anger, anxiety, loneliness, boredom, emptiness), Cognition (odd thinking, unusual perceptions, nondelusional paranoia, quasipsychosis), Impulse action patterns (substance abuse/dependence, sexual deviance, manipulative suicide gestures, other impulsive behaviors), and Interpersonal relationships (intolerance of aloneness, abandonment, engulfment, annihilation fears, counterdependency, stormy relationships, manipulativeness, dependency, devaluation, masochism/sadism, demandingness, entitlement). The test is available at no charge by contacting John Gunderson M.D. McLean Hospital in Belmont Massachusetts (617-855-2293).
  • Structured Clinical Interview (SCID-II)
    • The Structured Clinical Interview (now SCID-II) was formulated in 1997 by First, Gibbon, Spitzer, Williams, and Benjamin. It closely follows the language of the DSM-IV Axis II Personality Disorders criteria. There are 12 groups of questions corresponding to the 12 personality disorders. The scoring is either the trait is absent, subthreshold, true, or there is "inadequate information to code". SCID-II can be self administered or administered by third parties (a spouse, an informant, a colleague) and yield decent indications of the disorder. The questionnaire is available from the American Psychiatric Publishing for $60.00.
  • Personality Disorder Beliefs Questionnaire (PDBQ)
  • Other
    • Other commonly used assessment tests are rating tests such as the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD), and the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). In addition there are some free, informal tests available.
(Facing the Facts, 2010)

Empirically Supported Treatments
  • Borderline individuals remain some of the most difficult to treat effectively in therapeutic situations, whether they are outpatient or inpatient. Personality traits are not left at entrance, so they are quite visible during treatment.
  • The best treatment for BPD is Dialectical behavior therapy, credited to Marsha Linehan, a professor at University of Washington.
    • This treatment, established in 1993, focuses on helping the patient not only survive but to build a life that is meaningful to them by helping the patient to balance change and acceptance of the situations in their life.
    • First, life-threatening or harmful situations are dealt with.
    • Then they are gently pushed to experience emotions that are painful to them.
    • Part three addresses living problems.
    • The procedure is to help the patient feel complete as a person.
  • Trust is a critical concern; it is difficult to create and difficult to maintain when created. The therapeutic relationship is a teeter totter tilting back and forth the good and bad aspects of the therapist proclaimed by the patient. There is risk for suicide but the cries for help are difficult to separate out a true cry from a gesture that is not an emergency.
  • Other types of therapies may be used also, including cognitive-behavioral therapy, group therapy, and family therapy, along with individual therapy. Therapy sessions should have specific, special strategies, and the therapists should set boundaries for the client. Therapists should be aware that clients with BPD can be difficult to manage even for experienced mental health professionals.
  • A person with Borderline PD who seeks a mental health treatment is acutely emotionally distraught, and needs some relief from how she or he feels. Those that seek substance abuse treatment are probably only seeking treatment for the substance use disorder, and not the personality disorder (SAMHSA, 2009).
  • An overwhelming number of clinicians do not have the training or experience to effectively treat those with the disorder (Kreger, 2008).
  • Research-based therapies for BPD are not widely available and are only appropriate for a subsection of those with the disorder (Kreger, 2008).
  • 80 percent of psychiatric nurses believe that people with BPD receive inadequate care (Kreger, 2008)
  • A 30 year old woman with BPD typically has the medical profile of a woman in her 60s (Kreger, 2008)

  • Counseling a Client with Borderline Personality Disorder
    • Anticipate that client progress will be slow and uneven
    • Assess the risk of self-harm by asking about what is wrong, why now, whether the client has specific plans for suicide, past attempts, current feelings, and protective factors.
    • Maintain a positive but neutral professional relationship, avoid over-involvement in the client's perceptions, and monitor the counseling process frequently with supervisors and colleagues.
    • Set clear boundaries and expectations regarding limits and requirements in roles and behavior.
    • Assist the client in developing skills (e.g. deep breathing, meditation, cognitive restructuring) to manage negative memories and emotions.
    • (SAMHSA, 2009)

  • Key Issues and Concerns in the Treatment of Borderline Personality Disorders
    • slow progress in therapy
    • suicidal behavior
    • self-injury or harming behavior
    • client contracting
    • transference and counter transference
    • clear boundaries
    • resistance
    • subacute withdrawal
    • symptom substitution
    • somatic complaints
    • therapist well-being
    • (SAMHSA, 2009)

  • Types of Psychotherapy Used:
    • The psychotherapies that have been proved successful for BPD all strive to address underlying deficits in the ability of patients to relate to others, manage emotions, and confront longstanding problems that are typically rooted in childhood experience.
    • Cognitive-behavioral therapy (CBT):
      • This therapy approach allows the patient to learn how to recognize and change their maladaptive thought patterns. The main focus is on restructuring the dysfunctional cognitions through a process of identifying, challenging, and reshaping the thoughts. The other focus is on changing the process to prevent, alter, or replace unhealthy behavior with a healthier, and more effective, behavior.
    • Transference-focused therapy (TFP)
      • TFP is a psychodynamic treatment that was designed especially for patients with BPD.
      • It is a type of psychoanalysis that focuses on correcting the distortions in a patients perceptions of significant others and the therapist.
      • TFP places importance on the assessment and on the treatment contract between the client and therapist.
      • The treatment contract has parameters that are established in order to deal with the most likely threats to the treatment and the patients well-being that may or many not occur during the treatment.
    • Dialectical-behavioral therapy (DBT)
      • DBT targets suicidal and other dangerous, severe, or destabilizing behaviors. DBt strives to increase behavioral capabilities, improve motivation for skillful behavior through management of issues and problems as they come up in day-to-day life, reduce interfering emotions and cognitions, and to structure the treatment environment in a way that reinforces functional rather than dysfunctional behaviors.
      • DBT skills for emotion regulation include
        • identifying and labeling emotions
        • identifying obstacles to changing emotions
        • reducing vulnerability to emotion mind
        • increasing positive emotional events
        • increasing mindfulness to current emotions
        • taking opposite action
        • applying distress tolerance techniques
    • Schema-focused therapy (SFT)
      • builds on CBT and is also known as CBT with a psychodynamic component
      • It is an active, structured therapy for assessing and changing deep-rooted psychological problems by looking at repetitive life patterns and core life themes, which are called schemas.
      • Schema therapists use an inventory to assess the schemas that cause persistent problems in a patients life.
      • To change the schemas, they use a range of techniques that include:
        • congitive restructuring
        • limited re-parenting
        • changing schemas as they arise in the therapy relationship
        • intensive imagery work to access and change the source of schemas
        • creating dialogues between the schema side of the patients and the healthy side
    • Mentalization-based therapy (MBT)
      • Mentalization is the capacity to understand behavior and feelings, and how they are associated with specific mental states.
      • One of the many theories about Borderline Personality Disorders is that those who are diagnosed with BPD have a decreased capacity for mentalization.
      • The therapy itself seeks to help increase the capacity for mentalization, or the ability to perceive the mind of others as distinct from one's own.
      • Mentalization is a component in most of the traditional types of psychotherapy, but is usually not the main focus.
    • (Facing the Facts, 2010)

DSM-V Changes
  • Reformulated as Borderline Type
  • Individuals who match this personality disorder type have an extremely fragile self-concept that is easily disrupted and fragmented under stress and results in the experience of a lack of identity or chronic feelings of emptiness. As a result, they have an impoverished and/or unstable self structure and difficulty maintaining enduring intimate relationships.
  • Self-appraisal is often associated with self-loathing, rage, and despondency.
  • Individuals with this disorder experience rapidly changing, intense, unpredictable, and reactive emotions and can become extremely anxious or depressed. They may also become angry or hostile, and feel misunderstood, mistreated, or victimized.
  • They may engage in verbal or physical acts of aggression when angry.
  • Emotional reactions are typically in response to negative interpersonal events involving loss or disappointment.
  • Relationships are based on the fantasy of the need for others for survival, excessive dependency, and a fear of rejection and/or abandonment.
  • Dependency involves both insecure attachment, expressed as difficulty tolerating aloneness; intense fear of loss, abandonment, or rejection by significant others; and urgent need for contact with significant others when stressed or distressed, accompanied sometimes by highly submissive, subservient behavior.
  • At the same time, intense, intimate involvement with another person often leads to a fear of loss of an identity as an individual. Thus, interpersonal relationships are highly unstable and alternate between excessive dependency and flight from involvement.
  • Empathy for others is severely impaired.
  • Core emotional traits and interpersonal behaviors may be associated with cognitive dysregulation, i.e., cognitive functions may become impaired at times of interpersonal stress leading to information processing in a concrete, black-and white, all-or-nothing manner.
  • Quasi-psychotic reactions, including paranoia and dissociation, may progress to transient psychosis. Individuals with this type are characteristically impulsive, acting on the spur of the moment, and frequently engage in activities with potentially negative consequences.
  • Deliberate acts of self-harm (e.g., cutting, burning), suicidal ideation, and suicide attempts typically occur in the context of intense distress and dysphoria, particularly in the context of feelings of abandonment when an important relationship is disrupted.
  • Intense distress may also lead to other risky behaviors, including substance misuse, reckless driving, binge eating, or promiscuous sex.
  • Instructions
(APA, 2010)

Prognosis
  • The disorder usually peaks in young adulthood and frequently stabilizes after age 30.
  • Approximately 75–80% of borderline patients attempt or threaten suicide , and between 8–10% are successful.
  • If the borderline patient suffers from depressive disorder, the risk of suicide is much higher. For this reason, swift diagnosis and appropriate interventions are critical.
  • Remitted borderline patients were significantly less likely than non-remitted borderline patients to meet criteria for a number of other personality disorders, mostly anxious cluster disorders
    • BPD decreases significantly over time, especially for remitted borderline patients
    • (Zanarini, Frankenburg, Vujanovic, Hennen, Reich, & Silk, 2004)
  • The most co-occurring personality disorders declined significantly over time
    • Three exceptions were avoidant, dependent, and self-defeating PDs
    • Anxious cluster of disorders are the Axis II disorders that are most strongly associated with BPD failing to remit
    • (Zanarini et al., 2004)
  • There may be subtypes of BPD patients and some of these subtypes are most likely to remit in the short- to mid-term, making them less temperamentally impaired than those whose borderline pathology remains relatively constant
    • Treatment aimed at these subtypes needs to be developed
    • (Zanarini et al., 2004)

Prevention
  • Prevention recommendations are scarce. The disorder may be genetic and not preventable. The only known prevention would be to ensure a safe and nurturing environment during childhood

Medications
  • Medication is not considered a first-line treatment choice, but may be useful in treating some symptoms of the disorder and/or the mood disorders that have been diagnosed in conjunction with BPD. Recent clinical studies indicate that naltrexone may be helpful in relieving physical discomfort related to dissociative episodes
  • No FDA-approved medication exists for BPD (although many medications are used to treat the symptoms (Kreger, 2008)

Medications Studied and Used in the Treatment of Borderline Disorder (Kreger, 2008)
ANTIPSYCHOTICS
Drug class
Medications
Symptoms Improved by One or More Medications in the Class
Neuroleptics
thiothixene (Navane)
haloperidol (Haldol)
trifluoperazine (Stelazine)
flupenthixol
anxiety, obsessive-compulsivity, depression, suicide attempts, hostility, impulsivity,
self-injury/assaultive-ness, illusions, paranoid thinking, psychoticism, poor
general functioning
Atypical
olanzapine (Zyprexa)
aripiprazole (Abilify)
risperidone (Risperdal)
clozapine (Clozaril)
quetiapine (Seroquel)
anxiety, anger/hostility, paranoid thinking, self-injury, impulsive aggression,
interpersonal sensitivity, low mood, aggressions
ANTIDEPRESSANTS
Drug Class
Medications
Symptoms Improved by One or More Medications in the Class
SSRIs and
related antidepressants
fluoxetine (Prozac)
fluvoxamine (Luvox)
sertraline (Zoloft)
venlafaxine (Effexor)
anxiety, depression, mood swings, impulsivity, anger/hostility,
self-injury, impulsive aggression, poor general functioning
MAOIs
phenelzine (Nardil)
depression, anger/hostility, mood swings, rejection sensitivity,
impulsivity
Mood stabilizers
divalproex (Depakote)
lamotrigine (Lamictal)
topiramate (Topamax)
carbamazepine (Tegretol)
lithium
unstable mood, anxiety, depression, anger, irritability, impulsivity,
aggression, suicidality, poor general functioning


Economic Impact
  • Up to 40 percent of high users of mental health services have BPD
  • More than 50% of individuals with BPD are severely impaired in emplyability, with a resulting burden on Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), and Medicaid and Medicare
  • 12 percent of men and 28 percent of women in prison have BPD
(Kreger, 2008)

Information for the Family







Facing the Facts when a loved one has Borderline Personality Disorder
  • To the family members, BPD behavior is frustrating, and can feel unfair. Some common thoughts are:
    • You have been viewed as overly good and then overly bad
    • You have been the focus of unprovoked anger or hurtful actions, alternating with periods when the family member acts perfectly normal and very loving
    • Things that you have said or done have been twisted and used against you
    • You are accused of things you never did or said
    • You often find yourself defending and justifying your intentions
    • you find yourself concealing what you think or feel because you are not heard
    • You feel manipulated, controlled, and sometimes lied to
(Facing the Facts, 2010)

For More Information, Please Read:
  • Linehan, M.M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press.
  • Kreger, R. (2008). The essential family guide to borderline personality disorder: New tools and techniques to stop walking on eggshells. Center City, Minnesota: Hazeldon Publishing.

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301.50 Histrionic Personality Disorder



























What is a person with Histrionic Personality Disorder like?

  • The majority of cases of Histrionic Personality Disorder (HPD) are female. They may initially seem like average girls or young women, as their excessive focus on physicality can be seen in more reasonable quantities in most young ladies. At first this person may seem simply a little scattered, a little shallow, and a tad self-centered. However, a person with HPD exhibits far more than the normal amounts of all of these traits. Use of phrases that are ambiguous is frequent. "It was just like, you know, weird" would be a normative statement, or even "it was just like . . . you know?" This vague speech encompasses most of life, especially in regards to emotions and any cognitions. For example, one may see they have a distaste for something, and when inquiring as to why, simply get the response, "because it's bad/yucky" or "I just don't like it!" In this way, a person with HPD can often seem almost childlike in their speech patterns, as though they cannot introspect well enough to discern a more accurate description, or are too distracted or disinterested to even attempt to do so.

  • However, this vagueness does not mean they are unsure. People with HPD tend to be very sure of everything they think and do, even if what they think and feel changes moment to moment. This confidence can be seen in many of their actions, though they are often more than happy to act meek if it will acquire them attention. This confidence in the truth of their opinions seems to lead to them expressing emotions as if they are incredibly severe. Though it is often debated whether the person with HPD experiences emotions more intensely, or simply reports them as more intense; we normally see expression of incredibly powerful emotions, but short lived, and very shallow. Though the term shallow may sound odd when referring to an emotion, when one converses with a person with HPD it usually becomes abundantly clear rather quickly. There is very little subtlety or shades of grey to the emotional spectrum of a person with HPD. If they are sad, they are distraught and the entire world is in peril; when they are happy, they are ecstatic, and euphoria barely expresses the joy they feel. In this way, such things as 'bittersweet' or simply doing pleasantly seems to be outside of the person with HPD's realm of experience. Even emotions like envy, which are distinct to most people, seem to get subsumed into a broader emotion, such as anger. And where an average person may be irritable with someone, a person with HPD often skips straight to blind rage, and will start a fight or throw a tantrum in response.

  • This extremity of expression is seen also in their conceptions, or at least their reports on their conceptions, of interpersonal relationships. A person is an enemy, or they are thick as thieves. A person with HPD may refer to you as their BFF (best friend forever) after only a couple of meetings. After four meetings, they may express that not only are they in love with you, you are in love with them! This confidence may seem to overlap with narcissistic personality disorder in many ways, and in this single aspect, the two do have similarities, but expression in other symptoms is much more specific in HPD.

  • But, like the better known Narcissistic PD, people with HPD also crave the spotlight. They love, almost need to be the focal point of at least one person's attention at any given time, but the more, the better. Where the two disorders differ, is that HPD sufferers almost exclusively use physical attractiveness and sexuality to gain this attention. Though sometimes they resort to emotionality, often in the form of temper tantrums, more often than not they take on the role of seductress. A young lady with HPD may think nothing of taking off her shirt in a room full of people if she felt that focus was shifting somewhere else. Once again, though many people enjoy being the center of attention, and many normal young women may use their bodies or sensuality to become the center of attention (see the average spring break videos), these behaviors are exaggerated, more frequent, and occur in less appropriate situations in a person with HPD.

DSM-IV-TR criteria
  • A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following:
    1. Uncomfortable in situations where he or she is not the center of attention.
    2. Interactions with others are often characterized by inappropriate sexually seductive or provocative behavior.
    3. Displays rapid shifting and shallow expressions of emotions.
    4. Consistently uses physical appearance to draw attention to self.
    5. Has a style of speech that is excessively impressionistic and lacking in detail
    6. shows self dramatization, theatricality, and exaggerated expression of emotion
    7. is suggestible, i.e., easily influenced by others or circumstances
    8. Consider relationships more intimate than they actually are.

Associated features
  • Individuals have many emotional ups and downs. When not the center of attention in a social setting, individuals will find obvious ways to gain that attention back. They often, although unaware of it, act out a certain role, such as "victim" or "princess." They often have trouble with their relationships with same-sex friends because of their sexually provocative style, and they may alienate friends because of their constant need for attention. They often easily become bored with routine and are frustrated by situations that involve delayed gratification. They use flirtatious or sexually provocative behavior to get what they want, usually attention from others. The cognitive style of individuals with HPD is superficial and lacks detail. In their inter-personal relationships, individuals with HPD use dramatization with a goal of impressing others. The enduring pattern of their insincere and stormy relationships leads to impairment in social and occupational areas (Encyclopedia of Mental Disorders).
  • Treatment for patients is difficult ultimately because most who suffer from HPD don’t seek treatment because symptoms don’t usually interfere with daily life.

Child vs. adult presentation
  • HPD doesn’t show development until the teenage years, approximately 15 years of age. Treatment for sufferers is usually amongst the more mature age groups, generally in the early 40’s.

Gender and cultural differences in presentation
  • Women are more likely to have HPD than men. Registered cases show that 65% are women and 35% are men that suffer from Histrionic Personality Disorder. Women tend to be over diagnosed with this disorder. This is largely due to our culture. If a man brags about his accomplishment it is seen as being macho, If a woman seeks the same kind of attention, she is diagnosed with Histrionic Personality Disorder.
  • According to the Encyclopedia of Mental Disordersm HPD appears primarily in men and women with above-average physical appearances. Some research has suggested that the connection between HPD and physical appearance holds for women rather than for men. Both women and men with HPD express a strong need to be the center of attention.
  • HPD may be diagnosed more frequently in Hispanic and Latin-American cultures and less frequently in Asian cultures. Further research is needed on the effects of culture upon the symptoms of HPD.

Epidemiology
  • HPD affects an estimated 1-2% of the general population, whereas only 1% are involved in outpatient programs.
  • Prevalence rates are 10 to 15% in mental health settings (SAMHSA, 2009).
  • The lower prevalence rate is psychiatric settings may be understood in the context of the culturally adaptive qualities associated with the sex role stereotypes found in individuals with HPD.
  • No evidence of significant familial patterns. (Not necessarily a genetic link).
  • 10 to 15% of those in substance abuse treatment settings have HPD (SAMHSA, 2009).

Dual diagnoses


Etiology
  • The development of HPD illustrates a complicated interaction of biological predispositions and environmental responses. The temperament of extroversion and emotional expressiveness that underlie the character of an individual with HPD are recognized as having biological components. These factors interact with a lack of caregiver attention during formative years that led the child to develop strategies of attention grabbing presentation and shallow interaction that would elicit attention and connection
  • Neurochemical/Physiological Causes:
    • Studies show that patients with HPD have highly responsive noradrenergic systems, the mechanisms surrounding the release of a neurotransmitter called norepinephrine. Neurotransmitters are chemicals that communicate impulses from one nerve cell to another in the brain , and these impulses dictate behavior. The tendency towards an excessively emotional reaction to rejection, common among patients with HPD, may be attributed to a malfunction in a group of neurotransmitters called catecholamines. (Norepinephrine belongs to this group of neurotransmitters.)
  • Deveolpmental Causes:
    • Psychoanalytic theory, developed by Freud, outlines a series of psychosexual stages of development through which each individual passes. These stages determine an individual's later psychological development as an adult. Early psychoanalysts proposed that the genital phase, Freud's fifth or last stage of psychosexual development, is a determinant of HPD. Later psychoanalysts considered the oral phase, Freud's first stage of psychosexual development, to be a more important determinant of HPD. Most psychoanalysts agree that a traumatic childhood contributes towards the development of HPD. Some theorists suggest that the more severe forms of HPD derive from disapproval in the early mother-child relationship.
  • Defense Mechanisms:
    • Another component of Freud's theory, defense mechanisms are sets of systematic, unconscious methods that people develop to cope with conflict and to reduce anxiety. According to Freud's theory, all people use defense mechanisms, but different people use different types of defense mechanisms. Individuals with HPD differ in the severity of the maladaptive defense mechanisms they use. Patients with more severe cases of HPD may utilize the defense mechanisms of repression, denial , and dissociation.
      • Repression.
        • Repression is the most basic defense mechanism. When patients' thoughts produce anxiety or are unacceptable to them, they use repression to bar the unacceptable thoughts or impulses from consciousness.
      • Denial.
        • Patients who use denial may say that a prior problem no longer exists, suggesting that their competence has increased; however, others may note that there is no change in the patients' behaviors.
      • Dissociation.
        • When patients with HPD use the defense mechanism of dissociation, they may display two or more personalities. These two or more personalities exist in one individual without integration. Patients with less severe cases of HPD tend to employ displacement and rationalization as defenses.
      • Displacement
        • occurs when a patient shifts an affect from one idea to another. For example, a man with HPD may feel angry at work because the boss did not consider him to be the center of attention. The patient may displace his anger onto his wife rather than become angry at his boss.
      • Rationalization
        • occurs when individuals explain their behaviors so that they appear to be acceptable to others.
  • Biosocial Learning Causes:
    • A biosocial model in psychology asserts that social and biological factors contribute to the development of personality. Biosocial learning models of HPD suggest that individuals may acquire HPD from inconsistent interpersonal reinforcement offered by parents. Proponents of biosocial learning models indicate that individuals with HPD have learned to get what they want from others by drawing attention to themselves.
  • Sociocultural Causes:
    • Studies of specific cultures with high rates of HPD suggest social and cultural causes of HPD. For example, some researchers would expect to find this disorder more often among cultures that tend to value uninhibited displays of emotion.
  • Personal Variables:
    • Researchers have found some connections between the age of individuals with HPD and the behavior displayed by these individuals. The symptoms of HPD are long-lasting; however, histrionic character traits that are exhibited may change with age. For example, research suggests that seductiveness may be employed more often by a young adult than by an older one. To impress others, older adults with HPD may shift their strategy from sexual seductiveness to a paternal or maternal seductiveness. Some histrionic symptoms such as attention-seeking, however, may become more apparent as an individual with HPD ages.

Prevention
  • Early diagnosis can assist patients and family members to recognize the pervasive pattern of reactive emotion among individuals with HPD. Educating people, particularly mental health professionals, about the enduring character traits of individuals with HPD may prevent some cases of mild histrionic behavior from developing into full-blown cases of maladaptive HPD. Further research in prevention needs to investigate the relationship between variables such as age, gender, culture, and ethnicity and HPD.

Empirically supported treatments
  • There are no known treatments for HPD, most patients use psychotherapy, but complications are commonly caused. Medication is not a wise decision due to the risk of the patient involving the medication in a self destructive way. There are no currently no self help groups for people with HPD. The exaggerated emotional activity of HPD patients tends them to develop relationships with their therapist, severely limiting a psychologist's ability to help a HPD patient.
  • Psychodynamic therapy:
    • HPD, like other personality disorders, may require several years of therapy and may affect individuals throughout their lives. Some professionals believe that psychoanalytic therapy is a treatment of choice for HPD because it assists patients to become aware of their own feelings. Long-term psychodynamic therapy needs to target the underlying conflicts of individuals with HPD and to assist patients in decreasing their emotional reactivity. Therapists work with thematic dream material related to intimacy and recall. Individuals with HPD may have difficulty recalling because of their tendency to repress material.
  • Cognitive-behavioral therapy:
    • Cognitive therapy is a treatment directed at reducing the dysfunctional thoughts of individuals with HPD. Such thoughts include themes about not being able to take care of oneself. Cognitive therapy for HPD focuses on a shift from global, suggestible thinking to a more methodical, systematic, and structured focus on problems. Cognitive-behavioral training in relaxation for an individual with HPD emphasizes challenging automatic thoughts about inferiority and not being able to handle one's life. Cognitive-behavioral therapy teaches individuals with HPD to identify automatic thoughts, to work on impulsive behavior, and to develop better problem-solving skills. Behavioral therapists employ assertiveness training to assist individuals with HPD to learn to cope using their own resources. Behavioral therapists use response cost to decrease the excessively dramatic behaviors of these individuals. Response cost is a behavioral technique that involves removing a stimulus from an individual's environment so that the response that directly precedes the removal is weakened. Behavioral therapy for HPD includes techniques such as modeling and behavioral rehearsal to teach patients about the effect of their theatrical behavior on others in a work setting.
  • Group therapy:
    • is suggested to assist individuals with HPD to work on interpersonal relationships. Psychodrama techniques or group role play can assist individuals with HPD to practice problems at work and to learn to decrease the display of excessively dramatic behaviors. Using role-playing, individuals with HPD can explore interpersonal relationships and outcomes to understand better the process associated with different scenarios. Group therapists need to monitor the group because individuals with HPD tend to take over and dominate others.
  • Family therapy:
    • To teach assertion rather than avoidance of conflict, family therapists need to direct individuals with HPD to speak directly to other family members. Family therapy can support family members to meet their own needs without supporting the histrionic behavior of the individual with HPD who uses dramatic crises to keep the family closely connected. Family therapists employ behavioral contracts to support assertive behaviors rather than temper tantrums.

Medications
  • Pharmacotherapy is not a treatment of choice for individuals with HPD unless HPD occurs with another disorder. For example, if HPD occurs with depression, antidepressants may be prescribed. Medication needs to be monitored for abuse.

Portrayed in Popular Culture
  • Scarlett O'Hara from Gone with the Wind
  • Blance DuBois from A Streetcar Named Desire
  • The Penguin from Batman
    • He constantly compensates fro his short stance and horrible appearance with an active sense of panache
    • Constantly seeking attention to his small self
  • Bellatrix Lestrange from Harry Potter
    • The theatrical right-had woman of the Death Eaters craves the approval and appreciation of her master
    • Every movement of hers oozes sexuality

DSM-V Changes
(APA, 2010)

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301.81 Narcissistic Personality Disorder



A very intriguing interview with Charles Mansion.
http://www.youtube.com/watch?v=5uhmtAmwnDQ



















Individual diagnosed with Narcissistic PD discusses his disorder.

DSM-IV-TR criteria
  • A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
    1. has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
    2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love (perfect marriage to the perfect spouse)
    3. believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
    4. requires excessive admiration
    5. has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations ("You owe me because I'm that good")
    6. is inter-personally exploitative, i.e., takes advantage of others to achieve his or her own ends
    7. lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
    8. is often envious of others or believes that others are envious of him or her
    9. shows arrogant, haughty behaviors or attitudes

Other Symptoms:
  • history of intense but short-term relationships with others; inability to make or sustain genuinely intimate relationships
  • a tendency to be attracted to leadership or high-profile positions or occupations
  • a pattern of alternating between unrealistic idealization of others and equally unrealistic devaluation of them
  • assessment of others in terms of usefulness
  • a need to be the center of attention or admiration in a working group or social situation
  • hypersensitivity to criticism, however mild, or rejection from others
  • an unstable view of the self that fluctuates between extremes of self-praise and self-contempt
  • preoccupation with outward appearance, "image," or public opinion rather than inner reality
  • painful emotions based on shame (dislike of who one is) rather than guilt (regret for what one has done)

Associated features
  • Individuals with Narcissistic Personality Disorder are greatly lacking in empathy and are unwilling to recognize or identify with the feelings and needs of others. They see themselves as above others and feel a strong sense of entitlement and need for admiration. Narcissistic individuals do not perceive themselves as flawed and are not likely to seek treatment. Therefore, these individuals represent less than one percent of the clinical population.
  • Some people who suffer from NPD also have mood disorders. Narcissistic patients only pursue relationships that will benefit them in some way. Their inflated sense of self results in a devaluation of others and their accomplishments. Patients with narcissistic personality disorder exaggerate their achievements and talents and are surprised when they do not receive the recognition they expect. These patients are prone to be more envious of other people who possess knowledge, a specific skill, or some kind of belonging that they do not possess. Patients are very self-absorbed and have a hard time responding to the needs of others. Narcissistic individuals often exhibit a history of intense but short-term relationships with others, an inability to make or sustain genuinely intimate relationships, and an unstable view of self that fluctuates between extremes of self-praise and self-contempt. Criticism may haunt them and leave them feeling humiliated, degraded, hollow, and empty, although they don't show it. Because of the problems from entitlement and the need for admiration and their disregard for others, they have difficulty with interpersonal relationships. They may be unwilling to take part in situations in which there is risk and a possibility of defeat. NPD is also associated with anorexia nervosa, substance-related disorders, and other personality disorders.
  • If parents are neglectful, and they show no empathy toward the child, or if they devalue the child, then the child will always be seeking out this ideal sense of self, a narcissistic viewpoint. The reverse of this treatment by parents has also received some support. Narcissistic Personality Disorder could arise from parental overindulgence that is relatively painless but research is a little scarce for that proposition.

Hitler as an Example:
  • The first criterion for this disorder is the individual must have a lavish sense of self-importance, they over-estimate their abilities, and embellish their accomplishments. Hitler considered himself to be a very special person. He believed that he was an astounding artist and had no doubt that he was going to get into the art school in Vienna and when he didn’t he was astounded. He let the people around him believe that he had been accepted to the Viennese Academy of Fine Arts when in fact he was rejected twice.
  • The second criterion of Narcissistic Personality Disorder is the individual must be preoccupied with fantasies of unlimited success and power. In Hitler’s earlier years he had fantasies about becoming a great and powerful artist. Later he developed the fantasy of becoming the world’s greatest and most powerful leader by exterminating Jews.
  • The third criterion is that the individual believes that they are superior, special, or unique. Hitler believed that his opinions were more advanced than those around him. He insisted that everyone listen to him and he often quarreled with those who opposed him.
  • Hitler met the fourth criterion as well by needing excessive admiration. He was admired by many he came in contact with. He was able to string his friend Gustl around for so long because of the admiration Gustl had for Hitler.
  • The fifth criterion is the sense of entitlement. Hitler expected others to cater to his every need, especially his mother, sister, and aunt. Later in his life, he expected his servants and military men to serve and give him everything he wanted.
  • The sixth criterion and one of the ones Hitler showed most prominently is the exploitation of others. In his business deals, he did whatever he needed to, in order to benefit himself, even if that meant hanging others out to dry or throwing them under the bus so to speak.
  • The seventh criterion is the lack of empathy. Hitler had absolutely no empathy for what he was doing during World War II. Killing Jews and anyone who aided their survival was something easy and painless for Hitler. However, he did have empathy for his mother.
  • Envy is the eighth criteria. Individuals with Narcissistic Personality Disorder envy others and believe that others envy them as well. Hitler was very envious of Gustl’s acceptance into the Vienna Conservatoire to practice his Grand Piano.
  • The final criterion is an arrogant, snobbish, or patronizing attitude towards others. Adolf Hitler was to say the least arrogant, snobbish, and patronizing. He believed that he was the greatest artist, the smartest man, better than women, and anyone different from him was inferior.
  • It is evident that Hitler possessed characteristics that fall under all nine of the criteria so it could be possible that Hitler had Narcissistic Personality Disorder
  • (Kershaw, 2008)

Subtypes of NPD
  • Age Group Subtype:
    • According to the Encyclopedia of mental disorders, ever since the 1950s, when psychiatrists began to notice an increase in the number of their patients that had narcissistic disorders, they have made attempts to define these disorders more precisely. NPD was introduced as a new diagnostic category in DSM-III , which was published in 1980. Prior to DSM-III , narcissism was a recognized phenomenon but not an official diagnosis. At that time, NPD was considered virtually untreatable because people who suffer from it rarely enter or remain in treatment; typically, they regard themselves as superior to their therapist, and they see their problems as caused by other people's "stupidity" or "lack of appreciation."
    • psychiatrists have proposed dividing narcissistic patients into two subcategories based roughly on age: those who suffer from the stable form of NPD described by DSM-IVTR , and younger adults whose narcissism is often corrected by life experiences.
    • This age group distinction represents an ongoing controversy about the nature of NPD—whether it is fundamentally a character disorder, or whether it is a matter of learned behavior that can be unlearned. Therapists who incline toward the first viewpoint are usually pessimistic about the results of treatment for patients with NPD.
  • Personality Subtype
    • Other psychiatrists have noted that patients who meet the DSM-IV-TR criteria for NPD reflect different clusters of traits within the DSM-IV-TR list. One expert in the field of NPD has suggested the following subcategories of narcissistic personalities:
      • Craving narcissists. These are people who feel emotionally needy and undernourished, and may well appear clingy or demanding to those around them.
      • Paranoid narcissists. This type of narcissist feels intense contempt for him- or herself, but projects it outward onto others. Paranoid narcissists frequently drive other people away from them by hypercritical and jealous comments and behaviors.
      • Manipulative narcissists. These people enjoy "putting something over" on others, obtaining their feelings of superiority by lying to and manipulating them.
      • Phallic narcissists. Almost all narcissists in this subgroup are male. They tend to be aggressive, athletic, and exhibitionistic; they enjoy showing off their bodies, clothes, and overall "manliness."

Child vs. Adult Presentation
  • NPD has been seen in children, adolescents, and adulthood. There have been no further studies to determine the differences in age of this disorder. The presentation of the disorder in children and adolescents are similar the the adult presentation.

Gender and Cultural Differences in Presentation
  • NPD is seen more in men than in women (7.7% for men and 4.8% for women) based on 34,653 face-to-face structured interviews that included DSM-IV diagnostic criteria. Black men and Hispanic women had higher rates compared with Hispanic men and Caucasians of either gender. 50%-75% of all patients are men.

Epidemiology
  • The prevalence of Narcissistic Personality Disorder within the general population ranges from 2 to 16 percent in the general population, but is less than 1 percent in the clinical population. The fact that these individuals represent less than 1 percent of the clinical population is not surprising because these individuals rarely, if ever, seek out treatment. The reason is quite clear: These individuals see themselves (and their lives) as nearly perfect and do not see any need for change.
  • For NPD, there have been no known genetic or environmental factors. It is believed that this is seen when parents over-indulge in the amount of encouragement they display to their child, over-zealously praise the accomplishments of the child, tell their child that they are not responsible for their own wrongdoings or spoiling their child.
  • However,additional evidence suggests a genetic influence may be at play in determining the character of NPD. These inherited aspects include hypersensitivity, aggression, low frustration tolerance, and problems in affect regulation.
  • Some researchers believe that Narcissistic individuals don't grow out of the period when they don't see the viewpoint of others as a child.
  • In the clinical practice for substance abuse, 10 to 15% have Narcissistic Personality Disorder (SAMHSA, 2009).

Etiology
  • The Encyclopedia states that at present there are two major theories about the origin and nature of NPD. One theory regards NPD as a form of arrested psychological development while the other regards it as a young child's defense against psychological pain. The two perspectives have been identified with two major figures in psychoanalytic thought, Heinz Kohut and Otto Kernberg respectively
  • Both theories about NPD go back to Sigmund Freud's pioneering work On Narcissism, published in1914. In this essay, Freud introduced a distinction which has been retained by almost all later writers—namely, the distinction between primary and secondary narcissism. Freud thought that all human infants pass through a phase of primary narcissism, in which they assume they are the center of their universe. This phase ends when the baby is forced by the realities of life to recognize that it does not control its parents (or other caregivers) but is in fact entirely dependent on them. In normal circumstances, the baby gives up its fantasy of being all-powerful and becomes emotionally attached to its parents rather than itself. What Freud defined as secondary narcissism is a pathological condition in which the infant does not invest its emotions in its parents but rather redirects them back to itself. He thought that secondary narcissism developed in what he termed the pre-Oedipal phase of childhood; that is, before the age of three. From a Freudian perspective, then, narcissistic disorders originate in very early childhood development, and this early origin is thought to explain why they are so difficult to treat in later life.
  • Kohut and Kernberg agree with Freud in tracing the roots of NPD to disturbances in the patient's family of origin—specifically, to problems in the parent-child relationship before the child turned three. Where they disagree is in their accounts of the nature of these problems. According to Kohut, the child grows out of primary narcissism through opportunities to be mirrored by (i.e., gain approval from) his or her parents and to idealize them, acquiring a more realistic sense of self and a set of personal ideals and values through these two processes. On the other hand, if the parents fail to provide appropriate opportunities for idealization and mirroring, the child remains "stuck" at a developmental stage in which his or her sense of self remains grandiose and unrealistic while at the same time he or she remains dependent on approval from others for self-esteem
  • In contrast, Kernberg views NPD as rooted in the child's defense against a cold and unempathetic parent, usually the mother. Emotionally hungry and angry at the depriving parents, the child withdraws into a part of the self that the parents value, whether looks, intellectual ability, or some other skill or talent. This part of the self becomes hyperinflated and grandiose. Any perceived weaknesses are "split off" into a hidden part of the self. Splitting gives rise to a lifelong tendency to swing between extremes of grandiosity and feelings of emptiness and worthlessness.
  • In both accounts, the child emerges into adult life with a history of unsatisfactory relationships with others. The adult narcissist possesses a grandiose view of the self but has a conflict-ridden psychological dependence on others. At present, however, psychiatrists do not agree in their description of the central defect in NPD; some think that the problem is primarily emotional while others regard it as the result of distorted cognition, or knowing. Some maintain that the person with NPD has an "empty" or hungry sense of self while others argue that the narcissist has a "disorganized" self. Still others regard the core problem as the narcissist's inability to test reality and construct an accurate view of him- or herself

Macrosocial Causes.
  • One dimension of NPD that must be taken into account is its social and historical context. Psychiatrists became interested in narcissism shortly after World War II (1939–45), when the older practitioners in the field noticed that their patient population had changed. Instead of seeing patients who suffered from obsessions and compulsions related to a harsh and punishing superego (the part of the psyche that internalizes the standards and moral demands of one's parents and culture), the psychiatrists were treating more patients with character disorders related to a weak sense of self. Instead of having a judgmental and overactive conscience, these patients had a weak or nonexistent code of morals. They were very different from the patients that Freud had treated, described, and analyzed. The younger generation of psychiatrists then began to interpret their patients' character disorders in terms of narcissism.
  • In the 1960s historians and social critics drew the attention of the general public to narcissism as a metaphorical description of Western culture in general. These writers saw several parallels between trends in the larger society and the personality traits of people diagnosed with narcissistic disorders. In short, they argued that the advanced industrial societies of Europe and the United States were contributing to the development of narcissistic disorders in individuals in a number of respects. Some of the trends they noted include the following:
    • The mass media's preoccupation with "lifestyles of the rich and famous" rather than with ordinary or average people.
    • Social approval of open displays of money, status, or accomplishments ("if you've got it, flaunt it") rather than modesty and self-restraint.
    • Preference for a leadership style that emphasizes the leader's outward appearance and personality rather than his or her inner beliefs and values.
    • The growth of large corporations and government bureaucracies that favor a managerial style based on "impression management" rather than objective measurements of performance.
    • Social trends that encourage parents to be self-centered and to resent their children's legitimate needs.
    • The weakening of churches, synagogues, and other religious or social institutions that traditionally helped children to see themselves as members of a community rather than as isolated individuals

Empirically Supported Treatments
  • For NPD, the treatment of choice is normally Psychotherapy, but this method may prove problematic because the patient may become envious of the therapist and not respond to them. Long -Term Care Individual Counseling for these patients is recommended to help manage not only the self-aggrandizement, hypersensitivity, and need for control and attention, but also their anger and depression.
    Group Therapy is another option for patients, but the therapist should set down boundaries and limits on time, interruptions, the respect of others' feeling, responding to other group members, and listening to others' responses and feedback.
  • It's important to obtain treatment as quickly as possible to avoid the onset of other disorders. Also, treatment should be continued for as long as allowed as personality traits are often very difficult to change. The inability to change is even more of a problem for the narcissistic type because, after all, they have the best personality already

Psychotherapy
  • Several different approaches to individual therapy have been tried with NPD patients, ranging from classical psychoanalysis and Adlerian therapy to rationalemotive approaches and Gestalt therapy . The consensus that has emerged is that therapists should set modest goals for treatment with NPD patients. Most of them cannot form a sufficiently deep bond with a therapist to allow healing of early-childhood injuries. In addition, the tendency of these patients to criticize and devalue their therapists (as well as other authority figures) makes it difficult for therapists to work with them.
  • An additional factor that complicates psychotherapy with NPD patients is the lack of agreement among psychiatrists about the causes and course of the disorder. One researcher has commented that much more research is necessary to validate DSM-IV-TR 's description of NPD before outcome studies can be done comparing different techniques of treatment

Hospitalization
  • Low-functioning patients with NPD may require inpatient treatment, particularly those with severe self-harming behaviors or lack of impulse control. Hospital treatment, however, appears to be most helpful when it is focused on the immediate crisis and its symptoms rather than the patient's underlying long-term difficulties
  • Read more: www.minddisorders.com

Medication
  • As of 2002, there are no medications that have been developed specifically for the treatment of NPD. Patients with NPD who are also depressed or anxious may be given drugs for relief of those symptoms. There are anecdotal reports in the medical literature that the selective serotonin reuptake inhibitors, or SSRIs, which are frequently prescribed for depression, reinforce narcissistic grandiosity and lack of empathy with others

Prognosis
  • The prognosis for younger persons with narcissistic disorders is hopeful to the extent that the disturbances reflect a simple lack of life experience. The outlook for long-standing NPD, however, is largely negative. Some narcissists are able, particularly as they approach their midlife years, to accept their own limitations and those of others, to resolve their problems with envy, and to accept their own mortality. Most patients with NPD, on the other hand, become increasingly depressed as they grow older within a youth-oriented culture and lose their looks and overall vitality. The retirement years are especially painful for patients with NPD because they must yield their positions in the working world to the next generation. In addition, they do not have the network of intimate family ties and friendships that sustain most older people

Prevention
  • The best hope for prevention of NPD lies with parents and other caregivers who are close to children during the early preschool years. Parents must be able to demonstrate empathy in their interactions with the child and with each other. They must also be able to show that they love their children for who they are, not for their appearance or their achievements. And they must focus their parenting efforts on meeting the child's changing needs as he or she matures, rather than demanding that the child meet their needs for status, comfort, or convenience

Portrayed in Popular Culture
  • In Greek mythology, Narcissus was a very beautiful guy that all the girls wanted to date, but Narcissus wanted nothing to do with them. He would pass by the loveliest and the most beautiful girls, not even bothering to look at them. One of his spurned lovers prayed to the goddess Nemesis that "he who loves not others love himself". Nemesis granted that prayer, and when Narcissus bent over a clear pool to get a drink of water, he saw a reflection of himself and fell in love with it. He could not leave his image, and so he pined away, leaning perpetually over the pool, fixed in one long gaze until he died. They say that when his spirit crossed the river that encircles the world of the dead, it leaned over the boat to catch one last glimpse of itself in the water (Hamilton, 1969).
  • Wall Street (1987)
  • To Die For (1995)
  • The Scarecrow from Batman
    • A psychiatrist himself, highly intellectual and generally condescending
  • Gilderoy Lockhart from Harry Potter
    • Self-indulgent and always expecting admiration and adoration, even where lacking

DSM-V Changes
(APA, 2010)

For More Information, Please Read:

Links

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301.6 Dependent Personality Disorder


DSM-IV-TR criteria
  • A pervasive and excessive need to be taken are of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
    1. has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
    2. needs others to assume responsibility for most major areas of his or her life
    3. has difficulty expressing disagreement with others because of fear of loss of support or approval NOTE: Do not include realistic fears of retribution.
    4. has difficulty initiating projects or doing things on his or her own (because of lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)
    5. goes to excessive lengths to obtain nurture and support from others, to the point of volunteering to do things that are unpleasant
    6. feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself
    7. urgently seeks another relationship as a source of care and support when a close relationship ends
    8. is unrealistically preoccupied with fears of being left to take care of himself or herself






















Associated features
  • Dependent individuals are often very pessimistic, self-defeating, and exhibit low self-esteem. They tend to belittle their assets and to refer to themselves as "stupid." They take criticism very personally, seeing it as "proof" of their worthlessness. Their tendency is to seek out over protection and dominance from others. These individuals become very anxious when faced with a decision and may avoid positions of responsibility. Chronic physical illness or Separation Anxiety Disorder in childhood may predispose an individual to developing Dependent Personality Disorder.
  • There may be an increased risk of Mood Disorders, Adjustment Disorder, and Anxiety Disorders.
  • These individuals lack self confidence and lack a sense of autonomy. They see themselves as extremely weak and others very powerful. They are extremely dependent on others and have a great need to be taken care of, which makes these individuals cling to others and to be submissive to others' wishes and demands. When one relationship ends, they become desperate and have to form another relationship to replace the broken one. Some individuals panic if they have to be alone or separated from depended-upon people.
  • They do not demonstrate appropriate anger with other people because they are terrified of losing their support. As a result, they remain in psychologically and physically damaging and abusive relationships. They, in effect, lose their individuality because they let others make the decisions, both large and small in their lives.

Child vs. Adult Presentation
  • This diagnosis is only cautiously given to children and adolescents, as some dependent behavior may be developmentally appropriate at this time.
  • Symptoms in adults are very similar to Separation Anxiety in children.

Gender and Cultural Differences in Presentation
  • Prevalence rates are significantly higher in India and Japan, possible because dependent behaviors is expected and encouraged, especially for women.
  • Dependent Personality Disorder occurs more frequently in women, and is co-morbid with Borderline, Schizoid, Histrionic, Schizotypal, and Avoidant Personality disorders. There is also co-morbidity within the Axis I disorders of Bipolar Disorder, unipolar depression (or major depressive episode), anxiety disorders, and Bulimia Nervosa.

Epidemiology
  • Dependent PD is one of the most reported Personality Disorders in mental health clinics and they do not give a percentage of prevalence. But a reasonable estimate is from 0.5% to 1.5% of people in the general population have this type of PD. There is around 1.4% in outpatient psychiatric settings; there are no significant familial problems.
  • It is reported that about 10% of outpatients seen in mental health clinics also have Dependent PD (SAMHSA, 2009).

Etiology
  • Parents who are more authoritative (holds very high standard for achievement and low in giving love and attention to the child) can cause person to develop Dependent PD because the person is not used to making their own choices and decisions. Parenting styles are authoritative, meaning many rules and chores.
    • People with Dependent PD have very low sense of self-efficacy. There is restricted development of self-efficacy. They often don't believe that they are able to do some things by themselves.
    • Females diagnosed with Dependent PD generally have a history of depression or depressive symptoms in early adolescent girls.
    • Peers may have responded to these individuals with rejection, teasing, and other remarks on their dependence and incompetence, thereby reinforcing the views conveyed by caregivers that the person with DPD is in dire need of constant care.
    • Infantile temperament may be an additional variable that interacts with parenting style to further elicit overprotective and authoritarian responses to the individual child.

Empirically Supported Treatments
  • Psychotherapy
    • Used as treatment for people with dependent personality disorder. Cognitive-behavioral therapy focuses on patterns of maladaptive thinking and seeks to eliminate them. Often people in cognitive-behavioral therapy set goals that they eventually try to achieve without relying on others. Interpersonal therapy is also a useful approach. Often the patient is receptive to the treatment and seeks help with their personal relationships. With this particular kind of therapy, the therapist will help the patient understand how they interact with others and how this contributes to their dependency issues. This particular therapies purpose is to show the patient that their dependency comes with a high price and that they do have alternatives. Another type of therapy used to treat dependent personality disorder is group therapy. Often people taking part in group therapy must be highly motivated to see improvement. Studies show that time-limited assertiveness-training groups with very clear goals are successful. It has also been said that family or martial therapy can improve a person's independence by working on the families relationship as a whole.
  • Cognitive-behavioral therapy
    • Cognitive-behavioral approaches attempt to increase the affected person's ability to act independently of others, improve their self-esteem, and enhance the quality of their interpersonal relationships. Often, patients will play an active role in setting goals. Methods often used in cognitive-behavioral therapy (CBT) include assertiveness and social skills training to help reduce reliance on others, including the therapist.
  • Interpersonal therapy
    • Treatment using an interpersonal approach can be useful because the individual is usually receptive to treatment and seeks help with interpersonal relationships. The therapist would help the patient explore their long-standing patterns of interacting with others, and understand how these have contributed to dependency issues. The goal is to show the patient the high price they pay for this dependency, and to help them develop healthier alternatives. Assertiveness training and learning to identify feelings is often used to improve interpersonal behavior
  • Group therapy
    • When a person is highly motivated to see growth, a more interactive therapeutic group can be successful in helping him/her to explore passive-dependent behavior. If the individual is socially reluctant or impaired in his/her assertiveness, decision-making, or negotiation, a supportive decision-making group would be more appropriate. Time-limited assertiveness-training groups with clearly defined goals have been proven to be effective
  • Family and marital therapy
    • Individuals with dependent personality disorder are usually brought to therapy by their parents. They are often young adults who are struggling with neurotic or psychotic symptoms. The goal of family therapy is often to untangle the enmeshed family relationships, which usually elicits considerable resistance by most family members unless all are in therapy. Marital therapy can be productive in helping couples reduce the anxiety of both partners who seek and meet dependency needs that arise in the relationship.

Medications
  • According to the encyclopedia of mental disorders, Individuals with dependent personality disorder can experience anxiety and depressive disorders as well. In these cases, it may occasionally prove useful to use antidepressants or anti-anxiety agents. Unless the anxiety or depression is considered worthy of a primary diagnosis, medications are generally not recommended for treatment of the dependency issues or the anxiety or depressive responses. Persons with dependent personality disorder may become overly dependent on any medication used
  • Antidepressants, anti-anxiety agents, sedatives, and tranquilizers.
  • Dependency can eventually become an issue for someone using one of these medications, therefore most often they are not prescribed.

Prevention
  • Since dependent personality disorder originates in the patient's family, the only known preventive measure is a nurturing, emotionally stimulating, and expressive care giving environment

Portrayed in Popular Culture
  • Bella/Edward relationship from Twilight
  • They are completely dependent on each other to the point of being suicidal without the other
  • Peter Pettigrew from Harry Potter
    • The once friend of James Potter shifts the target of his submissive behavior from James and his friends to Voldemort and the Death Eaters.
    • In The Prisoner of Azkaban, when his transgressions are revealed, Peter soon tries to gain anybody's approval by groveling and pleading

DSM-V Changes
(APA, 2010)






















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301.82 Avoidant Personality Disorder


DSM-IV-TR criteria
  • A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety o contexts, as indicated by four (or more) of the following:
    1. avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
    2. is unwilling to get involved with people unless certain of being liked
    3. shows restraint within intimate relationships because of the fear of being shamed or ridiculed
    4. is preoccupied with being criticized or rejected in social situations
    5. is inhibited in new interpersonal situations because of feelings of inadequacy
    6. views self as socially inept, personally unappealing, or inferior to others
    7. is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Associated features
  • People with Avoidant Personality Disorder often appraise every movement and expression of those whom they are around. They can be fearful and tense which can elicit the ridicule of others which confirm preconceived self-doubts. They tend to be very anxious thinking that they will react to criticism with crying or blushing. Others describe them as "shy," "lonely," "timid," and "isolated." Their major problems are in social and occupational functioning. Their low self-esteem and hypersensitivity to rejection can restrict interpersonal contacts. Individuals may become isolated and do not usually have a large social support network to help them. They want affection and acceptance and fantasize over idealized relationships. The avoidance behaviors also adversely affect occupational functioning because of the fear the individuals have of social situations. They may try to avoid situations that are important for jobs and advancements.
  • These individuals are fearful of the possibility of criticism, rejection, or disapproval and therefore, will usually not engage in social relationships unless they are assured of being liked. However, these individuals desire affection and thus are often lonely and bored. They may even go to the extreme where they avoid work situations that involve a lot of interpersonal situations and contacts. Being alone is not enjoyed and is caused by their inability to relate to others, which causes extreme anxiety and often leads to low self-esteem and being excessively self-conscious. Ridicule and rejection are seen when in fact none exists. Also, they also tend to say or do little when they have to be involved in social situations because they are fearful that they will say something silly or foolish. They see themselves as being incompetent, inferior to other people, and are not risk takers. They generally do not get involved in or with new activities.
  • Co-morbidity is often displayed with Dependent Personality Disorder. This occurs because when a friend or friends are made, they become extremely attached to and dependent on that individual. Avoidant personality disorder is also co-morbid with Borderline PD and the Cluster A disorders, Paranoid, Schizoid, and Schizotypal. It is often diagnosed with Mood and Anxiety Disorders, especially generalized Social Phobia and unipolar depression.

Child vs. Adult Presentation
  • Avoidant Personality Disorder does not typically become a diagnosis of children. The normal guideline is that usually no one under the age of 18 are diagnosed with this disorder. Most patients, however, report that their symptoms were present during childhood or adolescents.

Gender and Cultural Differences in Presentation
  • There may be variations in the prevalence of diagnosed individuals across cultures as the degree of appropriate diffidence and avoidance differs between societies. Avoidant behavior may also be influenced by problems in acculturation following immigration ("culture shock"). Avoidant Personality Disorder seems to occur equally between males and females.

Epidemiology
  • Prevalence rates of Avoidant Personality Disorder for the general population are between 0.5% and 1%. There is a prevalence rate between 2% and 5% in the general population, and around 15% in psychiatric outpatient settings. It is reported that about 10% of outpatients seen in mental health clinics also have Avoidant Personality Disorder.
  • Avoidant behavior often starts in infancy. Shyness is normal in children, but tends to dissipate with age. Those who develop Avoidant Personality Disorder may become increasingly shy over time. Some evidence suggests that APD tends to lesson or remit with age.

Etiology
  • There is evidence to suggest that genetic factors play a role in the development of Avoidant PD. Shyness is also believed to be genetically inherited or linked to a person. There is a link to bio-genetic tendencies toward a lowered autonomic arousal threshold.
  • Environmental factors also play a role in a person with Avoidant PD. A history of being ridiculed or rejection may cause the person to later develop this disorder.
  • May have parental or peer rejection and/or ridicule.
  • Recent studies show evidence of shyness in post birth temperaments (compared to children the same age).

Empirically Supported Treatments
  • A mixture of medication to reduce sensitivity when being rejected and cognitive therapy seems to work best for people with Avoidant PD compared to medication alone or therapy alone.
  • Treatment can be vital to living anything close to a "normal" life. Without treatment, those who suffer from APD make retreat completely to their homes. They will begin to avoid every and any social event instead of just most. They might also develop a second disorder along with their APD that could have been completely avoided altogether.
  • Psychodynamically oriented therapies
    • According to the Encyclopedia of Mental Disorders these approaches are usually supportive; the therapist empathizes with the patient's strong sense of shame and inadequacy in order to create a relationship of trust. Therapy usually moves slowly at first because persons with avoidant personality disorder are mistrustful of others; treatment that probes into their emotional state too quickly may result in a more protective withdrawal by the patient. As trust is established and the patient feels safer discussing details of his or her situations, he or she may be able to draw important connections between their deeply felt sense of shame and their behavior in social situations.
  • Cognitive-behavioral therapy (CBT)
    • may be helpful in treating individuals with avoidant personality disorder. This approach assumes that faulty thinking patterns underlie the personality disorder, and therefore focuses on changing distorted cognitive patterns by examining the validity of the assumptions behind them. If a patient feels he is inferior to his peers, unlikable, and socially unacceptable, a cognitive therapist would test the reality of these assumptions by asking the patient to name friends and family who enjoy his company, or to describe past social encounters that were fulfilling to him. By showing the patient that others value his company and that social situations can be enjoyable, the irrationality of his social fears and insecurities are exposed. This process is known as "cognitive restructuring."
  • Group therapy:
    • may provide patients with avoidant personality disorder with social experiences that expose them to feedback from others in a safe, controlled environment. They may, however, be reluctant to enter group therapy due to their fear of social rejection. An empathetic environment in the group setting can help each member overcome his or her social anxieties. Social skills training can also be incorporated into group therapy to enhance social awareness and feedback.
  • Family and marital therapy:
    • Family or couple therapy can be helpful for a patient who wants to break out of a family pattern that reinforces the avoidant behavior. The focus of marital therapy would include attempting to break the cycle of rejection, criticism or ridicule that typically characterizes most avoidant marriages. Other strategies include helping the couple to develop constructive ways of relating to one another without shame.

Medications
  • The use of monoamine oxidase inhibitors (MAOIs) has proven useful in helping patients with avoidant personality disorder to control symptoms of social unease and experience initial success. The major drawback of these medications is limitations on the patient's diet. People taking MAOIs must avoid foods containing a substance known as tyramine, which is found in most cheeses, liver, red wines, sherry, vermouth, beans with broad pods, soy sauce, sauerkraut, and meat extracts.

Prevention
  • Since avoidant personality disorder usually originates in the patient's family of origin, the only known preventive measure is a nurturing, emotionally stimulating and expressive family environment.
  • Read more: www.encyclopediaofmentaldisorders.com

Avoidant PD versus Social Phobia
  • Looking at psychophysiological and cognitive variables, there are no differences between the two
  • There were differences on behavioral skill factors, molecular behaviors such as eye contact, and on overall skill
  • Avoidant PDs were less socially skilled than those with social phobia
    • APD reported:
      • more social avoidance and subjective distress
      • significantly higher score on the SCL-90-R Interpersonal Sensitivity scale as well as on the SCL-90-R Anxiety, Depression, and Obsessive-Compulsive subscales
(Turner, Beidel, Dancu, & Keys, 1986)

Portrayed in Popular Culture
  • Rubeus Hagrid from Harry Potter
    • Although he develops strong relationships with several characters in the series, his half-giant background and shameful exits from Hogwarts make him very sensitive to the opinions of others

DSM-V Changes
  • Reformulated as the Avoidant Type
  • Individuals who match this personality disorder type have a negative sense of self, associated with a profound sense of inadequacy, and inhibition in establishing intimate interpersonal relationships.
  • More specifically, they feel anxious, inadequate, inferior, socially inept, and personally unappealing; are easily ashamed or embarrassed; and are self-critical, often setting unrealistically high standards for themselves.
  • At the same time, they may have a desire to be recognized by others as special and unique.
  • Avoidant individuals are shy or reserved in social situations, avoid social and occupational situations because of fear of embarrassment or humiliation, and seek out situations that do not include other people.
  • They are preoccupied with and very sensitive to being criticized or rejected by others and are reluctant to disclose personal information for fear of disapproval or rejection.
  • They appear to lack basic interpersonal skills, resulting in few close friendships. Intimate relationships are avoided because of a general fear of attachments and intimacy, including sexual intimacy.
  • Individuals resembling this type tend to blame themselves or feel responsible for bad things that happen, and to find little or no pleasure, satisfaction, or enjoyment in life’s activities.
  • They also tend to be emotionally inhibited or constricted and have difficulty allowing themselves to acknowledge or express their wishes, emotions – both positive and negative – and impulses.
  • Despite high standards, affected individuals may be passive and unassertive about pursuing personal goals or achieving successes, sometimes leading to aspirations or achievements below their potential.
  • They are often risk averse in new situations
  • Instructions
(APA, 2010)






















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301.4 Obsessive-Compulsive Personality Disorder


DSM-IV-TR Criteria
  • A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
    1. is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
    2. shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met)
    3. is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)
    4. is over conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)
    5. is unable to discard worn-out or worthless objects even when they have no sentimental value
    6. is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things
    7. adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes
    8. shows rigidity and stubbornness

Associated Features
  • Obsessive compulsive personality disorder (OCPD) is a disorder in which the subject suffers from an obsession with control and rules and becomes so fixated on following these rules or rituals that it becomes detrimental to their day to day lives. They believe that these rules and rituals keep them from harm. This harm is something they perceive out of their own warped perspective. People with OCPD experience things such as rigidity, indecisiveness, and depressed demeanor.
  • Relationships are hard to maintain due to their volatility. This volatility surfaces when this person is put in a situation where they have lost control. Some resort to aggressive behavior while others may simply withdraw from the situation completely. The subject generally does not express emotion very well. People who suffer from this disease tend to excel at school or work because of their devotion to rules. Though beneficial in some situations this dedication to rules often leads to failure because of their lack of flexibility when unexpected change occurs.
  • These individuals are preoccupied with maintaining control mentally and in their interpersonal relationships. They make sure they do not make a mistake, and often check for the presence of mistakes. Much attention to detail is observed, and this often causes homework to not get completed because of perfectionist qualities. They tend to be workaholics and are not involved in many leisure activities; there may be problems in relaxing or having any type of fun.
  • They demand everything be done their way and posses stubborn qualities. Individuals are usually serious, rigid, formal, inflexible, and tend to be extremely moral. They tend to be stingy and want to save useless stuff of no value. Basically, those that cannot let loose, are cold, and stiff with anal tendencies most likely retentive. The OCPD is different from obsessive-compulsive disorder (OCD) in that the personality disorder does not include the obsessions and compulsions that define OCD. These disorders are contrary to popular belief that they are related on the same spectrum
  • Co-morbidity is often seen with Dependent Personality Disorder, and Avoidant Personality Disorder.
  • The most common types of obsessions in persons with OCD in Western countries are:
      • fear of contamination (impurity, pollution, badness)
      • doubts (worrying about whether one has omitted to do something)
      • an intense need to have or put things in a particular order
      • aggressive or frightening impulses
      • recurrent sexual thoughts or image
  • The most common types of compulsions in persons with OCD in Western countries are:
    • washing/cleaning
    • counting
    • hoarding
    • checking
    • putting objects in a certain order
    • repeated "confessing" or asking others for assurance
    • repeated actions
    • making lists The most common compulsions in Western countries are:


Child vs. Adult Presentation
  • Once this disorder begins to manifest itself in early adulthood, there is no child presentation to compare with the adult presentation.
  • Unusual behaviors in children that may be signs of OCD include:
      • Avoidance of scissors or other sharp objects. A child may be obsessed with fears of hurting herself or others.
      • Chronic lateness or dawdling. The child may be per forming checking rituals (repeatedly making sure all her school supplies are in her book bag, for example).
      • Daydreaming or preoccupation. The child may be counting or performing balancing rituals mentally.
      • Spending long periods of time in the bathroom. The child may have a hand washing compulsion.
      • Schoolwork handed in late or papers with holes erased in them. The child may be repeatedly checking and correcting her work.

Gender and Cultural Differences in Presentation
  • Men are twice as likely to suffer from this disorder as women. Some researchers theorize that the cause of the gender difference is due to the Western culture allowing men to act more controlling and stubborn.

Epidemiology
  • This disorder appears to only be present in approximately 1% of the United States population. It also seems to affect men more often than women. There is prevalence between 2% and 8% in the general population, and between 8% and 9% in outpatient psychiatric settings. And anywhere from 3% to 10% of individuals in mental health clinics have Obsessive-Compulsive Personality Disorder. There are no significant familial problems.

Etiology
  • The causes of OCPD are not well-known. Research leads us to believe that most sufferers are genetically predisposed. Another assumption is that OCPD is caused by things such as rigid parenting with young children. Children that are punished too harshly and receive little or no positive reinforcement for their good behavior are likely to develop this disorder. In most cases the children who develop OCPD are the oldest children in their families. Individuals were often punished for failing to be perfect and received no rewards for success. Affection and emotions were expected to be controlled or remain unexpressed.
  • These individuals do not generally present themselves voluntarily to treatment settings, thus making these disorders more difficult to properly research. Those that do come in are in a debilitated state, and it becomes difficult to specify the causal factors because we have to go back and piece together the etiological pieces of the puzzle. The most critical problem is that many of the Personality Disorders are co-morbid with each other, making it very difficult to separate out which factors are unique to each disorder.
  • Individuals with OCPD expect others to judge and criticize them in the same way that caregivers did during their development. Therefore, individuals with OCPD judge others by the same strict standards and self-criticize in the same manner as the caregivers who once criticized them.
  • Psychosocial causes:
    • In the early part of the century, Sigmund Freud theorized that OCD symptoms were caused by punitive, rigid toilet-training practices that led to internalized conflicts. Other theorists thought that OCD was influenced by such wider cultural attitudes as insistence on cleanliness and neatness, as well as by the attitudes and parenting style of the patient's parents. Cross-cultural studies of OCD indicate that, while the incidence of OCD seems to be about the same in most countries around the world, the symptoms are often shaped by the patient's culture of origin
  • Biological causes:
    • There is considerable evidence that OCD has a biological component. Some researchers have noted that OCD is more common in patients who have suffered head trauma or have been diagnosed with Tourette's syndrome. Recent studies using positron emission tomography (PET) scanning indicate that OCD patients have patterns of brain activity that differ from those of people without mental illness or with some other mental illness. Other studies using magnetic resonance imaging (MRI) found that patients diagnosed with OCD had significantly less white matter in their brains than did normal control subjects. This finding suggests that there is a widely distributed brain abnormality in OCD. Some researchers have reported abnormalities in the metabolism of serotonin, an important neurotransmitter, in patients diagnosed with OCD. Serotonin affects the efficiency of communication between the front part of the brain (the cortex) and structures that lie deeper in the brain known as the basal ganglia. Dysfunction in the serotonergic system occurs in certain other mental illnesses, including major depression. OCD appears to have a number of features in common with the so-called obsessive-compulsive spectrum disorders, which include Tourette's syndrome; Sydenham's chorea; eating disorders; trichotillomania ; and delusional disorders. There appear to be genetic factors involved in OCD. The families of persons who are diagnosed with the disorder have a greater risk of OCD and tic disorders than does the general population. Childhood-onset OCD appears to run in families more than adult-onset OCD, and is more likely to be associated with tic disorders. Twin studies indicate that monozygotic, or identical twins, are more likely to share the disorder than dizygotic, or fraternal twins (www.minddisorders).

Empirically Supported Treatments
  • Treatment for this disease is mostly limited to psychotherapy and self help treatments. Generally very difficult to treat, Cluster C seems most promising to treat and Cluster A least so.
  • Medicine seems to only alleviate some depressive symptoms but doesn’t seem to improve symptoms in the long term sense. Obsessions can be influenced with selective serotonin re-uptake inhibitors or mono amine oxidase inhibitors.
  • In extreme cases electro-convulsive therapy (ECT) or neurosurgery are used.
  • Prevention is also almost impossible. As stated earlier most cases are people who are genetically predisposed. Early detection and treatment offers the best results.
  • Therapy for this disorder can be quite difficult. Because of patients obsession with rules and doing things their own way it is difficult to teach them a new concept.

Medications
  • According to the encyclopedia of Menatal Disorders, the most useful medications for the treatment of OCD are the selective serotonin reuptake inhibitors (SSRIs), which affect the body's reabsorption of serotonin, a chemical in the brain that helps to transmit nerve impulses across the very small gaps between nerve cells. These drugs, specifically **clomipramine** (Anafranil), **fluoxetine** (Prozac), fluvoxamine (Luvox), **sertraline** (Zoloft), and **paroxetine** (Paxil) have been found to relieve OCD symptoms in over half of the patients studied. It is not always possible for the doctor to predict which of the SSRIs will work best for a specific patient. Lack of response to one SSRI does not mean that other drugs within the same family will not work. Treatment of OCD often proceeds slowly, with various medications being tried before the most effective one is found. While studies report that about half of those treated with SSRIs show definite improvement, relapse rates may be as high as 90% when medications are discontinued.

Portrayed in Popular Culture
  • Jerry from Seinfeld
    • He is characterized by rigid conformity to rules, moral codes, and excessive orderliness
  • Monk from Monk
  • Sheldon Cooper from Big Bang Theory
  • Harvey Dent Two-Face from Batman
    • Has a preoccupation with coin-flipping
  • Mr. Edward Nygma (The Riddler) from Batman
    • He has to leave riddles behind
    • In a 1999 issue of Gotham Adventures, he tries to commit a crime without leaving a riddle, but fails
  • Dolores Umbridge from Harry Potter
    • The temporary Headmistress and Inquisitor of Hogwarts upon Dumbledore's disappearance is the perfect picture of obsessiveness and rigidity.
    • She has to maintain order at all times

DSM-V Changes
  • Reformulated as the Obsessive-Compulsive Type
  • Individuals who match this personality disorder type are ruled by their need for order, precision, and perfection.
  • Activities are conducted in super-methodical and overly detailed ways. They have intense concerns with time, punctuality, schedules, and rules.
  • Affected individuals exhibit an overdeveloped sense of duty and obligation, and a need to try to complete all tasks thoroughly and meticulously.
  • The need to try to do things perfectly may result in a paralysis of indecision, as the pros and cons of alternatives are weighed, such that important tasks may not ever be completed.
  • Tasks, problems, and people are approached rigidly, and there is limited capacity to adapt to changing demands or circumstances.
  • For the most part, strong emotions – both positive (e.g., love) and negative (e.g., anger) – are not consciously experienced or expressed.
  • At times, however, the individual may show significant insecurity, lack of self confidence, and anxiety subsequent to guilt or shame over real or perceived deficiencies or failures.
  • Additionally, individuals with this type are controlling of others, competitive with them, and critical of them.
  • They are conflicted about authority (e.g., they may feel they must submit to it or rebel against it), prone to get into power struggles either overtly or covertly, and act self-righteous or moralistic.
  • They are unable to appreciate or understand the ideas, emotions, and behaviors of other people.
  • Instructions
(APA, 2010)

Electro-convulsive Therapy
Electro-convulsive Therapy



































































An example of how Obsessive-Compulsive Personality Disorder is portrayed in pop culture. In the television show Big Bang Theory, Sheldon Cooper, a theoretical physicist who shows signs of Asperger Syndrome and Obsessive-Compulsive Personality Disorder, has a compulsive need to knock three times, say the persons name three times, and repeat for a total of three times.

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301.9 Personality Disorder Not Otherwise Specified (PDNOS)

  • PDNOS was first introduced in the DSM-III in 1980
  • It is one of the most frequently used personality disorder diagnoses
  • One can meet diagnostic criteria in a number of ways, such as:
    • having a PD that is not among the officially recognized diagnostic categories
    • having features of more than one of the officially recognized diagnostic categories that do not meet the full criteria of any one PD but that together cause clinically significant distress or functional impairment
    • having a clinically significant, although sub-threshold, variant of a specific diagnostic category
  • This category can also be used when the clinician judges that a specific Personality Disorder that is not included in the Classification is appropriate.
  • Examples include:
    • depressive personality disorder
    • passive-aggressive personality disorder.
  • Guidelines for PDNOS are relatively unspecified and difficult to follow when assessing PDs
  • There are no explicit algorithms provided for mixed, atypical, and other PDs
  • Only slightly more than half studies provide an operational definition of PDNOS
    • The most frequently occurring definition is "mixed" PD
  • There are different Axis II instruments that provide different guidelines for diagnosing PDNOS, such as:
    • International Personality Disorder Examination (IPDE)
      • requires the presence of at least 10 diagnostic criteria of different specific PDs in order for PDNOS to be diagnosed
    • Structured Interview for DSM-IV Personality (SIDP-IV)
      • recommends using PDNOS only when two or more disorders are just one criterion short of diagnostic threshold
    • Personality Disorder Interview-IV (PDI-IV)
      • requires that the respondent meet the general diagnostic criteria for a PD

(Verheul & Widiger, 2004)

Epidemiology
  • Less then half of all studies providing overall Axis II prevalences provide a separate rate for PDNOS
    • Studies that do not take PDNOS into account may be grossly understimating the prevalance and/or failing to consider adequately the extent to which personality pathology has impacted the results
  • The best estimate of the absolute prevalence of PDNOS in patient samples is in the range of 8 to 13%
  • The best estimate of the relative prevalence of PDNOS is in the range of 21 to 49%
  • In structured interview studies, PDNOS is the third most frequently used PD diagnosis, whereas in non-structured interview studies, PDNOS is often the single most frequently used diagnosis
  • PDE/IPDE yielded higher PDNOS prevalences than either the SCID or SIDP
(Verheul & Widiger, 2004)

Associated Features
  • Symptoms are a large mixed list of any personality linked dysfunction, sign, symptom, or complaint that will not fit into a specific disorder category.
  • The only required sign and symptom is that a person's social or mental personality be effected or impaired in such a way that it causes a distress or dysfunction in one or more of the important areas of life.
    • The important areas of life are:
      • social
      • occupational
      • sexual
      • interpersonal
  • Those that meet the criteria for Personality Disorder Not Otherwise Specified have a higher risk of behavioral, educational, and interpersonal problems during childhood and early adulthood than those with a specified personalty disorder.
  • They also have an increased risk of having later education failures, interpersonal relationship difficulties, psychiatric disorders and serious physical aggression acts by the time that they are adults.

DSM-V Changes
  • Personality Disorder Not Otherwise Specified will not be included in DSM-5. This disorder should be represented and diagnosed by a combination of core impairments in personality functioning and patients' unique pathological personality traits.
  • Prominent Personality Traits: Unique to each individual
(APA, 2010)

For More Information, Please Read:

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Depressive Personality Disorder


DSM-IV-TR Criteria
  • A pervasive pattern of depressive cognitions and behaviors beginning by early adulthood and present in a variety of contexts, as indicated by five
    (or more) of the following:
    1. usual mood is dominated by dejection, gloominess, cheerlessness, joylessness, unhappiness
    2. self-concept centers around beliefs of inadequacy, worthlessness, and low self-esteem
    3. is critical, blaming, and derogatory toward self
    4. is brooding and given to worry
    5. is negativistic, critical, and judgmental toward others
    6. is pessimistic
    7. is prone to feeling guilty or remorseful
  • Does not occur exclusively during Major Depressive Episodes and is not better accounted for by Dysthymic Disorder.

Associated Features
  • These individuals may be quiet, introverted, passive, and unassertive, preferring to follow others rather than taking the lead.
  • This pattern may occur with approximately equal frequency in females and males.
  • Individuals with this presentation may be predisposed to developing Dysthymic Disorder and possibly Major Depressive Disorder.
    • These conditions may exist on a spectrum, with depressive personality disorder being the early-onset, persistent, trait like variant of the Depressive Disorders.
    • Preliminary evidence suggests that depressive personality disorder may have an increased prevalence in family members of probands with Major Depressive Disorder.
    • Conversely, Major Depressive Disorder may occur with increased frequency in family members of probands with depressive personality disorder who do not themselves have Major Depressive Disorder.

Typical Beliefs
  • I am always disappointed with myself and cynical about others and the future.
  • I do not consider the spreading of good cheer to be among my responsibilities.
  • I am not eager for authority.
  • I expect those under me to take on a great deal of work.
  • When I am in charge, the work atmosphere need not be upbeat, personally encouraging, or even supportive.
  • I can be quite critical of those who work under me.
  • I never expect things to go right.
  • I don't get much pleasure from anything outside of work.
  • I What's the use of looking at life from the bright side.
  • Life is just work, pain, and loss.
  • I'll believe it when I see it.
  • Life is depressing; I have a right to always be pessimistic.
  • I believe that my dark views of things is just being realistic.
  • Bad news is interesting and reassuring because it represents reality.
  • A person should remain faithful to their spouse, even if their spouse does not.
  • I expect worse from others.
  • I am very critical of my mate.
  • Other people expect too much of me.
  • Parents should teach their children not to expect too much from life.
  • Parents should inculcate the value of work; activities outside of homework and chores should be restricted.
  • I am severely limited as a person; if only I'd been born with a different temperament.
  • My life has been a series of failures and I am helpless in the face of forces beyond my control.
  • I should continually prepare for the worst.
  • I must keep my nose to the grindstone, adhere to routine, and remain un-distracted by impulses and passion.
  • I should always think everything through before acting, not take risks or challenge fate, and never try to escape into pleasure.
  • There is no hope, now or ever.
(Beck & Freeman, 1990)

In Terms of the 5-Factor Model of Personality
  • They Experience:
    • High neuroticism
    • Low extroversion
    • Low openness
    • Low agreeableness
    • High conscientiousness
(McCrae, 1994)

DSM-V Changes
(APA, 2010)

For More Information, Please Read:
  • Finnerty, T. (2009). Depressive personality disorder: Understanding current trends in research and practice. Columbus, OH: WorldWideMentalHealth.com
  • Phillips, K.A., Gunderson, J.D., Triebwasser, J., Kimble, C.R., Faedda, G., Lyoo, I.K., & Renn, J. (1998). Reliability and validity of depressive personality disorder. American Journal of Psychiatry, 155, 1044-1048.

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Passive-Aggressive Personality Disorder (Negativistic Personality Disorder)


DSM-IV-TR Criteria
  • Passive-aggressive behavior is a pattern of expressing your negative feelings in an indirect way.
  • A pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following (Rotenstein):
    • Passively resists fulfillment
    • Routine social and occupational tasks
    • Complains of being misunderstood and unappreciated by others
    • Sullen and argumentative
    • Unreasonably criticizes and scorns authority
    • Expresses envy and resentment
    • Toward those apparently more fortunate
    • Voices exaggerated and persistent complaints of personal misfortune
    • Alternates between hostile defiance and contrition
    • Does not occur exclusively during Major Depressive Episodes and is not better accounted for by Dysthymic Disorder
    • Different from previous formulations, the DSM-IV description of the disorder places emphasis on the pattern of sullen and irritable moods and negativistic attitudes (DSM-IV, APA, 1994).

Associated Features
  • It is a long-term (chronic) condition in which a person seems to actively comply with the desires and needs of others, but actually passively resists them. In the process, the person becomes increasingly hostile and angry (Moore & Jefferson, 2004).
  • These individuals are often overtly ambivalent, wavering indecisively from one course of action to its opposite.
  • They may follow an erratic path the causes endless tension with others and disappointments for themselves.
  • An intense conflict between dependence on others and the desire for self-assertion are characteristics of these individuals.
  • Their self-confidence is often poor despite a superficial boldness.
  • They foresee the worst possible outcome for most situations, even those that are going well.
  • They have an outlook of always being defeated, which can evoke hostile and negative responses from others who are subjected to the complaints of these individuals.
  • They will typically not confront others directly about problems, but will instead attempt to undermine their confidence or their success through comments and actions that can be explained away easily so as not to place any blame on themselves.
  • This pattern of behavior often occurs in individuals with Borderline, Histrionic, Paranoid, Dependent, Antisocial, and Avoidant Personality Disorders.
  • Manifest itself as: resentment, stubbornness, procrastination, sullenness, dawdling, deliberate inefficiency, pretended forgetfulness, unreasonable criticism of people in authority, or intentional failure at doing requested tasks.
    • For example: They might take so long to get ready for a party that they don't want to go to, that by the time they are ready, the party is nearly over.
  • It is often seen in people who view themselves as peaceful.
    • Expressing their anger this way is morally favorable to direct confrontation.
  • Symptoms often include:
    • putting things off
    • "forgetting" to do things others ask
    • being stubborn
    • disliking people who are in charge, or having a bad attitude about them
    • complaining frequently
    • purposely working poorly or slowly
    • feeling unappreciated
    • blaming problems on others
    • being irritable
    • disliking the ideas of other people, even if they are useful
    • arguing frequently
    • (McCrae, 1994)

Gender and Cultural Differences in Presentation
  • Although little research has dealt with gender differences regarding PAPD, Mair and colleagues(1992) have noted that PAPD tends to be more frequently diagnosed in females.
  • The passive-aggressive style may be a way for women to avoid the social stigma and rejection that are often associated with women who are seen as challenging or aggressive in advocating for their own need and wants.

Epidemiology
  • The prevalence rate for Passive-Aggressive Personality Disorder is 3.3%

Etiology
  • The exact cause is still unknown due to a lack of research in this area however some have suggested that this disorder, like most personality disorders, hails from a combination of genetic and environmental factors.
    • May also be a result of society's conditioning of individuals.
      • Society teaches that direct confrontation can lead to harmful consequences.
  • Childhood abuse and/or neglect as well as sexual abuse has appeared to contribute to this disorder.

Empirically Supported Treatments
  • The most common, is psychological treatment for those individuals who do not see themselves as having a problem. They are usually forced into treatment, e.g., family, employers, or the legal system. These clients with PAPD have minimal insight; they fail to admit that they are a major factor in the problems they have.
  • Counseling is useful in helping the person identify and change the behavior.
  • Cognitive therapy and antidepressant drugs are very effective to control negative attitude (McCrae, 1994).

Typical beliefs
  • I am self-sufficient, but I do need others to help me reach my goals.
  • The only way I can preserve my self-respect is by asserting myself indirectly, for example, by not carrying out instructions exactly.
  • I like to be attached to people but I am unwilling to pay the price of being dominated.
  • Authority figures tend to be intrusive, demanding, interfering, and controlling.
  • I have to resist the domination of authorities but at the same ti me maintain their approval and acceptance.
  • Being controlled or dominated by others is intolerable.
  • Making deadlines, complying with demands, and conforming are direct blows to my pride and self-sufficiency.
  • If I follow the rules the way people expect, it will inhibit my freedom of action.
  • It is best not to express my anger directly but to show my displeasure by not conforming.
  • I know what's best for me and other people shouldn't tell me what to do.
  • Rules are arbitrary and stifle me.
  • Other people are often too demanding.
  • If I regard people as too bossy, I have a right to disregard their demands.
(Beck & Freeman, 1990)

In Terms of the 5-Factor Model of Personality
  • They have:
    • High neuroticism
    • High extroversion
    • Low openness
    • Low Agreeableness
    • High conscientiousness
(McCrae, 1994)

Fun Fact
  • The term "passive-aggressive" arose in the U.S. military during World War II, when officers noted that some soldiers shirked their duties by adopting these types of behaviors.

DSM-V Changes
  • Passive-Aggressive (Negativistic) Personality Disorder will be represented and diagnosed by a combination of core impairment in personality functioning and specific pathological personality traits, rather than as a specific type.
  • Personality Traits
  • Oppositionality, Hostility, Guilt/shame
(APA, 2010)

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Diagnostic Dilemmas in Classifying Personality Disorders


  • Poor correspondence between DSM-IV-TR diagnostic categories and typical presentations
  • Different structured interviews show poor agreement
  • Statistical analysis of PD criteria and traits fail to replicate DSM concepts
  • Investigations consistently fail to support the categorical representations of personality phenotypes
  • (Livesley, 2003)

Problems with DSM-IV-TR
  • Limited Clinical Utility
    • Conditions of the patients do not match the diagnostic concepts very closely
    • Specific diagnoses have a limited value for planning treatment or predicting outcome
    • Most diagnoses are global constructs
      • Pharmacological treatments tend to target specific dimensions rather than global diagnoses
      • Psychosocial interventions are directed toward specific behaviors
  • Lack of Exclusiveness and Exhaustiveness
    • Multiple diagnoses are the norm instead of being mutually exclusive
      • The most exclusive category is Obsessive-Compulsive PD, but it still has about 70% of all cases meeting the criteria for a second PD
    • Accroding to some studies, the PDNOS is the most common diagnosis
      • This suggests that the system does not reflect common presentations
  • Psychometric Limitations
    • Aggrement across different interviews is modest
    • Construct validity is an even greater problem
      • Internal validity
        • Internal consistency improved with the DSM-IV-R
        • Coefficient alpha falls below 0.7 for Histrionic, Dependent, and Schizotypal personality diosorders
      • External validity
        • Convergent validity
          • Different measurement leading to the same diagnosis shows only modest agreement among different measures
        • Discriminante validity
          • Diagnoses are not distinct from each other
        • Predicitive validity
          • Little evidence that diagnoses predict important variables related to etiology and outcome
  • Lack of Empirical Support for Diagnostic Concepts
    • Multivariate studies of personality characteristics consistently fail to generate factors that resemble DSM diagnoses
  • Atheoretical approach
    • It is atheoretical when it comes to etiology
    • Fails to offer a rationale for selecting diagnoses and criteria
      • Arbitrary selections that are drawn from diverse sources
        • Classical phenomenology
        • Traditional psychoanalytic theory
        • Spectrum disorders
        • Object relatons theory
        • Psychoanalytic thinking
        • Social learning concepts
  • Use of Categorical Diagnoses
    • Clinicians have to make arbitrary decisions, which leads to poor diagnostic agreement
    • This accounts for great diagnostic overlap, prevalence of the diagnosis NOS and limited validity
(Livesley, 2003)

Failures of the Categorical Model
  • Excessive Diagnostic Co-Occurrence
    • DSM-IV-TR routinely fails to indicate the presence of a specific pathology and suggest a specific treatment
    • Diagnostic comorbidity is so extensive that some argue for abandoning the term comorbidity in favor of a term that is more simply descriptive
    • Much of the PD diagnostic co-occurrence is readily explained if the DSM-IV-TR PDs are understood as maladaptive variants of general personality structure
  • Inadequate Coverage
    • PDNOS is one of the most frequently used Axis II diagnosis in clinical practice
    • Not entirely clear how clinicians are using PDNOS within their practice, but it is suggested that clinicians are not finding the existing diagnostic categories to be adequate in their coverage of PD symptomatology
    • Efforts to demarcate a limited number of specific categories to identify homogeneous and distinct groups, yet also provide adequate coverage, will likely continue to be problematic and frustrating
  • Arbitrary and Unstable Boundaries with Normal Psychological Functioning
    • DSM-IV-TR provides specific and explicit rules for distinguishing between the presence versus absence of each of the individual diagnostic categories but the schizotypal and borderline diagnoses are the only two for which a published rationale has ever been provided
    • No explanation, rationale, or even supportive discussion has ever been attempted for the diagnostic thresholds for the Avoidant, Schizoid, Paranoid, Histrionic, Narcissistic, Dependent, or Obsessive-Compulsive PDs
    • There have been many revisions, deletions, and additions to the criterion sets that the current diagnostic thresholds no longer relate well to the original thresholds
      • These unanticipated and substantial shifts in prevalence rates across revisions to the DSM are problematic to scientific theory and public health decisions
      • Seemingly minor changes to criterion sets result in substantial changes in prevalence rates
  • Heterogeneity Among Persons with the Same Diagnosis
    • DSM-III-R switched to polythetic criterion sets in which only a subset of diagnostic criteria are required
    • Polythetic criterion sets do not resolve the problems associated with the heterogeneity among persons sharing the same diagnosis
    • Polythetic criterion sets are simply an acknowledgement of the existence of this problematic heterogeneity
  • Inadequate Scientific Base
    • The only PD whose literature is clearly alive and growing is that of Borderline PD
    • There has been little comparable research on the etiology, course, pathology, or treatment of the Paranoid, Schizoid, Histrionic, Avoidant, Passive-Aggressive, or Obsessive-Compulsive PDs
(Widiger & Trull, 2007)

Dimensional Model of Classification
  • Five Factor Model (FFM)
    • FFM was developed originally through empirical studies of trait terms within existing languages
    • Lexical paradigm is guided by the compelling hypothesis that what is of most importance, interest, or meaning to persons is encoded within the language
    • Most important domains of personality functioning are those with the greatest number of terms to describe and differentiate various manifestations and nuance, and the structure of personality is evident in the empirical relationship among these trait terms
    • Initial lexical studies were conducted with the English language, and found a 5-factor Structure
      • Extraversion
      • Agreeableness
      • Conscientiousness
      • Emotional Instability
      • Openness
    • Disagreement about the single best term to describe each domain
      • Difficult to identify a single term to adequately characterize the entire range of personality functioning included within a large domain
    • Empirical support for the construct validity of the FFM as a dimensional model of personality structure is extensive
    • Heritability
      • Behavior genetic research has generally supported the validity of the domains and facets of the FFM and even the FFM structural model
      • Yamagata et al. concluded that the results support the view that the FFM reflects a genetic structure that is universal
      • Behavior genetic studies of individual PDs have been confined to Borderline, Antisocial, and Schizotypal PDs
        • Research concerning the seven other PDs have been so sparse that reviews of the heritability of these PDs have in fact based many of their conclusions on the behavior genetic research of normal personality traits, implicitly assuming that these PDs are in fact maladaptive variants of general personality structure
    • Universality
      • Etic studies
        • They use constructs and measures from one culture imported into another, determining whether the importation reproduces the nomological net of predictons previously obtained in other cultures
      • Emic studies
        • They use constructs and measures that are indigenous to a particular culture, determining whether a particular model of personality structure is evident from the perspective of that culture
      • FFM lexical studies would be considered emic studies
      • Virtually o systematic emic studies of PDs
      • Criticism of the emic lexical paradigm is that it might simply be studying folk concepts that lack any validity beyond the belief systems of a particular culture
      • There have been a few etic studies of the PD nomenclature of the DSM-IV-TR
        • Some have applied the PDs within an individual culture that is different from the predominant Western society in which the manual was largely created
          • It appears to be only one systematic multinational study, in which the DSM-III-R PD criterion sets were assessed in 14 mental health centers located in 11 different countries of North America, Europe, Africa, and Asia
      • The etic cross-cultural support for the FFM personality structure is extensive
        • Results show that the 5-dimensional structure was highly robust across major regions of the world, including: North America, South America, Western Europe, Eastern Europe, Southern Europe, the Middle East, Africa, Oceania, South-Southeast Asia, and East Asia
    • Childhood Antecedents
      • Remarkably little research examining the childhood and adolescent antecedents of the DSM-IV-TR PDs, with perhaps the exceptions of Antisocial, Borderline, and Schizotypal studies
      • Child and adolescent temperaments are probably among the best candidates for general broadband developmental antecedents for adult PDs
      • Limited amount of research relating empirically the temperaments of childhood with adult personality traits, but Shiner (1998) suggest that many of the apparently disparate temperaments being studied do appear to be well organized within 4 of the 5 broad domains of the FFM (extroversion, neuroticism, conscientiousness, and agreeableness)
        • Missing from Shiner's theoretical model of childhood temperament was an openness dimension, which could reflect that preschool teachers do not generally distinguish curiosity and creativity from conscientiousness
    • Temporal stability
      • Fundamental to the concept of personality is temporal stability
      • Empirical support for the temporal stability of PDs has been elusive
      • Apparent failure of longitudinal studies to verify the temporal stability of PDs
      • Temporal stability has been well documented for general personality structure
(Widiger & Trull, 2007)

Five Factor Model of Personality Disorder
  • Integration of the psychiatric PD nomenclature with psychological models of general personality structure would go far in buttressing the weak construct validity of the DSM-IV-TR diagnostic categories
  • Primary concerns are obtaining a consensus structure, implementation, and clinical utility
  • Consensus structure
    • 18 alternative proposals for a dimensional model of PD
    • Proposals are so disparate that no consensus is likely to emerge
    • The FFM has been used effectively in many prior studies and reviews as a basis for comparing, contrasting, and integrating seemingly diverse sets of personality scales
    • Strengths of the Big Five taxonomy is that it can capture, at a broad level of abstraction, the commonalities among most of the existing systems of personality traits, thus providing an integrative descriptive model for research
    • One alternative proposal for DSM-V
      • Simply convert each diagnostic category to a 5-point Liker scale
      • One could then use these scales to provide profile descritptons of a patient
      • Limitaiton of this proposal is that dimensons consisting of the existing categories would be grossly overlapping
    • Two predominant dimensional models of the DSM-IV-TR PD symptomatology
      • 18 scales of the Dimensional Assessment of Personality Pathology
      • 12 scales of the Schedule for Non-adaptive and Adaptive Personality
      • They were both constructed by factor analyzing PD diagnostic criteria and symptoms to yield more distinctive scales of maladaptive personality triats
      • They would both provide profile descriptions that would be more differentiating and less susceptible to construct and scale overlap than 5-point Likert scales of existing diagnostic categories
      • Limitation of both of these scales as a sole replacement for the DSM-IV-TR diagnostic categories would be an absence of an explicit coordinaton with general personality structure
      • The ideal solutoin is likely to be a common integrative representaton that includes the important contributions and potentonal advantages of each respecitive model
  • Implementation
    • Second concern is how a dimensional model of general personality structure would in fact be implemented in clinical practice
    • Dimensional classification is better suited for myriad clinical decisions that than the existing diagnostic categories because it can include different cutoff points for different clinical decisions
    • FFM description
      • 4 step procedure for an FFM diagnosis of PD
        1. Obtain a hierarchical and multifactorial description of an individual's general personality structure in terms of the 5 domains and 30 facets of the FFM, providing a reasonably comprehensive description of the person's adaptive and maladaptive personality traits
          • Recommend that clinicians use both a self-reprot inventory and a semi-structured interview because multiple methods provide more valid assessments of PD
        2. Identify social and occupational impairments and distress associated with extreme scores on the FFM personality traits
        3. Determine whether the dysfunction and distress reach a clinically significant level of impairment that would warrant a diagnosis of PD
          • An important area of future research will be studies relating the GAF to maladaptive personality functioning in order to develop precise cutoff points for specific clinical decisions
        4. Quantitative matching of the individual's FFM personality profile to prototypic profiles of diagnostic constructs
          • Provided for clinicians and researchers who wish to continue to provide or study single diagnostic constructs
          • Clinicians and researchers can develop FFM profiles for PD constructs not included within DSM-IV-TR
          • Prototypal matching serves primarily to indicate the extent to which any single construct fails to provide a fully accurate or precise description of the individual person
  • Clinical Utility
    • Maser, Kaelber, and Weise (1991) indicated that the section of the DSM with which most were dissatisfied was the section of the personality disorders
    • Likely sources of frustration for clinicians
      • Heterogeneity of diagnostic membership
      • Lack of precision in description
      • Excessive diagnostic co-occurrence
      • Failure to lead to a specific diagnosis
      • Reliance on the personality disorder NOS wastebasket diagnosis
      • Unstable and arbitrary diagnostic boundaries
    • There have been no adequate empirical studies on the treatment of the Avoidant, Schizoid, Paranoid, Histrionic, Narcissistic, Obsessive-Compulsive, or Dependent PDs
    • PDs are among the more difficult disorders to treat
      • Treatment rarely invovles a comprehensive or complete cure of the PD and does not appear to focus on the entire personality structure
    • An integrated dimensional model of PD would consist precisely of the dimensions of maladaptive personality functioning that are currently the focus of clinical attention
    • Limitation of the FFM
      • Some of the lower order facet scales focus primarily on the normal variants of personality functioning that are themselves unlikely to be the focus of clinical interventions
(Widiger & Trull, 2007)


Medications to Treat Personality Disorders


  • According to Essentials of Abnormal Psychology by Andrew Gatzfeld for most of the PD's, psychotropic medications are somethimes used in treatement. In order to determine which drug to perscribe is based on the Axis I disorder the persoanlity disorder resembles. When unipolar depression occurs in a PD, SSRIs such as Prozac (fluoxetine) is useful. Avoidant Personality Disorder patients can be prescribed anxiolytics such as Xanax (alprazolam) to help alleviate their phobias and social anxieties. Drugs such as Risperdal (risperidone) can be given to Schizotypal PD pateints (Getzfeld, 238).

  • Text has shown that no one medication is ideal to treat Borderline PD. Antidepressants and anxiolytics may help calm some of the emotions of a borderline patient, but will not alter the long-term maladaptive behavioral patterns. Prozac (fluoxetine) seems to help in reducing aggression, depression, and impulsivity in those with borderline. LIthium also appears to reduce anger and suicidal behaviors and gestures, while antipsychotics appear to reduce anxiety along with suicidal behaviors and gestures and their psychotic symptoms. Boderline patients however have an increased risk for abusing drugs and a greater risk for successfully completing suicide, as a warning these drugs must be given with extreme caution. ASPD patients may be given Lithium and Tegretal (carbamazepine, and anticonvulsant) for the anger or rage these patients may have but data for the usage of these drugs are rare. Anxiolytics may be used but because of the impulse control of ASPD patients is poor, using it is not recommended. Antisocial PD remaines under knowledged therefore medications are not recommended (Getzfeld, 238).

  • According to the Mayo Clinic there are no medications specifically approved by the Food and Drug Administration to treat personality disorders. However, several types of psychiatric medications may help with various personality disorder symptoms.
    • Antidepressant medications.
      • Antidepressants may be useful if you have a depressed mood, anger, impulsivity, irritability or hopelessness, which may be associated with personality disorders.
    • Mood-stabilizing medications.
        • As their name suggests, mood stabilizers can help even out mood swings or reduce irritability, impulsivity and aggression.
    • Anti-anxiety medications.
        • These may help if you have anxiety, agitation or insomnia. But in some cases, they can increase impulsive behavior.
    • Antipsychotic medications.
      • Also called neuroleptics, these may be helpful if your symptoms include losing touch with reality (psychosis) or in some cases if you have anxiety or anger problems.



Seeking Help

  • To find more information, causes, symptoms and treatments visit www.minddisorders.com.
  • Also when talking to a physician seek someone other than the primary physician for a second opinion due to biases and the likelihood of being misdiagnosed.


References


Mental Disorders. In The encyclopedia of Mental Disorders online. retrieved from http:www.minddisorders.com
www.mayoclinic.com
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