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					Personality Disorders: An Overview


The Nature of Personality and Personality Disorders

   These concepts date all the way back to Galen’s
   humors (460-377 B.C.)!

   Black bile: Melancholia (sad)
   Yellow bile: Choleric (angry)
   Phegmatic: Lethargic (sluggish)
   Sanguine (lots of blood): Cheerful, confident
Personality Disorders: An Overview


The Nature of Personality and Personality Disorders

   Enduring and relatively stable predispositions (i.e.,
   ways of relating and thinking).

   Predispositions are inflexible and maladaptive,
   causing distress and/or impairment.

   Coded on Axis II of the DSM-IV and DSM-IV-TR.
   Can interfere with or constrain tx of Axis I disorders.
Personality Disorders: An Overview



 Personality disorders appeared in early iterations of
 the DSM, however criteria were vague, and
 diagnostic categories were unreliable.

 Improvement brought about by 1) DSM-III specified
 criteria and 2) the development of structured
 interviews specially designed for assessing these
 disorders (e.g., SCID-II).
Personality Disorders: An Overview


  Interrater Reliability (Zanarini et al., 2000)
      Paranoid                      .86
      Schizoid                      .69
      Schizotypal                   .91
      Borderline                    .90
      Histrionic                    .83
      Narcissistic                  .88
      Antisocial                    .97
      Dependent                     .87
      Avoidant                      .79
      OC                            .85
Personality Disorders: An Overview


 Test Retest Reliability (Zimmerman et al., 1995)
    Paranoid                    .57
    Schizoid                    n/a
    Schizotypal                 .11
    Borderline                  .56
    Histrionic                  .40
    Narcissistic                .32
    Antisocial                  .84 (historical info more reliable?)
    Dependent                   .15
    Avoidant                    .41
    OC                          .52
Personality Disorders: Facts & Stats

  Prevalence of Personality Disorders
     About 0.5% to 2.5% of the general population
     Rates are higher in inpatient and outpatient settings
  Origins and Course of Personality Disorders
     Thought to begin in childhood
     Run a chronic course
     Comorbidity rates are high
  Gender Distribution and Gender Bias
     Gender bias believed to exist in diagnosis
Personality Disorders: Facts & Stats


 All psychodynamic theories trace the etiology of
 personality disorders to qualities of early
 relationships, such as

      e.g.,   Demanding parents,
              Distant rigid fathers.
              Overcontrolling, rejecting mothers
              Lack of love
DSM-IV Personality Disorder Clusters

    Cluster A
       Odd or eccentric
       Includes paranoid, schizoid, schizotypal
    Cluster B
       Dramatic, emotional, erratic
       Includes antisocial, borderline, narcissistic, histrionic
    Cluster C
       Fearful or anxious
       Examples dependent, avoidant, obsessive-compulsive,
       passive-aggressive?
DSM-IV Personality Disorder Clusters


   Cluster A - Odd or eccentric
      Symptoms are similar to, but not as severe as, what
      is seen schizophrenia. Many have relatives with
      schizophrenia.
      Examples: suspiciousness, social withdrawal,
      peculiar ways of thinking. These leave the individual
      socially isolated.

      Some call these „schizophrenia-spectrum disorders.‟
Cluster A: Paranoid Personality
Disorder

 Overview and Clinical Features
     Pervasive and unjustified mistrust and suspicion
     Excessive jealousy
 The Causes
     Biological and psychological contributions are unclear
     Early learning that the world is a dangerous place
     Anecdotal: victims of crime such as sexual assault
     Functional paranoia (adaptive) should not be mistaken as PPD
 Treatment Options
     Few seek professional help on their own
     Treatment focuses on development of trust
     Cognitive therapy to counter negativistic thinking
     Lack good outcome studies
Cluster A: Schizoid Personality
Disorder

 Overview and Clinical Features
     Pervasive pattern of detachment from social relationships
     Very limited range of emotions in interpersonal situations
     Anecdotal: “Loners,” unabomber syndrome, masked hatred?
 The Causes
     Etiology is unclear
     Preference for social isolation resembles autism
 Treatment Options
     Few seek professional help on their own
     Focus on the value of interpersonal relationships
     Building empathy and social skills
     Lack good outcome studies
Cluster A: Schizotypal Personality
Disorder

 Overview and Clinical Features
     Odd and unusual behavior and appearance
     Most are socially isolated, highly suspicious
     Magical thinking, ideas of reference, and illusions
     Anecdotal: Cult leaders, mitigated schizophrenia (Kety et al.,1968)
 The Causes
     A phenotype of a schizophrenia genotype?
     Enlarged ventricles, less temporal lobe gray matter
 Treatment Options
     Main focus is on developing social skills
     Treatment also addresses comorbid depression
     Medical treatment similar to schizophrenia
     Treatment prognosis is generally poor
DSM-IV Personality Disorder Clusters


  Cluster B
     Dramatic, emotional, erratic
     Includes antisocial, borderline, narcissistic, histrionic
     These individuals are so dramatic, emotional, or erratic
     that is almost impossible for them to have relationships
     that are truly satisfying or giving.
     There is a disruption in normal affection and reciprocity.
     Their behavior often creates problems for other people.
Cluster B: Antisocial Personality
Disorder

 Overview and Clinical Features
     Noncompliance with social norms
      Violate rights of others
     Irresponsible, impulsive, and deceitful
     Lack a conscience, empathy, and remorse
     Fail to learn/respond to punishment cues, cannot delay gratification
 Relation with Conduct Disorder and Early Behavior Problems
     Early histories of behavioral problems (e.g., conduct disorder; under
      debate due to lack of diffs as compared to those without; Langbehn &
      Cadoret, 2001).
     Families with inconsistent parental discipline and support
     Families have histories of criminal and violent behavior (80% of
     incarcerated people meet criteria; synonomous with criminality?)
Neurobiological Contributions and
Treatment of Antisocial Personality


   Prevailing Neurobiological Theories
      Brain damage – Little support for this view
      Underarousal hypothesis – Cortical arousal is too low
      Cortical immaturity hypothesis – Cortex is not fully developed,
      reduced frontal gray matter

   Treatment
       Few seek treatment on their own
       Antisocial behavior is predictive of poor prognosis
       Emphasis is placed on prevention and rehabilitation
       Often incarceration is the only viable alternative
Cluster B: Borderline Personality
Disorder

 Overview and Clinical Features
     Patterns of unstable moods and relationships
     Impulsivity, fear of abandonment, very poor self-image
     Self-mutilation and suicidal gestures are common
     Most common personality disorder in psychiatric settings
     Comorbidity rates are high
 The Causes
     Runs in families
     Early trauma and abuse seem to play some role
 Treatment Options
     Few good treatment outcome studies, other than DBT
     Antidepressant medications – Some short-term relief
     Dialectical behavior therapy – Most promising treatment
Cluster B: Histrionic Personality
Disorder

 Overview and Clinical Features
     Overly dramatic, sensational, and sexually provocative
     Impulsive and need to be the center of attention
     Thinking and emotions are perceived as shallow
     Common diagnosis in females, flamboyant gay „Drama Queen‟
 The Causes
     Etiology is largely unknown
     Sex-typed variant of antisocial personality?
 Treatment Options
     Focus on attention seeking / long-term consequences
     Address problematic interpersonal behaviors
     Little evidence that treatment is effective
Cluster B: Narcissistic Personality
Disorder

   Overview and Clinical Features
       Exaggerated / unreasonable sense of self-importance
       Preoccupation with receiving attention
       Lack sensitivity and compassion for other people
       Sensitive to criticism, envious, and arrogant, Ted Baxter
   The Causes
       Link with early failure to learn empathy as a child
       Sociological view – Product of the “me” generation
   Treatment Options
       Focuses on grandiosity, lack of empathy
       May also address co-occurring depression
       Little evidence that treatment is effective
DSM-IV Personality Disorder Clusters


   Cluster C
      Fearful or anxious
      Includes dependent, avoidant, obsessive-compulsive.

      Although this group of disorders certainly resembles
      mood and anxiety disorders, the few studies that exist
      do not suggest a link.

      Treatment of this cluster is more successful than A, B.
Cluster C: Avoidant Personality
Disorder

 Overview and Clinical Features
     Extreme sensitivity to the opinions of others
     Highly avoidant of most interpersonal relationships
     Interpersonally anxious and fearful of rejection
 The Causes
     Numerous factors have been proposed
     Difficult temperament and early rejection
 Treatment Options
     Several well-controlled treatment outcome studies exist
     Treatment is similar to that used for social phobia
     Treatment targets include social skills and anxiety
Cluster C: Dependent Personality
Disorder

  Overview and Clinical Features
      Reliance on others to make major and minor life decisions
      Unreasonable fear of abandonment
      Clingy and submissive in interpersonal relationships
  The Causes
      Still largely unclear
      Linked to early disruptions in learning independence
  Treatment Options
      Research on treatment efficacy is lacking
      Therapy typically progresses gradually
      Treatment targets include skills that foster independence
Cluster C: Obsessive-Compulsive
Personality Disorder

    Overview and Clinical Features
        Excessive and rigid fixation on doing things the right way
        Highly perfectionistic, orderly, and emotionally shallow
        True obsessions and compulsions are rare
    The Causes
        Are largely unknown
    Treatment Options
        Data supporting treatment are limited
        Addresses fears related to the need for orderliness
        Rumination, procrastination, and feelings of inadequacy
                  Summary


Personality Disorders
   Long-standing patterns of behavior
   Begin early in development and run a chronic course
Disagreements Exist
   Over how to categorize personality disorders
   Categorical vs. dimensional, or some combination of
    both

Causes are difficult to pinpoint.
Treatment is often difficult and prognosis poor.
                 Summary


Problems with Axis II Disorder Categories:
Too many unobservable symptoms that are necessary for
discriminating between certain pairs of disorders.

For example, to separate paranoid from schizoid from
anxious, the clinician must first ask, “Do you typically
avoid social relationships?” and then “Why is that?”
                 Summary


Problems with Axis II Disorder Categories:
Too many similarities between and across categories.

For example,
Avoidant and dependent overlap heavily.
Borderline traits are often found in those diagnosed with
dependent p.d.
Avoidant traits often found in schizoid p.d., dependent
traits in histrionic p.d., etc.
                  Summary


New scheme suggested for DSM V.

Based on four trait dimensions:
Extraversion-introversion
Stable-unstable
Impulsive-inhibited
Positive-negative affectivity

Borderline: extraversion, unstable, impulsive, negative
Histrionic: extraversion, unstable, impulsive, neg/pos
Avoidant: introversion, stable, inhibited, negative
Video…
  Dialectical Behavior Therapy -
           Treating BPD


History of DBT as a treatment approach for BPD

   DBT developed as an application of standard behavior
   therapy during the 1970‟s.

   Primarily conceived of as a way to treat individuals
   with eating disorders and suicidal behavior.
   Dialectical Behavior Therapy -
            Treating BPD


Recognition that treatment focusing on the need for
behavior change alone was ineffective for this population
(Swann et al., 1992)

Led to the introduction of mindfulness and radical
acceptance as constructs to be incorporated into
behavioral treatment methods
              Core elements of DBT


Biosocial etiology of BPD: The etiology of BPD lies in
interaction between an individual‟s biological disposition
(poor self regulation) and their learning history (the world
is unpredictable, unstable, unsafe).

Treatment goals within each stage are prioritized
collaboratively between the therapist and client.
Functions for treatment methods are outlined along with
specific methods that will be used to fulfill each function.
     Core elements of DBT



The philosophy of dialectics itself emerged
thousands of years ago, became historically
associated with Marxist philosophy, and was
more recently incorporated into behavioral
therapy by pioneers such as Marsha
Linehan.
1. Dialectics dictates a dynamic process of exchange
   between knowledge about individual realities and
   action or behavior.

2. As such, the whole of this process or system is
   greater than the sum of its parts (i.e. knowledge
   and action are meaningless unless taken in
   context together), and it is the complex interaction
   between the parts and the whole that give rise to
   adaptive change.
3. Overall, the role of dialectics in DBT can be
   conceptualized as a dynamic system involving
   thesis (knowledge or understanding), antithesis (a
   challenge to that knowledge), and synthesis (an
   interaction of the two resulting in change or new
   knowledge and understanding)

4. The therapeutic relationship provides the
   environmental context in which the dialectics of
   therapy will play out
     The role of Mindfulness in DBT


- comes from Western contemplative and Eastern (e.g.,
  Zen) meditation practices

- refers to the state of observing and evaluating
    knowledge and behavior encountered within the
    therapeutic process (and indeed in everyday life)
    without value judgment

- leads to radical acceptance for clients -- the ability to
    fully experience and embrace difficult emotions,
    experiences, and behavior patterns just as they are --
    giving way to change and growth
      What is dialectics?



     Dialectics has two meanings:

1) The fundamental meaning of reality -
     (challenge, modify, assimilate);
  2) Persuasive dialogue, therapeutic
  relationship as a vehicle of change.
  Fundamentals of DBT

BPD is characterized by emotional
vulnerability & poor ability to
modulate strong emotions.

Vulnerability - 1) very high sensitivity
to emotional stimuli, 2) very intense
response to emotional stimuli, 3) a
slow return to emotional baseline
following emotional arousal.
  Fundamentals of DBT

Emotion modulation - ability to…

1) inhibit inappropriate behavior
related to strong emotions (+ or -),

2) organize oneself for coordinated
action in service of an external goal,
  Fundamentals of DBT

Emotion modulation - ability to…

3) self soothe physiological arousal,

4) refocus attention in the presence
of strong emotion.
  Fundamentals of DBT

Emotion modulation - ability to…

3) self soothe physiological arousal,

4) refocus attention in the presence
of strong emotion.
  Fundamentals of DBT

4 areas are emphasized -

1) Acceptance and validation of
behavior as it is in the moment.

2) Treating therapy-interfering
behaviors of both client and therapist.
  Fundamentals of DBT


4 areas are emphasized -

3) The assumption that the
therapeutic relationship is essential
to the treatment.

4) Dialectic process (persuasive
dialogue, focus on reality).
   Fundamentals of DBT

In-class exercise 1:
Split up into 4 supervision teams.

Observe two sessions of DBT with
Linehan and a BPD client, Stacey.

Rate Linehan on her use of the
specific DBT techniques (1/team).
   Fundamentals of DBT

In-class exercise 2:
Teams 1 and 2,
Provide feedback for Linehan,
including a critique of basic
therapist skills, the use of specific
DBT skills, and overall, the
effectiveness of the session.
   Fundamentals of DBT


In-class exercise 2:
Teams 3 and 4,
Develop a plan for the subsequent
sessions with Stacey.
What specific aspects of BPD remain
problematic? How might the
therapist address the problems in
future sessions?

				
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