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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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