Understanding Personality Disorders: Types, Diagnosis, and Treatments, Slides of Abnormal Psychology

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Slides & Handouts by Karen Clay Rhines, Ph.D. Northampton Community College Personality Disorders Docsity.com Personality • What is personality? – Personality is a unique and long-term pattern of inner experience and outward behavior – Personality tends to be consistent and is often described in terms of “traits” • These traits may be inherited, learned, or both – Personality is also flexible, allowing us to adapt to new environments • For those with personality disorders, however, that flexibility is usually missing Docsity.com Classifying Personality Disorders • Personality disorders are diagnosed on Axis II of the DSM-IV- TR • These patterns are not typically marked by changes in intensity or periods of clear improvement • Those diagnosed with personality disorders are often also diagnosed with an Axis I disorder – This relationship is called “comorbidity” • Axis II disorders may predispose people to develop an Axis I disorder, or Axis I disorders may set the stage for Axis II disorders, or some biological condition may set the stage for both! – Whatever the reason, research indicates that the presence of a personality disorder complicates and reduces a person’s chances for a successful recovery Docsity.com Classifying Personality Disorders • The DSM-IV-TR identifies ten personality disorders and separates these into three categories or “clusters”: – Odd or eccentric behavior • Paranoid, schizoid, and schizotypal personality disorders – Dramatic, emotional, or erratic behavior • Antisocial, borderline, narcissistic, and histrionic personality disorders – Anxious or fearful behavior • Avoidant, dependent, and obsessive-compulsive personality disorders Docsity.com Classifying Personality Disorders • The various personality disorders overlap each other so much that it can be difficult to distinguish one from another • The frequent lack of agreement between clinicians and diagnosticians has raised concerns about the validity (accuracy) and reliability (consistency) of these categories • It should be clear that diagnoses of such disorders can easily be overdone Docsity.com “Odd” Personality Disorders • Clinicians have learned much about the symptoms of odd personality disorders, but little of their causes or how to treat them – In fact, people with these disorders rarely seek treatment Docsity.com Paranoid Personality Disorder • This disorder is characterized by deep distrust and suspicion of others – Although inaccurate, the suspicion is usually not “delusional” – the ideas are not so bizarre or so firmly held as to clearly remove the individual from reality • As a result of their mistrust, people with paranoid personality disorder often remain cold and distant Docsity.com Paranoid Personality Disorder • They are critical of weakness and fault in others, particularly at work – They are unable to recognize their own mistakes and are extremely sensitive to criticism – They often blame others for the things that go wrong in their lives and they repeatedly bear grudges • Between 0.5% and 3% of adults are believed to experience this disorder, apparently more men than women Docsity.com Treatments for Paranoid Personality Disorder • Object relations therapists try to see past the patient’s anger and work on the underlying wish for a satisfying relationship • Behavioral and cognitive therapists try to help clients control anxiety and improve interpersonal skills – Cognitive therapists also try to restructure clients’ maladaptive assumptions and interpretations • Drug therapy is of limited help Docsity.com Schizoid Personality Disorder • This disorder is characterized by persistent avoidance of social relationships and limited emotional expression – Withdrawn and reclusive, people with this disorder do not have close ties with other people; they genuinely prefer to be alone – People with schizoid personality disorder focus mainly on themselves and are often seen as flat, cold, humorless, and dull – The disorder is estimated to affect fewer than 1% of the population • It is slightly more likely to occur in men than in women Docsity.com How Do Theorists Explain Schizoid Personality Disorder? • Many psychodynamic theorists, particularly object relations theorists, link schizoid personality disorder to an unsatisfied need for human contact – The parents of those with the disorder are believed to have been unaccepting or abusive of their children Docsity.com Treatments for Schizoid Personality Disorder • Cognitive-behavioral therapists have sometimes been able to help people with this disorder experience more positive emotions and more satisfying social interactions – The cognitive end focuses on thinking about emotions – The behavioral end focuses on the teaching of social skills • Group therapy is apparently useful as it offers a safe environment for social contact • Drug therapy is of little benefit Docsity.com Schizotypal Personality Disorder • This disorder is characterized by a range of interpersonal problems, marked by extreme discomfort in close relationships, odd (even bizarre) ways of thinking, and behavioral eccentricities – These symptoms may include ideas of reference and/or bodily illusions – People with the disorder often have great difficulty keeping their attention focused; conversation is typically digressive and vague, even sprinkled with loose associations Docsity.com Schizotypal Personality Disorder • Socially withdrawn, people with schizotypal personality disorder seek isolation and have few friends • It has been estimated that 2% to 4% of all people (slightly more males than females) may have the disorder Docsity.com “Dramatic” Personality Disorders • The cluster of “dramatic” personality disorders includes: – Antisocial personality disorder – Borderline personality disorder – Histrionic personality disorder – Narcissistic personality disorder Docsity.com “Dramatic” Personality Disorders • The behaviors of people with these disorders are so dramatic, emotional, or erratic that it is almost impossible for them to have relationships that are truly giving and satisfying • These personality disorders are more commonly diagnosed than the others – Only antisocial and borderline personality disorders have received much study • The causes of the disorders are not well understood • Treatments range from ineffective to moderately effective Docsity.com Antisocial Personality Disorder • Sometimes described as “psychopaths” or “sociopaths,” people with antisocial personality disorder persistently disregard and violate others’ rights – Aside from substance-related disorders, this is the disorder most linked to adult criminal behavior • The DSM-IV-TR requires that a person be at least 18 years of age to receive this diagnosis – Most people with an antisocial personality disorder displayed some patterns of misbehavior before they were 15 years old Docsity.com Antisocial Personality Disorder • Children with a conduct disorder and an accompanying attention-deficit hyperactivity disorder apparently have a heightened risk of developing antisocial personality disorder Docsity.com How Do Theorists Explain Antisocial Personality Disorder? • Psychodynamic theorists propose that this disorder begins with an absence of parental love, leading to a lack of basic trust • Many behaviorists have suggested that antisocial symptoms may be learned through modeling or unintentional reinforcement Docsity.com How Do Theorists Explain Antisocial Personality Disorder? • The cognitive view says that people with the disorder hold attitudes that trivialize the importance of other people’s needs • A number of studies suggest that biological factors may play a role – Lower levels of serotonin, impacting impulsivity and aggression – Deficient functioning in the frontal lobes of the brain – Lower levels of anxiety and arousal, leading them to be more likely than others to take risks and seek thrills Docsity.com Borderline Personality Disorder • Many of the patients who come to mental health emergency rooms are individuals with the disorder who have intentionally hurt themselves • Their impulsive, self-destructive behavior can include: – Alcohol and substance abuse – Reckless behavior, including driving and unsafe sex – Cutting themselves – Suicidal actions and threats • People with the disorder frequently form intense conflict- ridden relationships while struggling with recurrent fears of impending abandonment Docsity.com Borderline Personality Disorder • Between 1.5% and 2.5% of the general population are thought to suffer from this disorder – Close to 75% of those diagnosed are women • The course of the disorder varies – In the most common pattern, the instability and risk of suicide reach a peak during young adulthood and then gradually wane with advancing age Docsity.com How Do Theorists Explain Borderline Personality Disorder? • Because a fear of abandonment tortures so many people with the disorder, psychodynamic theorists look to early parental relationships to explain the disorder – Object-relations theorists propose a lack of early acceptance or abuse/neglect by parents • Research has found some support for this view, including a link to early sexual abuse Docsity.com Treatments for Borderline Personality Disorder • Contemporary psychodynamic therapy has been somewhat more effective than traditional psychodynamic approaches when it focuses on the patient’s central relationship disturbance, poor sense of self, and pervasive loneliness and emptiness • Over the past two decades, an integrative treatment approach, called “dialectical behavior therapy,” has received growing research support and is now considered the treatment of choice in many clinical circles Docsity.com Treatments for Borderline Personality Disorder • Antidepressant, antibipolar, antianxiety, and antipsychotic drugs have helped some individuals to calm their emotional and aggressive storms – Given the high risk of suicide attempts by these patients, their use of drugs on an outpatient basis is controversial • Some patients have benefited from a combination of drug therapy and psychotherapy Docsity.com Histrionic Personality Disorder • People with histrionic personality disorder are extremely emotional and continually seek to be the center of attention – They often engage in attention-getting behaviors and are always “on stage” • Approval and praise are the lifeblood of these individuals – People with histrionic personality disorder are often described as vain, self-centered, and demanding • Some make suicide attempts, often to manipulate others Docsity.com How Do Theorists Explain Histrionic Personality Disorder? • Cognitive theorists look at the lack of substance and the extreme suggestibility found in people with the disorder – Some propose that people with histrionic personality disorder hold a general assumption that they are helpless to care for themselves • Sociocultural theorists believe the disorder is caused in part by society’s norms and expectations – The vain, dramatic, and selfish behavior may be an exaggeration of femininity as defined by our culture Docsity.com Treatments for Histrionic Personality Disorder • Unlike people with most other personality disorders, those with histrionic personality disorder often seek treatment on their own • Working with them can be difficult because of their demands, tantrums, seductiveness, and attempts to please the therapist Docsity.com Treatments for Histrionic Personality Disorder • Cognitive therapists try to help people with this disorder change their belief that they are helpless and try to help them develop better, more deliberate ways of thinking and solving problems • Psychodynamic therapy and group therapy have also been applied • Clinical case reports suggest that each of the approaches can be useful – Drug therapy is less successful, except as a means of relieving the depression experienced by some patients Docsity.com How Do Theorists Explain Narcissistic Personality Disorder? • Psychodynamic theorists more than others have theorized about this disorder, focusing on cold, rejecting parents – Object-relations theorists interpret this grandiose self- presentation as a way for people with this disorder to convince themselves that they are self-sufficient and without need of warm relationships – In support of this theory, research has found increased risk for developing the disorder among abused children and those who lost parents through adoption, divorce, or death Docsity.com How Do Theorists Explain Narcissistic Personality Disorder? • Cognitive-behavioral theorists propose that narcissistic personality disorder may develop when people are treated too positively rather than too negatively in early life – Those with the disorder have been taught to “overvalue their self-worth” • Finally, many sociocultural theorists see a link between narcissistic personality disorder and “eras of narcissism” in society Docsity.com Treatments for Narcissistic Personality Disorder • This disorder is one of the most difficult personality patterns to treat – Clients who consult therapists usually do so because of a related disorder, most commonly depression – Once in treatment, the individuals may try to manipulate the therapist into supporting their sense of superiority • None of the major treatment approaches have had much success Docsity.com Avoidant Personality Disorder • People with avoidant personality disorder are very uncomfortable and inhibited in social situations, overwhelmed by feelings of inadequacy, and extremely sensitive to negative evaluation – They believe themselves unappealing or inferior and often have few close friends Docsity.com Avoidant Personality Disorder • The disorder is similar to social phobia, and many people with one disorder experience the other – Similarities between the two disorders include a fear of humiliation and low self-confidence – A key difference is that people with social phobia mainly fear social circumstances, while people with avoidant personality disorder tend to fear close social relationships • Between 1% and 2% of adults have avoidant personality disorder, men as frequently as women Docsity.com How Do Theorists Explain Avoidant Personality Disorder? • Theorists often assume that avoidant personality disorder has the same causes as anxiety disorders, including: – Early trauma – Conditioned fears – Upsetting beliefs – Biochemical abnormalities • Research has not directly tied the personality disorder to the anxiety disorders Docsity.com Treatments for Avoidant Personality Disorder • People with avoidant personality disorder come to therapy seeking acceptance and affection – Keeping them in therapy can be challenging because they often begin to avoid sessions • A key task of the therapist is to gain the individual’s trust – Beyond building trust, therapists tend to treat the disorder as they treat social phobia and anxiety • These treatments have had modest success • Group therapy formats, especially those that follow cognitive-behavioral principles, also help by providing practice in social interactions • Antianxiety and antidepressant drug therapy may also be useful Docsity.com Dependent Personality Disorder • People with dependent personality disorder have a pervasive, excessive need to be taken care of – As a result, they are clinging and obedient, fearing separation from their loved ones – They rely on others so much that they cannot make the smallest decision for themselves • The central feature of the disorder is a difficulty with separation Docsity.com Dependent Personality Disorder • Many people with this disorder feel distressed, lonely, and sad – Often they dislike themselves • They are at risk for depression, anxiety, and eating disorders and may be especially prone to suicidal thoughts • Studies suggest that over 2% of the population experience the disorder – Research suggests that men and women are affected equally Docsity.com How Do Theorists Explain Dependent Personality Disorder? • Cognitive theorists identify two maladaptive attitudes as helping to produce and maintain this disorder: – “I am inadequate and helpless to deal with the world” – “I must find a person to provide protection so I can cope” • Such thinking prevents sufferers of the disorder from making efforts to be autonomous Docsity.com Treatments for Dependent Personality Disorder • In therapy, people with this disorder usually place all responsibility for their treatment and well-being on the clinician – A key task is to help patients accept responsibility for themselves – Couple or family therapy can be helpful; both are often recommended Docsity.com Treatments for Dependent Personality Disorder • Treatment can be at least modestly helpful – Psychodynamic therapy focuses on many of the same issues as therapy for people with depression – Cognitive-behavioral therapists try to help clients challenge and change their assumptions of incompetence and helplessness and provide assertiveness training – Antidepressant drug therapy has been helpful for those whose disorder is accompanied by depression – Group therapy can be helpful because it provides clients an opportunity to receive support from a number of peers and because group members may serve as models for one another Docsity.com How Do Theorists Explain Obsessive-Compulsive Personality Disorder? • Most explanations of obsessive-compulsive personality disorder borrow heavily from those of obsessive-compulsive anxiety disorder, despite doubts concerning a link between the two • Psychodynamic explanations dominate and research is limited Docsity.com How Do Theorists Explain Obsessive-Compulsive Personality Disorder? • Freudian theorists suggest that people with obsessive-compulsive personality disorder are anal regressive – Because of overly harsh toilet training, people become angry and remain fixated at this stage of psychosexual development • To keep their anger under control, they resist both their anger and their instincts to have bowel movements • As a result, they become extremely orderly and restrained Docsity.com How Do Theorists Explain Obsessive-Compulsive Personality Disorder? • Cognitive theorists have little to say about the origins of the disorder, but they do propose that illogical thinking processes help maintain it Docsity.com Multicultural Factors: Research Neglect • According to DSM-IV-TR, a pattern diagnosed as a personality disorder must “deviate markedly from the expectations of a person’s culture” – Given the importance of culture in the definition, it is striking how little multicultural research has been conducted Docsity.com Multicultural Factors: Research Neglect • Clinical theorists have suspicions, but no compelling evidence, that cultural differences exist and that such differences are important to the field’s understanding and treatment of personality disorders • The lack of multicultural research is of special concern with regard to borderline personality disorder – Theorists are convinced that gender and other cultural differences may be particularly important in both the development and diagnosis of this disorder Docsity.com What Problems Are Posed by the DSM-IV-TR Categories? • Most of today’s clinicians believe that personality disorders are important and troubling patterns – Yet these disorders are particularly hard to diagnose, easy to misdiagnose, and raise serious issues of reliability and validity – Several specific problems have been raised… Docsity.com What Problems Are Posed by the DSM-IV-TR Categories? • Because of these problems, diagnosticians keep changing the criteria used to assess the personality disorders – For example, DSM-IV-TR dropped a past category, passive-aggressive personality disorder, but it is now being studied more carefully and may be included once again in future editions of DSM Docsity.com Are There Better Ways to Classify Personality Disorders? • The leading criticism of DSM-IV-TR’s approach to personality disorders is that the classification system uses multiple categories – rather than dimensions – of personality Docsity.com Are There Better Ways to Classify Personality Disorders? • Like a light switch, DSM-IV-TR’s categorical approach assumes that: – Problematic personality traits are either present or absent – A personality disorder is either displayed or not displayed – A person who suffers from a personality disorder is not markedly troubled by personality traits outside of that disorder Docsity.com Are There Better Ways to Classify Personality Disorders? • The “Big Five” Theory of Personality and Personality Disorders – Many proponents of the five-factor model further argue that it would be best to describe all people with personality disorders as being high, low, or in-between on the five supertraits, and to drop the DSM-IV-TR’s current use of personality disorder categories altogether Docsity.com Are There Better Ways to Classify Personality Disorders? • Alternative Dimensional Approaches – Although many clinical theorists now agree that a dimensional approach would reflect personality pathology more accurately than the categorical approach of DSM-IV-TR, not all of them believe that the “Big Five” model is the most useful dimensional approach – Thus, alternative dimensional models have also been proposed Docsity.com Are There Better Ways to Classify Personality Disorders? • Alternative Dimensional Approaches – It is not yet certain where these proposed dimensional models of personality pathology will lead, although a number of influential theorists predict that the next edition of DSM (DSM-V) will use some such model rather than the current categorical model Docsity.com