Personality Disorder Part One

Why do PDs exist?

• psychiatric disorders are episodic (they come and go in episodes)

• Many only need to be there for a little while (2 weeks? 6 months?) to be diagnosed

• In diagnosing, we ask questions like, “When was the last time you felt like your normal self?”

• For some people, nearly their entire lives have been marked by a pattern that is distressing, deviant, and dysfunctional

• PDs may predispose people to episodic disorders as well

PDs are?

among the most controversial and least understood disorders in the DSM

What are Freud’s early descriptions of personality disorder?

• Psychoanalysts thought of PDs as resulting from “fixations” during Freudian psychosexual developmental stages (e.g. oral, anal)

• Stable over time, but not related to anxiety or distress

• Believed to be not treatable

What did the DSM add in relation to personality disorders?

• Descriptions of various specific personality disorders

• A focus on observable behavioral criteria for diagnosis, instead of unmeasurable, abstract things

• Acknowledgment that PDs aren’t so different from regular disorders, and they are treatable

• Age cutoff of 18+

What is a personality disorder according to the DSM?

an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture

What are the personality disorders pattern areas?

• Cognition (e.g., interpretations of events)

• Affect (i.e. emotional response – in terms of range, intensity, lability, and appropriateness)

• Interpersonal functioning o Impulse control

What is the pattern entail for personality disorders?

inflexible, pervasive across a broad range of situations, and stable (traced back to at least adolescence/early adulthood)

What is the categorical controversy of personality disorder?

DSM-5 proposal that these be rated dimensionally —> ultimately scrapped

What is the comorbid rate of personality disorder?

Most individuals with one PD also are diagnosed with another PD

What are the biases of personality disorder?

gender and racial biases:

• Perceive women as dramatic (histrionic PD)

• Perceive Black people as violent (antisocial PD)

How are the clusters of personality disorders divided?

10 personality disorders

What are the three clusters of personality disorders?

• Cluster A (odd, eccentric)

• Cluster B (dramatic, emotional, or erratic)

• Cluster C (anxious, fearful)

Who can you think of when you think of Cluster A personality disorder specifically paranoid PD?

Peter

What is the main indictator of paranoid PD?

A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts

What are all of the indicators of paranoid PD?

• Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her

• Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates

• Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her

What are paranoid PD’s other symptoms?

• Reads hidden demeaning or threatening meanings into benign remarks or events,

• Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights),

• Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack

• has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

MAD-Eye Moody’s symptoms of preparing own food and drinks from his own flask due to his paranoia he’ll be poisoned, catchphrase is "constant vigilance,” & seems to have a core belief that “the world is a dangerous place” is an example of?

paranoid PD

If we think of schizoid PD, who do we think of?

Batman

What are the symptoms of schizoid PD?

• Aloof, a loner

• Emotionally cold

• detached from others

• Doesn’t have many close friends or confidants

• Little, if any, interest in sex

What are the therapeutic targets in schizoid PD?

emotional awareness, social skills

What is schizotypal personality disorder?

many features in common with schizophrenia, but less severe

What are the factors that determine schizotypal personality disorder?

strong link to psychotic disorders

• E.g., high rates of Cluster A PD comorbid with psychotic disorders

• First degree relative with schizophrenia = risk factor

What is the idea of reference?

irrational beliefs that random or irrelevant occurrences in the world directly relate to you

What is an example of the idea of reference?

believing that your thoughts, actions, or presence caused something to occur

Who do we think of when we think of schizotypal disorder?

Luna Lovegood

What are two of the main symptoms of schizotypal disorder?

1. Odd beliefs that are outside of cultural norms

   1. E.g., superstitions, telepathy, “sixth sense”

2. unusual perceptual experiences (e.g. feeling of floating)

What are the other symptoms of schizotypal PD?

• Odd thinking and speech (e.g., metaphorical, overelaborate)

  • “What’s up?” “Metaphysically, philosophically, or metaphorically?”

• Inappropriate or constricted affect

• Lack of close friends or confidants

• Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about oneself

• Behavior or appearance that is odd, eccentric, or peculiar

What are the medication treatments for Cluster A?

antipsychotic medication

What are the CBT treatments for Cluster A personality?

• Look for objective evidence of thoughts in environment

  • E.g., “The songs on the radio are meant especially for me”

• Practice identifying which thought are bizarre and challenging such thoughts when they arise

What is Cluster B personality disorder?

dramatic, emotional, erratic

Who do we think of when we think of histronic PD?

Regina George, Derek Zoolander

What is histronic PD mainly described as?

Pervasive pattern of excessive emotionality and attention seeking

What are the symptoms of histronic personality disorder?

• Is uncomfortable in interpersonal situations in which they are not the center of attention

• Interaction with others is often characterized by sexually provocative or seductive behavior

• Consistently uses physical appearance to draw attention to the self

• Displays rapidly shifting and shallow expressions of emotion

• Shows self-dramatization, theatricality, and exaggerated expressions of emotion

• Is suggestible (easily influenced by circumstances and other people)

• Considers relationships to be more intimate than they really are

How is cluster C defined?

anxious or fearful

How is avoidant PD defined?

Pervasive pattern of social inhibition, inadequacy, and hypersensitivity to negative evaluation

What are the symptoms of avoidance PD?

• Avoids occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection.

• Is unwilling to get involved with people unless sure of being liked

• Shows restraint within intimate relationships because of fear of being shamed or ridiculed

• Is preoccupied with fears of being rejected in interpersonal situations because of feelings of inadequacy

• Is inhibited in social situations due to fears of not being adequate.

• Views self as socially inadequate, unappealing, and inferior to others

• Is unusually reluctant to engage in new activities or take personal risks because of fear of being embarrassed

How is avoidant PD different than schizoid PD?

Schizoid PD don’t see selves as deficient —> simply more emotionally distant

How is avoidant PD difference than social anxiety disorder?

In social anxiety, beliefs of inadequacy = less prominent – they fear others will think that but tend not to think it themselves

How is dependent PD defined?

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation

Who can we think of that has dependent PD?

Buster Bluth

What are the main symptoms of dependent PD?

• Has difficulty making everyday decisions without excessive amounts of advice and reassurance from others

• Needs others to assume responsibility for major areas of their life

• Has difficulty expressing disagreement with others because of fear of loss of support or approval

• Has difficulty initiating projects or doing things on their own (because of a lack of self-confidence in judgment or abilities)

• Goes to excessive lengths to obtain support from others, to the point of volunteering to do things that are unpleasant

• Feels uncomfortable or helpless when alone

• Urgently seeks a relationship as a source of care or support when a close relationship ends

• Is unrealistically preoccupied with fears of being left to care for oneself

How is obsessive compulsive PD (OCPD) defined?

preoccupation with orderliness, perfectionism, and mental and interpersonal control – at the expense of flexibility, openness, and efficiency

Who can we think of that had OCPD?

Monica from Friends

What are the symptoms of OCPD?

• Shows a preoccupation with rules, details, lists, order, so much so the major goal or point of the activity is lost (aka losing the forest for the trees)

• Shows perfectionism that interferes with finishing the task (e.g., doesn’t finish a project because own high standards are not met)

• Is overly devoted to work and being productive at the expense of engaging in leisure activities

• Is overconscientious and inflexible about matters of morality or values

• Is reluctant to give tasks to other people unless agree to do it his or her way

• Has a hard time spending money on self or other people

• Is rigid and stubborn

What are the extreme interpersonal difficulties of borderline PD?

• Frantically tries to avoid being abandoned (terrified of being alone!)

• Has unstable and intense relationships

• Alternates between the extremes of idolizing and then devaluing someone

What are the impulsivities of borderline PD?

• Impulsive to a self-damaging degree (e.g., reckless driving, binge eating, spending, risky sex)

• Recurrent suicidal gestures or threats

• Self-harming behavior

What are the emotion regulation difficulties of borderline PD?

• Mood instability

• Intense anger (e.g., recurrent physical fights)

• Brief paranoid ideation

• Dissociation

What is mood instability?

intense episodes of sadness, irritability, or anxiety usually lasting a few hours and difficult to control

What is poor sense of self in borderline personality disorder?

• unstable self image

• chronic feelings of empitness

What is the heritability estimate of borderline PD?

~45%

What are the environmental causes of borderline PD?

Very high rates of child abuse/neglect:

• Emotional (73% vs 51%)

• Physical (59% vs 34%)

• Sexual (61% vs 32%)

How many percentage of people report childhood abuse or neglect?

90%

What are some of the controversies with BPD?

• misdiagnosed as bipolar disorder

• very stigmatized (among mental health pracitioners)

• 3:1 female: male ratio

What is the prevalence non-suicidal self-injury?

common in BPD in which 17% lifetime prevalence in adolescence and 5% in adulthood

Why do people with BPD do non-suicidal self-injury?

• relief, distraction

• externally convey extent of emotional pain

Why is ice water test and electric shock the most common non-suicidal self-injury?

Higher pain thresholds / diminished pain perception

How is non-suicidal self-injury (NSSI) treated?

DBT:

• Track it

• Acknowledge its “pros”

• Replace it with other behaviors

• Reduce access to means/tools

What is the prevalence of suicide in borderline PD?

• common in which 75% people attempt suicide and 10% complete

How can people treat borderline PD?

• constant suicide watch:

  • Track suicidal urges

  • Reduce access to means

  • Make emergency plan —> Signs it’s getting dangerous, coping skills, who I can call

What is dialectical thinking?

wrapping your head around seemingly contradictory information to see that two opposing things can be true at the same time

What is the format of dialetical thinking?

use group therapy - ½ skills group and ½ diary cards as a group

What are the diary cards?

• Tracking

• Prioritizes tracking of the most concerning things:

  • Life-threatening behaviors

  • Therapy-interfering behaviors

What is the skills group?

• Kind of like a class Homework

• Teach skills on a white board + practice them together

What are the four skills that are reviewed in the skills group?

• Interpersonal effectiveness (How can I improve my relationships?)

• Emotion regulation (How can I more effectively regulate my emotions on a daily basis?

• Distress tolerance (When I’m in crisis, what can I do to get through it?)

• Mindfulness (How can I become more accepting, and less reactive?)

What is the D in the DEAR request in interpersonal effectiveness?

Describe the facts of the situation

What is the E in the DEAR request in interpersonal effectiveness?

Express your emotions with “I” statements

What is the A in the DEAR request in interpersonal effectiveness?

Ask for what you want, clearly and specifically

What is the R in the DEAR request in interpersonal effectiveness?

Reinforce what the other person gets out of it if they meet your request

How can the distress tolerance skill be studied?

dive reflex