Personality Disorders MA Psikologi Abnormal Semester Ganjil 200910

Personality Disorders MA Psikologi Abnormal Semester Ganjil 2009/10

Personality Disorders (PD) l l l Longstanding, pervasive, inflexible patterns of behavior and inner experience Coded on Axis II Patterns present in at least 2 areas: » » l l l Cognition Emotions Relationships Impulse control Patterns are not the effects of substance abuse nor general medical condition Patterns are not necessarily comorbid with Axis I disorders. Even though comorbidity with Axis I is more often than not More severe symptoms and poorer outcome when comorbid – 50+% of people diagnosed with a personality disorder meet criteria for another personality disorder – More than two-thirds meet lifetime criteria for an Axis I disorder (Lenzenwenger et al. , 2007) 2

Personality Disorders (PD) l Patterns are not necessarily comorbid with Axis I disorders. Even though comorbidity with Axis I is more often than not l More severe symptoms and poorer outcome when comorbid – 50+% of people diagnosed with a personality disorder meet criteria for another personality disorder – More than two-thirds meet lifetime criteria for an Axis I disorder (Lenzenwenger et al. , 2007) l l Initial onset: adolescence or young adulthood Nature of symptoms: ego-syntonic and alloplastic “problems are not with me, they are with people”

Key Features of the DSM-IV-TR Personality Disorders 4

Rates of DSM-IV Personality Disorders in the Community and in Treatment Settings 5

Classifying Personality Disorders l l DSM-IV-TR categorical approach Classifies in 3 clusters: » Cluster A Odd/Eccentric » Cluster B Dramatic/Erratic » Cluster C Anxious/Fearful l Diagnostic reliability » Initially poor; improved since DSM-III l Test-retest reliability (diagnostic stability) » ½ of those initially diagnosed with PD did not receive same diagnosis 1 year later (Shea et al. , 2002) l Gender bias » Certain diagnoses applied more often to men, others to women 6

Dimensional Approach: Five-Factor Model l Five-factor model (Mc. Crae & Costa, 1990) » Neuroticism, extraversion/introversion, openness to experience, agreeableness/antagonism, and conscientiousness » Five factors are heritable l Personality traits form a continuum » Individuals with PDs endorse the extremes l Dimensional approach involves rating each individual on the five factors » Avoids applying a categorical label which may not completely fit 7

Dimensional Approach: Five-Factor Model l Most personality disorders are characterized by high neuroticism and antagonism. High extraversion tied to histrionic and narcissistic disorders (involve dramatic behavior) Low extraversion linked to disorders that involve social isolation, such as schizoid, schizotypal, and avoidant personality disorders 8

Table 12. 4 Sample Items from the Revised NEO Personality Inventory assessing Five-Factor Model 9

Odd/Eccentric (A) Cluster: Paranoid Personality Disorder l Suspicious » Secretive; reluctant to confide in others l Expects to be mistreated/exploited » Vigilant for hints of abuse l l Blames others when things go wrong Easily feel threatened Questions loyalty No hallucinations or full blown delusions l l More common in men than women Cormorbidity high for » Schizotypal » Borderline » Avoidant 10

Odd/Eccentric (A) Cluster: Schizoid Personality Disorder l Avoids close interpersonal relationships l » Few close friends » Aloof & distant l Comorbidity high for » Schizotypal » Avoidant » Paranoid Loner » Likes solitary activities l l l Rarely report strong emotions Little interest in sex Experiences anhedonia: tdk menikmati peristiwa menyenangkan yg dilakukannya 11

Odd/Eccentric Cluster: Schizotypal Personality Disorder l l Interpersonal difficulties similar to schizoid Odd beliefs or magical thinking » Superstitious » Telepathic l Illusions » Feels the presence of a force or person not actually present. l Odd/eccentric behavior or appearance » Wears strange clothes » Talks to self l Ideas of reference 12

Etiology of the PDS in Odd/Eccentric Cluster l l Highly heritable Links to schizophrenia » Relatives of individuals with schizophrenia at greater risk for schizotypal » Individuals with schizotypal PD show problems similar to those found in schizophrenia – Cognitive and neuropsychological deficits – Enlarged ventricles – Less temporal gray matter 13

Dramatic/Erratic (B) Cluster: Borderline Personality Disorder (BPD) l l l l l Impulsive, self-damaging behaviors Unstable, stormy, intense relationships Emotional reactivity Frantic efforts to avoid abandonment Unstable sense of self Anger control problems Chronic feelings of emptiness Recurrent suicidal gestures Transient psychotic or dissociative symptoms 14

Dramatic/Erratic Cluster: Borderline Personality Disorder (BPD) l l Onset during adolescence or early adulthood Prognosis poor within 10 years of diagnosis » Later in life, most no longer meet diagnostic criteria (Paris, 2002) l Cormorbidity high with PTSD, MDD, substance-related, and eating disorders » Comorbidity predicts symptoms 6 years later l Suicide rates high » Self-mutilation also a problem 15

Etiology of Borderline Personality Disorder (BPD): Neurobiological factors l Genetic component » Highly heritable » May play a role in impulsivity and emotional dysregulation Decreased functioning of serotonin system l Frontal lobe dysfunction l Increased activation of amygdala l 16

Etiology of Borderline Personality Disorder (BPD): Social Environmental Factors l l l Parental separation Verbal and emotional abuse during childhood Object-Relations Theory (Kernberg, 1985) » Introjection » Object-representation – BPD involves disturbed object representations, possibly due to inconsistent parenting » Conflict between introjected values and current needs – Splitting 17

Etiology of Borderline Personality Disorder (BPD): Social Environmental Factors l Linehan’s Diathesis-Stress Theory » Individuals with BPD have difficulty controlling their emotions – Possible biological diathesis » Family invalidates or discounts emotional experiences and expression » Interaction between extreme emotional reactivity and invalidating family → BPD 18

Linehan’s Diathesis-Stress Theory of BPD 19

Dramatic/Erratic (B) Cluster: Histrionic Personality Disorder l l l Formerly known as hysterical personality Overly dramatic and attention seeking behavior Craves attention » Loves to be in the spotlight l l Emotionally shallow despite strong displays of emotion Easily influenced by others Overly concerned with physical attractiveness May be sexually provocative and seductive 20

Etiology of Histrionic Personality Disorder l Psychoanalytic theory » Emotional displays and seductiveness result from parental seductiveness – Father’s sexual attention towards daughter » Conflicting family attitudes towards sexuality – Negative attitudes towards sex while simultaneously acknowledging titillation l Theory untested 21

Dramatic/Erratic (B) Cluster: Narcissistic Personality Disorder l Grandiose view of self » Preoccupied with fantasies of success l Self-centered » Demands constant attention and adulation l l l Feelings of entitlement and arrogance Envious of others Little concern for needs and well being of others » Lacks empathy l l Sensitive to criticism Seeks out high-status partners 23

Etiology of Narcissistic Personality Disorder l Kohut’s Self-Psychology Model » Characteristics mask low self-esteem » In childhood, narcissist valued as a means to increase parent’s own self-esteem – Not valued for his or her own competency and self worth l » People with high levels of narcissism report cold parents who overemphasized child’s achievement Social cognitive model » Narcissist has low self esteem » Sense of self depends on “winning” » Interpersonal relationships are a way to bolster sagging self esteem rather than increase closeness to others » Lab studies reveal cognitive biases that maintain narcissism 24

Dramatic/Erratic Cluster: Antisocial Personality Disorder l Pervasive disregard for the rights of others since age 15 » » » Lies Aggression Impulsiveness Violates the law Irresponsible Lacks remorse l Conduct disorder before age 15 l l Substance abuse most common comorbid disorder Culture plays a role l More common among lower SES groups » Truancy, running away, lying, theft, arson, destruction of property » More common in US than Scotland 25

Dramatic/Erratic (B) Cluster: Antisocial Personality Disorder l l l Psychopathy (sociopathy) (Cleckley, 1941) Predates DSM-IV-TR category Focuses on internal thoughts and feelings l » Interpersonal symptoms – Pathological lying, manipulativeness, and charm » Poverty of emotion » Affective symptoms – Negative emotions l – Lack of remorse and empathy, shallow affect Lacks shame and anxiety – Positive emotions l Used to manipulate others » Impulsivity – Behave irresponsibly for thrills Psychopathy Checklist – revised (Hare, 2008) l Onset before age 15 not required. 26

Etiology of Antisocial Personality Disorder l Genetics » Antisocial behavior heritable – Estimates as high as. 96 » Genetic risk for APD, psychopathy, conduct disorder, and substance abuse related. l Family environment » Lack of warmth, negativity, and parental inconsistency predict APD » Poverty, exposure to violence » Family environment interacts with genetics 27

Etiology of Antisocial Personality Disorder l Emotion and psychopathy » Lack of fear or anxiety » Low baseline levels of skin conductance » Skin conductance reactivity at age 3 predicted APD at age 28 (Glenn et al. , 2007) l l Makes it difficult for them to avoid behavior that leads to punishment Also show less SCR to other’s distress » Lack empathy Figure 12. 3 28

Anxious/Fearful (C) Cluster: Avoidant Personality Disorder l Avoids interpersonal situations » Fears criticism or rejection l Hesitant about involvement with others » Wants to be certain of acceptance l Restrained and inhibited in interpersonal situations » Fears ridicule » Feelings of inadequacy l Avoids taking risks or trying new activities » Doesn’t want to risk embarrassment l High comorbidity with major depression and generalized social phobia » Related to. Japanese syndrome called taijin kyofusho (taijin means “interpersonal” and kyofusho means “fear”). 29

Anxious/Fearful (C) Cluster: Dependent Personality Disorder l l l l Lack of self confidence Excessive reliance on others Intense need to be cared for Uncomfortable when alone Feels helpless to care for self Behavior focused on maintaining relationships Quickly initiates new relationship if current one fails Prevalence higher in India and Japan than US 30

Anxious/Fearful Cluster: Obsessive-Compulsive Personality Disorder l l A perfectionist Preoccupied with rules, details, & organization Rigid and inflexible Overly focused on work » Little time for leisure, family, & friends l Tendency to hoard » Difficulty discarding worthless items l l Reluctant to delegate Moral inflexibility Does not have the obsessions/compulsions of OCD Most frequently comorbid with Avoidant PD 31

Etiology of Personality Disorders in the Anxious/Fearful Cluster l l Not much available research Avoidant PD » Overly protective and authoritarian parents l Obsessive-Compulsive PD » Fixation at anal stage of development (Freud) » More recent theorists – Cope with fears of losing control by overcompensation l Dependent PD » Disruption of early childhood attachment by death, neglect, rejection, or overprotectiveness 32

Treatment of Personality Disorders l Axis I disorder usually drives individual to treatment » Presence of PD, reduces success of treatment for Axis I l Medications » Avoidant PD – Antianxiety medication or antidepressants » Schizotypal PD – Antipsychotic medications l Psychotherapy » Psychodynamic – Seek awareness of early childhood problem » Cognitive behavioral – Break personality disorder down into discrete problems l Treat sensitivity to criticism with social skills training 33

Maladaptive Cognitions Associated with PD 34

Treatment of Borderline PD l Difficult to treat » Interpersonal problems play out in therapy » Attempts to manipulate therapist l l Object Relations Therapy (Kernberg et al. , 1985) Dialectical Behavioral Therapy (Linehan, 1987) » Acceptance and empathy plus CBT, emotion regulation, and social skills l Schema-Focused Cognitive Therapy for BPD » Identify maladaptive assumptions that underlie cognitions l Medications » Antidepressants » Antipsychotics – Olanzapine 35

Treatment of Psychopathy Intensive psychoanalytic therapy l Cognitive behavioral therapy l Issue remains l » Are therapy successes ‘faking good’ or genuinely improved? 36