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Personality Disorders

(9-25-06)

Tell me who your friends are and I’ll tell you who you are

Sean Gaffney & Seamus Cashman, Ed.s (1974, p. 39). Proverbs & Sayings of Ireland. New York: MJF Books.

Borderline Personality Disorder

(10-28-09)

DSM-IV Mnemonic

  • A.M. SUICIDE (Pinkofsky, 1997, p. 1198)
    • A [1] Abandonment
    • M [6] Mood instability (marked reactivity of mood)
    • S [5] Suicide (or self-mutilating) behavior
    • U [2] Unstable and intense relationships
    • I [4] Impulsivity (in two potentially self-damaging areas)
    • C [8] Control of anger
    • I [3] Identity disturbance
    • D [9] Dissociative (or paranoid) symptoms that are transient and stress related
    • E [7] Emptiness (chronic feelings of)
  • ARISES MAD (Reeves & Bullen, 1995)
    • A Anger
    • R Relationships
    • I Impulsivity
    • S Self-image unstable
    • E Emptiness
    • S Suicidal behavior
    • M Mood reactivity, affective instability
    • A Abandonment fears
    • D Dissociative symptoms, paranoia

Necessary and Exclusionary criteria (Benjamin & Strand, 1998, Benjamin, 1993)

necessary: “Coerces care as antidote to fear of abandonment; self-sabotage following happiness or success” (p. 783)
exclusionary: “Tolerance of aloneness on a long-term basis” (p. 785)

Kroll’s view of Borderline syndrome

Two styles or processes:

  1. Cognitive Style: poorly focused thinking, self-rumination, transient dissociative states, disorganization under stress, use of impulsive action to end unpleasant mental states
    • Difficulty in focusing attention
    • Loss of relevant detail
    • Impressionistic and global perceptions
    • Distortion of meaning or significance of an event
    • Imprecision and exaggeration
    • Memory difficulties and distortions
    • Confusion and disorganization of thinking
    • Cannot reason logically
    • Morbid introspection into own thinking
    • Tendency to short-circuit thought with action
    • Diminished ability to process information
    • Thoughts dominated by a few themes: intrusive and negative imagery
    • Misperceptions of outside intervention
  2. Emotional intensity or lability which is felt by the patient as overwhelming
    • Claims to feel own feelings intensely
    • Claims to be overwhelmed by own feelings
    • Cannot maintain neutral & conflict free relationships
    • Intrudes personal issues into tasks
    • Drives relationships into increasing intensity
    • Evokes strong feelings in others
    • Rapid changes of mood in response to environmental stimuli
    • Major moods are depression, anger, and neediness/emptiness

Two key themes around which many symptoms are organized:

  1. Victimization
  2. Loneliness/Emptiness

Role of repetitive sexual abuse: neither necessary nor sufficient

DSM-IV-TR BPD

  • Pervasive pattern of instability in relationships, self-image, and affect, and marked impulsivity
  • Beginning by early adulthood
    • Paris (1999) discusses data that children with “borderline” traits do not necessarily develop into BPD adults: “In fact, borderline children go on to develop a wide variety of personality disorders.” (p. 633); also notes that majority of children labeled “borderline” are males, whereas most adult cases are female.
    • Garnet et al. (1994) found that four DSM symptoms (anger, suicidal threats, identity disturbance, and emptiness) predicted continuance of borderline psychopathology in adolescents
  • Present in a variety of contexts
  • 1-2% of general population; significantly more prevalent in clinical populations
  • Long term prognosis relatively good but 9-10% suicide (some recent reports have found lower figures for death from suicide but still a significant risk)

Treatment issues for Borderline Personality Disorder

  1. Clear, specific, and honest treatment goals
    • 1a. Maintenance of therapeutic relationship
    • 1b. Written therapy contracts
  2. Anticipate course of treatment
    • 2a. Variable
    • 2b. Long course, but not necessary long therapy
    • 2c. Focus on progress
  3. Treating comorbid problems
    • 3a. Distress problems (depression, anxiety)
      • 3a1. Monitor medication compliance
    • 3b. Substance Abuse
    • 3c. Acting out (SIB, criminal behavior, parasuicide, high risk sexual behavior)
  4. Building positives (health/coping skills) approach
    • 4a. Enhancing positive coping skills may be much more productive than dealing with to any great extent with history and/or problems
      • 4a(1) some form of arousal management very helpful
      • 4a(2) some building of legitimate sense of self-worth/meaning in life/positive values very helpful
      • 4a(3) some form of rational/adaptive reality testing very helpful, especially with respect to meaning of interpersonal events
    • 4b. At least some problems tend to take care of themselves as client adapts move productive and satisfying approaches to self/others/life
  5. Always work with misinterpretations and distortions of you/your communication
    • 5a. Confrontation and feedback
    • 5b. Indirect communication
  6. 6. Attend to your own physical and emotional health
    • 6a. Practice forgiveness
    • 6b. Supervision

Antisocial Personality Disorder

(11-9-09)

  • DSM-IV Mnemonic
    • CORRUPT (Pinkofsky, 1997, p. 1198)
      • C [1] Conformity to law lacking
      • O [6] Obligations ignored
      • R [5] Reckless disregard for safety of self or others
      • R [7] Remorse lacking
      • U [2] Underhanded (deceitful, lies, cons others)
      • P [3] Planning insufficient (impulsive)
      • T [4] Temper (irritable and aggressive)
  • Necessary and Exclusionary criteria (Benjamin & Strand, 1998; Benjamin, 1993)
    • necessary: “Control of others and autonomy for self; detachment and lack of remorse” (p. 783)
    • exclusionary: “Fear of abandonment; entitlement; dependency” (p. 784)

Reid’s 2-Factor Conceptualization of Psychopathy

  • Factor 1: Selfish, callous, and remorseless use of others
    • Psychopathy Checklist Factors
      • 1. Glibness/superficial charm
      • 3. Egocentricity/grandiose self of self-worth
      • 5. Pathological lying and deception
      • 6. Conning/lack of sincerity
      • 7. Lack of remorse or guilt
      • 8. Lack of affect and emotional depth
      • 9. Callous/lack of empathy
      • 20. Failure to accept responsibility for own actions
      • 22. Drug or alcohol not direct cause of antisocial behavior
  • Factor 2: Chronically unstable and antisocial life-style; social deviance
    • 4. Proneness to boredom/low frustration tolerance
    • 10. Parasitic life-style
    • 11. Short-tempered/poor behavioral controls
    • 13. Early behavior problems
    • 14. Lack of realistic long-term plans
    • 15. Impulsivity
    • 16. Irresponsible behavior as a parent
    • 17. Frequent marital relationships
    • 18. Juvenile delinquency
    • 19. Poor probation or parole risk
    • 21. Many types of offenses

Harpur, T.J., Hare, R.D., & Hakstian, A.R. (1989). Two-factor conceptualization of psychopathy: Construct validity and assessment implication. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1, 6-17.

Malingering

  • Etiological Considerations
    • Animal Models of Psychopathy
      • SHF syndrome (Zinbarg, 1990)
        • lesions to a neural system consisting of the medial septum, hippocampus, and prefrontal cortex (SHF system) in animals produces behavior similar to several aspects of human psychopaths
          • impaired learning in conflict between approach tendencies: passive avoidance deficit similar to that observed in psychopaths
          • impaired ability to withhold responses in DRL tasks: similar to delay of gratification problems in psychopaths

Histronic Personality Disorder

(10-5-04)

  • DSM-IV Mnemonic
    • PRAISE ME (Pinkofsky, 1997, p. 1198)
      • P [2] Provocative (or sexually seductive) behavior
      • R [8] Relationships (considered more intimate than they are)
      • A [1] Attention (uncomfortable when not the center of attention)
      • I [7] Influenced easily
      • S [5] Style of speech (impressionistic, lacks detail)
      • E [3] Emotions (rapidly shifting and shallow)
      • M [4] Made up (physical appearance used to draw attention to self)
      • E [6] Emotions exaggerated (theatrical)
  • Necessary and Exclusionary criteria (Benjamin & Strand, 1998; Benjamin, 1993)
    • necessary: “Coercive dependency” (p. 783)
    • exclusionary: “Self-sabotage following happiness or success” (p. 784)
  • Relationship to physical characteristics
    • Bornstein (1999) notes that is the only DSM-IV personality disorder categories clearly associated with physical characteristics: “Several researchers have noted that HPD tends to appear in women and men who are above average in physical attractiveness” (p. 542); discusses this observation in the context of seductiveness as a key feature
  • Relationship to other personality disorders
    • Bornstein discusses comorbidity of HPD in males with antisocial traits, and the hypothesis that HPD in females and Antisocial Personality Disorder in male are the same disorder (Hamburger, Lilenfeld, & Hogben, 1996; see also Hart & Hare, 1989)

Narcissistic Personality Disorder

(10-5-04)

  • DSM-IV Mnemonic: Narcissistic Personality Disorder
    • SPE3CIAL (Pinkofsky, 1997, p. 1198)
      • S [3] Special (believes he or she is special or unique)
      • P [2] Preoccupied with fantasies (of unlimited success, power, brilliance, beauty, or ideal love
      • E [8] Envious (of others, or believes others are envious of him/her)
      • E [5] Entitlement
      • E [4] Excessive admiration required
      • C [1] Conceited (grandiose sense of self importance)
      • I [6] Interpersonal exploitation
      • A [9] Arrogant (haughty)
      • L [7] Lacks empathy
  • Necessary and Exclusionary criteria (Benjamin & Strand, 1998; Benjamin, 1993)
    • necessary: “Grandiose sense of self importance; entitlement” (p. 783)
    • exclusionary: “Uncaring recklessness with self” (p. 784)
  • Ronningstam & Gunderson (1990) used a semi-structured Diagnostic Interview for Narcissism to assess 82 patients meeting following criteria: 1. 17-45 years of age; 2. capable of participation in diagnostic interview; 3. no known organic impairment; 4. official clinical diagnoses in one of three categories:
    • a. Narcissistic personality disorder (n=24): a prototypic sample which excluded patients with complicating Axis I diagnosis (major depression or concurrent substance abuse). Used LEAD (Longitudinal/Expert/All Data) standard (Spitzer, 1983).
    • b. Other “dramatic” cluster personality disorder (n=36)–borderline (Diagnostic Interview for Borderline Patients) & antisocial (SCID-II). Near-neighbor diagnoses increase specificity for disorder rather than features that are just prevalent (highly sensitive). For instance, in this study were aggressive, exploitive, & envious (Kernberg) but these features did not discriminate. Also they were hypersensitive, showed intense reactions to criticisms, and idealized/devalued others (Kohut); but these did not discriminate.
    • c. Other psychiatric disorders (n=22)
      “The most outstanding features of the patients with narcissistic personality disorder was their grandiosity (i.e. belief in their uniqueness and superiority, combined with an unrealistic overvaluation of their own abilities, and grandiose fantasies)” Ronningstam & Gunderson, 1990, p.921). Nine characteristics best discriminated:
      • 1. Superiority: sustained unrealistic view self as better than others; viewing others as different from self & inferior; disdain for others.
      • 2. Uniqueness: sense of self as unique; belief that few have much in common with oneself; often feel misunderstood.
      • 3. Exaggeration of talents: even though generally capable, exaggerate aptitudes or achievements in unrealistic ways.
      • 4. Boastful or pretentious behavior: brag and behave ostentatiously; assume interest and naivete of others
      • 5. Grandiose fantasies: fantasies of unlimited success, power, beauty, wealth, or ideal love occupy
      • 6. Self-centered and self-referential behavior: observably self-preoccupied, and prone to assign personal meanings to events (personalize) independent & unrelated to them; lack of interest in opinions and reactions of others
      • 7. Need for attention and admiration: consider admiring attention from other important, report working hard to get it; do not believe they have unrealistic expectations about getting attention and admiration.
      • 8. Arrogant and haughty behavior: snobbish, supercilious, patronizing behavior in relation to others
      • 9. High achievement: often have sustained periods of successful academic, employment, or creative achievement. Used as justification for their sense of superiority. Also a reason they are more apt to be seen in private practice than in clinics. Not useful as criterion for pathological narcissism, but does help demographic differentiation.

Schizoid Personality Disorder

(10-5-04)

  • DSM-IV Mnemonic: Schizoid Personality Disorder
    • DISTANT (Pinkofsky, 1997, p. 1198)
      • D [7] Detached (or flattened) affect
      • I [6] Indifferent to criticism and praise
      • S [3] Sexual experiences of little interest
      • T [2] Tasks (activities) done solitarily
      • A [5] Absence of close friends
      • N [1] Neither desires nor enjoys close relations
      • T [4] Takes pleasure in few activities
  • Necessary and Exclusionary criteria (Benjamin & Strand, 1998; Benjamin, 1993)
    • necessary: “Social withdrawal” (p. 783)
    • exclusionary: “Stong affect; eccentricity; complex manipulative skills; abandonment fear; wish for love” (p. 784)
  • Etiological factors
    • Blum et al., (1997) reported an association between the dopamine D2 receptor Taq A1 allele and schizoid/avoidant behavior; a weaker association was reported between the 480-pb VNTR 10/10 allele of the dopamine transporter (DAT1) gene
  • DSM-IV Mnemonic: Avoidant Personality Disorder
    • CRINGES (Pinkofsky, 1997, p. 1198)
      • C [2] Certainty (of being liked required before willing to get involved with others
      • R [4] Rejection (or criticism) preoccupies ones’ thoughts in social situations
      • I [3] Intimate relationships (is inhibited in)
      • N [5] New interpersonal relationships (is inhibited in)
      • G [1] Gets around occupational activity (involving significant interpersonal contact)
      • E [7] Embarrassment (potential) prevents new activity or taking personal risks
      • S [6] Self-viewed (as unappealing, inept, or inferior)
  • Wolff (2000) describes child onset cases diagnosed as schizoid personality disorder. Their “core features” were characterized as:
    • 1. solitariness
    • 2. lack of empathy and emotional detachment
    • 3. increased sensitivity at time with paranoid ideas
    • 4. regidity of mental set, especially the single-minded pursuit of special interests
    • 5. unusual or odd styles of communication (such as over or undercommunicativeness, vagueness, and odd use of metaphor) p. 281
  • “Our later studies found the chlidren to have one further characteristic, described also by Asperger (1944): (6) un unusual fantasy life.” p. 281
  • They distinguished between “solitariness (e.g., having no close friends)” with “being ‘outgoing.’ This feature consisted of superficial socialbility, verbosity, and often tackless verbal communications with little regard to the needs and interests of the other person, in constract to the verbal uncommunicativeness and apparent shyness that characterized others of our children.” (p. 281)
  • “Two conclusions follow for the clinician: (1) there is a group of children, not as clearly impaired as children with autism or AS as currently defined, … who need to be diagnosed because their more subtle, underlying difficulties are long lasting, and schools and families need to accomodate to the children’s special personality make-up; and (2) their overall outcome is reasonably good.” (p. 285)

Avoidant Personality Disorder

(10-5-04)

  • DSM-IV Mnemonic: Avoidant Personality Disorder
    • CRINGES (Pinkofsky, 1997, p. 1198)
      • C [2] Certainty (of being liked required before willing to get involved with others
      • R [4] Rejection (or criticism) preoccupies ones’ thoughts in social situations
      • I [3] Intimate relationships (is inhibited in)
      • N [5] New interpersonal relationships (is inhibited in)
      • G [1] Gets around occupational activity (involving significant interpersonal contact)
      • E [7] Embarrassment (potential) prevents new activity or taking personal risks
      • S [6] Self-viewed (as unappealing, inept, or inferior)
  • Necessary and Exclusionary criteria (Benjamin & Strand, 1998; Benjamin, 1993)
    • necessary: “Defensive withdrawal; wishes for acceptance” (p. 783)
    • exclusionary: “Affective detachment; avoidance of aloneness; instrumental incompetence; consistent failure to perform” (p. 785)

Schizotypal Personality Disorder

(10-5-04)

  • DSM-IV Mnemonic: Schizotypal Personality Disorder
    • ME PARTICULAR (Pinkofsky, 1997, p. 1198)
      • M [2] Magical thinking or odd beliefs
      • E [3] Experiences unusual perceptions
      • P [5] Paranoid Ideation
      • E [7] Eccentric behavior or appearance
      • C [6] Constricted (or inappropriate) affect
      • U [4] Unusual (odd) thinking and speech
      • L [8] Lack of close friends
      • I [1] Ideas of reference
      • A [9] Anxiety in social situations
      • R Rule out psychotic disorders and pervasive developmental disorders
  • Necessary and Exclusionary criteria (Benjamin & Strand, 1998; Benjamin, 1993)
    • necessary: “Thought disorder implying autistic control; social withdrawal” (p. 783)
    • exclusionary: “Fear of autonomy; proud disregard for social norms; demanding dependency” (p. 784)

Obsessive-compulsive Personality Disorder

(10-5-04)

  • DSM-IV Mnemonic: Obsessive-compulsive Personality Disorder
    • LAW FIRMS (Pinkofsky, 1997, p. 1198)
      • L [1] Loses point of activity (due to preoccupation with detail)
      • A [2] Ability to complete tasks (compromised by perfectionism)
      • W [5] Worthless objects (unable to discard)
      • F [3] Friendships (and leisure activities) excluded (due to preoccupation with work)
      • I [4] Inflexible, scrupulous, overconscienctious (on ethics, values, morality, not accounted for by religion or culture)
      • R [6] Reluctant to delegate (unless other submit to exact guidelines)
      • M [7] Miserly (toward self and others)
      • S [8] Stubbornness (and rigidity)
  • Necessary and Exclusionary criteria (Benjamin & Strand, 1998; Benjamin, 1993)
    • necessary: “Devotion to perfection; unreasonable control” (p. 783)
    • exclusionary: “Irresponsible behaviors; emotional excesses; contempt for authority” (p. 784)

Paranoid Personality Disorder

(10-5-04)

  • Necessary and Exclusionary criteria (Benjamin & Strand, 1998; Benjamin, 1993)
    • necessary: “Perception of intent to harm when it’s not there” (p. 783)
    • exclusionary: “Worry about abandonment; deference to authority” (p. 784)

Dependent Personality Disorder

(10-5-04)

  • Necessary and Exclusionary criteria (Benjamin & Strand, 1998; Benjamin, 1993)
    • necessary: “submissiveness steming from sense of instrumental inadequacy” (p. 783)
    • exclusionary: “Long term comfort with autonomy; coercive demands for nurturance; intimate only if safe; insist on submission; scorn for authority” (p. 785)

Passive-agressive Personality Disorder

(10-5-04)

  • Necessary and Exclusionary criteria (Benjamin & Strand, 1998; Benjamin, 1993)
    • necessary: “Compliant defiance of demands to perform” (p. 783)
    • exclusionary: “Uncomplicated deference; devotion to productivity” (p. 785)

Dimensional view of personality & personality disorders

(11-20-03)

  • Early dimensional views of personality
    • Eysenck factor theory
      • Extraversion
      • Neuroticism/Anxiety Proneness
      • Psychoticism/Maleness/Tough Mindedness
    • Cattell’s factor theories
    • 15 source (primary) traits of temperament
      2 source traits of ability
      10 source traits of motivation
  • Five Factor Theory
  • Coloninger’s Model
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