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Personality Styles and Disorders Timothy C. Thomason Northern Arizona University Ten Personality Disorders in DSM-5 • • • • • • • • • • Paranoid Schizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-Compulsive Additional Personality Disorders • Personality disorders in DSM-III-R – Sadistic personality disorder • A pattern of cruel, demeaning, and aggressive behavior – Self-defeating personality disorder (masochistic) • Behavior that undermines one’s pleasure and goals • Personality disorders in DSM-IV, Appendix B – Depressive personality disorder • A pattern of negative thoughts and behaviors – Passive-aggressive personality disorder (negative) • A pattern of negative attitudes and passive resistance Additional Personality Disorders • Personality disorders in ICD-10 – Dissocial personality disorder – Emotionally unstable personality disorder – Anankastic personality disorder (OCD) – Anxious (avoidant) personality disorder – Eccentric personality disorder – Immature personality disorder – Psychoneurotic personality disorder Personality Disorder Clusters • A: the weirds: Paranoid, schizoid, schizotypal • B: the wilds: Antisocial, borderline, histrionic, narcissistic • C: the wimps: Avoidant, dependent, obsessive-compulsive Prevalence of Personality Disorders • Point prevalence: 10% • Lifetime prevalence: 30-40% Prevalence of P. D.s in Descending Order • • • • • • • • • • Obsessive-Compulsive Paranoid Avoidant Borderline Histrionic Antisocial Schizoid Schizotypal Dependent Narcissistic 2.1% 1.7 1.7 1.6 1.5 1.1 0.9 0.9 0.7 0.5 Celebrity Examples of Personality Styles and Disorders • Paranoid Richard Nixon; Fox Mulder on “The X-Files” • Schizoid Sherlock Holmes; Ted Kaczynski (Unabomber) • Schizotypal Prince; Kramer on “Seinfeld” • Borderline Princess Diana; Courtney Love; the Lisa character in the movie Life Interrupted; the Glenn Close character in the movie Fatal Attraction • Antisocial Tony Soprano on “The Sopranos;” Hannibal Lector • Narcissistic Donald Trump; Barbra Streisand; Madonna; Bill Clinton; Gene Simmons; Kanye West; Dali; Picasso • Histrionic Scarlett O’Hara in GWTW; Mick Jagger; Bjork; Jerry Lewis; Jim Carey; Cher; all the singers on “American Idol;” the characters on “Glee” • Avoidant The Boo Radley character in To Kill a Mockingbird • Dependent Marilyn Monroe • Obsessive-Compulsive The Felix Unger character in “The Odd Couple;” the Monica character in “Friends;” Stanley Kubrick Personality Disorders Vary in Severity • Mild Dependent; Histrionic; Narcissistic; Antisocial • Moderate Schizoid; Avoidant; Obsessive-Compulsive • Severe Schizotypal; Paranoid; Borderline Etiology of Personality Disorders • Genetic factors contribute 40-50% of the variation in the development of personality disorders. • Personality results from the interaction of heredity and environment, as shaped in childhood. Genetics of Personality • What are the personality styles of your parents? • What is your personality style? • Is your style the same as one of your parents, or a mix of their styles? Interaction of Domains • Psychological symptoms (eg. anxiety; depression) are analogous to fever or cough. • Certain patterns of symptoms compose mental disorders. • Mental disorders occur within the context of the person’s personality. Personality is a means of coping, analogous to the immune system. Interaction of Domains, cont. • Personality exists within the context of psychosocial stressors. Marital, economic, and other stressors are analogous to infectious agents. • Psychosocial stressors and Personality Disorders interact to produce mental disorders. Millon’s Typology of Personalities • • • • Pleasure-deficient personalities Interpersonally-imbalanced personalities Intrapsychically-conflicted personalities Structurally-defective personalities Pleasure-Deficient Personalities • Schizoid: the asocial pattern • Avoidant: the withdrawn pattern • Depressive: the giving-up pattern Interpersonally-Imbalanced Personalities • • • • Dependent: the submissive pattern Histrionic: the gregarious pattern Narcissistic: the egotistic pattern Antisocial: the aggrandizing pattern Intra-psychically-Conflicted Personalities • • • • Sadistic: the abusive pattern Compulsive: the conforming pattern Negativistic: the vacillating pattern Masochistic: the aggrieved pattern Structurally-Defective Personalities • • • • Schizotypal: the eccentric pattern Borderline: the unstable pattern Paranoid: the suspicious pattern Decompensated: the terminal pattern P. D.s, Strategies and Beliefs Paranoid – Defensive – “Goodwill hides a hidden motive.” Schizoid – Autonomous – “Relationships are messy.” Antisocial – Predatory – “Others are patsies.” Histrionic – Exhibitionistic – “I can go by my feelings.” Narcissistic – Competitive – “I’m above the rules.” Avoidant – Withdrawal – “People will reject me.” Dependent – Help-Eliciting – “I need people to survive.” Obsessive – Ritualistic – “Details are crucial.” Treatment of P. D.s • Few people who have a personality disorder request treatment for their personality disorder. • Typically they complain of psychological symptoms that comprise mental disorders. • If they have a personality disorder, ethically it should be diagnosed. Personality Disorders are Treatable • Personality disorders are not necessarily chronic. • In one research study, 40% of patients with borderline personality disorder no longer met criteria for the disorder at the two-year follow-up assessment, and 88% had remitted after ten years. • Some people seem to age-out of borderline personality disorder in middle age. • In another study, more than half of patients with borderline, obsessive-compulsive, avoidant, or schizotypal personality disorders no longer had the disorder after two years. • However, most of the patients still had residual problems, often impairment in social relationships. • Aberrant personality traits are more chronic than personality disorders. • After treatment, many patients with borderline P. D. continue to exhibit emotional instability and inappropriate anger, but their frantic efforts to avoid abandonment and repetitive self-injury disappear. • People with personality disorders have stable extreme personality traits plus aberrant behavioral problems designed to cope with the consequences of these traits. Dimensional Disorders • Avoidant P. D. is the same as severe social anxiety disorder. • Borderline P. D. may be a severe form of mood disorder. • Schizotypal P. D. may be a part of the schizophrenia spectrum. Comorbidity • The average patient who has one personality disorder meets the criteria for two other personality disorders. • When DSM-IV was in use, the third most common personality disorder diagnosis was Personality Disorder NOS. • Patients with seriously disturbed personalities often fail to fit into one of the DSM categories. Heterogeneity • Patients who have the same diagnosis can differ markedly. • E.g. To qualify for the Obsessive-compulsive PD, patients must have 4 of the 8 criteria. One patient could have the first 4 symptoms while another patient had the second 4 symptoms. • Both patients would receive the same diagnosis without sharing a single symptom. Research Base • Only one of the P. D.s has a robust research base (Borderline). • Two others have a reasonable data base (Antisocial and Schizotypal). • The evidence base for the other seven P.D.s is very small. P. D.s and the Five Factor Model • Patients with borderline, schizotypal, obsessive-compulsive, or avoidant P. D. scored high on Neuroticism, low on Agreeableness, and low on Conscientiousness. • Some studies suggest that the Five Factor Model does not distinguish among the different personality disorders; there is not a distinct FFM profile for each of the P. D.s. • Overall, P. D.s tend to be associated with elevated Neuroticism and low Agreeableness. • A meta-analysis did find some distinctive profiles: Antisocial: very low A and C, average N, E, O Avoidant: high N, low E, average A, C, O Borderline: high N, low A, average E, C, O Patients Are Complicated • Do not force patients into the procrustean beds of our diagnostic categories. • Diagnoses must be flexible, allowing the distinctive characteristics of patients be displayed in their full complexity. • We should be comfortable diagnosing personality mixtures, such as borderlineavoidant; borderline-histrionic; or any other combination of two or more prototypes. • Clinical syndromes should be understood in the context of personality and psychosocial stressors. • For example, depression should be understood as a product of the interaction of a particular personality type enmeshed in a specific situational context for which the personality is vulnerable. Change either the personality or the stressors, and depression might not result. Psychotherapy Should Be Tailored to the Patient’s Personality • The clinical syndromes should be seen as an outgrowth of the patient’s overall personality style. • Patients with different personality vulnerabilities perceive and cope with life’s stressors differently. • Two patients who are depressed will experience and express the depression differently because their personalities are different. • Faced with the same stressor (e.g. divorce) a dependent and a narcissist will respond differently. Therapy should be different for each of these patients. • Similar symptoms do not necessarily call for the same treatment if the pattern of patient vulnerabilities and coping styles differ. • Treatment should be personalized to match the patient’s personality. Resources & Recommended Reading Books by Theodore Millon: • Disorders of Personality, 2011 • Personality and Psychopathology, 2006 • Personality Disorders in Modern Life, 2004 • Toward a New Personology, 1990 • Millon’s website: www.millon.net