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Transcript
Personality Disorders
MA Psikologi Abnormal
Semester Ganjil 2009/10
Personality Disorders (PD)



Longstanding, pervasive, inflexible patterns of behavior and inner
experience
Coded on Axis II
Patterns present in at least 2 areas:
»
»
»
»



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)

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)


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


DSM-IV-TR categorical approach
Classifies in 3 clusters:
» Cluster A Odd/Eccentric
» Cluster B Dramatic/Erratic
» Cluster C Anxious/Fearful

Diagnostic reliability
» Initially poor; improved since DSM-III

Test-retest reliability (diagnostic stability)
» ½ of those initially diagnosed with PD did not receive same
diagnosis 1 year later (Shea et al., 2002)

Gender bias
» Certain diagnoses applied more often to men, others to
women
6
Dimensional Approach: Five-Factor
Model

Five-factor model (McCrae & Costa, 1990)
» Neuroticism, extraversion/introversion, openness
to experience, agreeableness/antagonism, and
conscientiousness
» Five factors are heritable

Personality traits form a continuum
» Individuals with PDs endorse the extremes

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



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

Suspicious
» Secretive; reluctant to confide
in others

Expects to be
mistreated/exploited
» Vigilant for hints of abuse






More common in men than
women
Cormorbidity high for
» Schizotypal
» Borderline
» Avoidant
Blames others when things
go wrong
Easily feel threatened
Questions loyalty
No hallucinations or full
blown delusions
10
Odd/Eccentric (A) Cluster:
Schizoid Personality Disorder

Avoids close interpersonal
relationships

» Few close friends
» Aloof & distant

Comorbidity high for
» Schizotypal
» Avoidant
» Paranoid
Loner
» Likes solitary activities



Rarely report strong
emotions
Little interest in sex
Experiences anhedonia: tdk
menikmati peristiwa
menyenangkan yg
dilakukannya
11
Odd/Eccentric Cluster: Schizotypal
Personality Disorder


Interpersonal difficulties similar to schizoid
Odd beliefs or magical thinking
» Superstitious
» Telepathic

Illusions
» Feels the presence of a force or person not actually present.

Odd/eccentric behavior or appearance
» Wears strange clothes
» Talks to self

Ideas of reference
12
Etiology of the PDS in Odd/Eccentric
Cluster


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)









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)


Onset during adolescence or early adulthood
Prognosis poor within 10 years of diagnosis
» Later in life, most no longer meet diagnostic criteria
(Paris, 2002)

Cormorbidity high with PTSD, MDD,
substance-related, and eating disorders
» Comorbidity predicts symptoms 6 years later

Suicide rates high
» Self-mutilation also a problem
15
Etiology of Borderline Personality Disorder
(BPD): Neurobiological factors

Genetic component
» Highly heritable
» May play a role in impulsivity and emotional
dysregulation
Decreased functioning of serotonin
system
 Frontal lobe dysfunction
 Increased activation of amygdala

16
Etiology of Borderline Personality Disorder
(BPD): Social Environmental Factors



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

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



Formerly known as hysterical personality
Overly dramatic and attention seeking behavior
Craves attention
» Loves to be in the spotlight




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

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

Theory untested
21
Dramatic/Erratic (B) Cluster:
Narcissistic Personality Disorder

Grandiose view of self
» Preoccupied with fantasies of success

Self-centered
» Demands constant attention and adulation



Feelings of entitlement and arrogance
Envious of others
Little concern for needs and well being of others
» Lacks empathy


Sensitive to criticism
Seeks out high-status partners
23
Etiology of Narcissistic Personality
Disorder

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

» 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

Pervasive disregard for the rights of others since
age 15
»
»
»
»
»
»

Lies
Aggression
Impulsiveness
Violates the law
Irresponsible
Lacks remorse
Conduct disorder before age 15
» Truancy, running away, lying, theft, arson, destruction of
property


Substance abuse most common comorbid
disorder
Culture plays a role
» More common in US than Scotland

More common among lower SES groups
25
Dramatic/Erratic (B) Cluster:
Antisocial Personality Disorder



Psychopathy (sociopathy)
(Cleckley, 1941)
Predates DSM-IV-TR
category
Focuses on internal thoughts
and feelings

» Interpersonal
symptoms
– Pathological lying,
manipulativeness, and
charm
» Poverty of emotion
– Negative emotions

» Affective symptoms
Lacks shame and anxiety
– Lack of remorse and
empathy, shallow
affect
– Positive emotions

Used to manipulate
others
» Impulsivity
– Behave irresponsibly for
thrills
Psychopathy
Checklist – revised
(Hare, 2008)

Onset before age 15
not required.
26
Etiology of Antisocial Personality
Disorder

Genetics
» Antisocial behavior heritable
– Estimates as high as .96
» Genetic risk for APD, psychopathy, conduct
disorder, and substance abuse related.

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

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)


Makes it difficult for them
to avoid behavior that
leads to punishment
Also show less SCR to
other’s distress
Figure 12.3
» Lack empathy
28
Anxious/Fearful (C) Cluster:
Avoidant Personality Disorder

Avoids interpersonal situations
» Fears criticism or rejection

Hesitant about involvement with others
» Wants to be certain of acceptance

Restrained and inhibited in interpersonal situations
» Fears ridicule
» Feelings of inadequacy

Avoids taking risks or trying new activities
» Doesn’t want to risk embarrassment

High comorbidity with major depression and generalized
social phobia
» Related toJapanese syndrome called taijin kyofusho (taijin
means “interpersonal” and kyofusho means “fear”).
29
Anxious/Fearful (C) Cluster:
Dependent Personality Disorder








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




A perfectionist
Preoccupied with rules, details, & organization
Rigid and inflexible
Overly focused on work
» Little time for leisure, family, & friends

Tendency to hoard
» Difficulty discarding worthless items




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


Not much available research
Avoidant PD
» Overly protective and authoritarian parents

Obsessive-Compulsive PD
» Fixation at anal stage of development (Freud)
» More recent theorists
– Cope with fears of losing control by overcompensation

Dependent PD
» Disruption of early childhood attachment by death,
neglect, rejection, or overprotectiveness
32
Treatment of Personality Disorders

Axis I disorder usually drives individual to treatment
» Presence of PD, reduces success of treatment for Axis I

Medications
» Avoidant PD
– Antianxiety medication or antidepressants
» Schizotypal PD
– Antipsychotic medications

Psychotherapy
» Psychodynamic
– Seek awareness of early childhood problem
» Cognitive behavioral
– Break personality disorder down into discrete problems

Treat sensitivity to criticism with social skills training
33
Maladaptive Cognitions Associated with PD
34
Treatment of Borderline PD

Difficult to treat
» Interpersonal problems play out in therapy
» Attempts to manipulate therapist


Object Relations Therapy (Kernberg et al., 1985)
Dialectical Behavioral Therapy (Linehan, 1987)
» Acceptance and empathy plus CBT, emotion regulation, and
social skills

Schema-Focused Cognitive Therapy for BPD
» Identify maladaptive assumptions that underlie cognitions

Medications
» Antidepressants
» Antipsychotics
– Olanzapine
35
Treatment of Psychopathy
Intensive psychoanalytic therapy
 Cognitive behavioral therapy
 Issue remains

» Are therapy successes ‘faking good’ or
genuinely improved?
36