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Personality Disorders
101
Mike Pett MSW;RSW
Advanced Practice Clinician
Complex Mental Illness Program
+ Objectives for the Presentation
-Common Pathways of Offending for SMI
population
-Personality Disorders Defined
-Cluster B personality disorders:
Borderline, Narcissistic, and Antisocial/Psychopathic
-Treatment of Personality Disorders
-Question Period
+
Conventional Path to Offending: Part
1.
Biological:
Temperament
Family history
Cognitive ability
Psychological:
Antisocial
attitudes
Conduc
t
Disorde
ASPD/
Substance
r
Psychopath
Use
y
Andrews & Bonta 2006
Social:
Poor parent-child rel’ns
Social learning of
antisocial behaviour
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Conventional Path to Offending:
Part 2
Proximal motivations (the “weather”)
Motives: material gain, sexual,
power, jealousy, revenge
Instrumental
High Risk
Individual
Reactive
Motives: anger, intoxication,
perceived threat, emotional
stressor
Substance
s
Motives: obtain drugs of abuse
Disadvantage
d
Motives: minor crimes for food,
shelter
Peterson et al. 2010
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Paths to Offending in SMI
Positive
Symptoms
Serious Mental
Illness
High Risk
Individual
(ASPD)
Disorganization
SMI vs. Gen Pop:
•Higher rate of Conduct dis.
•Higher rate of ASPD
Instrumental
•Higher rate of substance
•Higher rate of poverty
Reactive
Substance
s
Disadvantage
d
The direction of these
relationships is unclear
The proportion of each
motivation is unclear
+
The False Dichotomy
Symptom Conventional
Motives
Driven
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Personality Disorders 101
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Personality Disorder Clusters

Cluster A (“mad”)
Schizoid
Schizotypal
Paranoid

Cluster B (“bad”)
Borderline
Antisocial
Narcissistic
Histrionic

Cluster C (“sad”)
Obsessive-Compulsive
Avoidant
Dependent
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Activity: Personalities ‘R Us
Corporate Structure:
President: ?
Vice President: ?
Personnel: ?
Advertising: ?
Legal Department: ?
Research: ?
Customer Service: ?
+
Personalities ‘R Us Corporate
Structure

President: Narcissist

Vice President: Paranoid

Personnel: Borderline

Middle Management:
Advertising: Histrionic
Research: Schizo-typal
Legal Department: Anti-social
Customer Service: Passive-Aggressive
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Borderline Personality Disorder


Recorded on Axis II of the DSM-IV
Defined by the DSM-IV:
“an enduring pattern of inner experience and behavior that
deviates markedly from the expectations of the individual’s culture,
is pervasive and inflexible, has an onset in adolescence or early
adulthood, is stable over time, and leads to distress or impairment”

Not the result of:

Cultural and social expectations

Another mental disorder

A substance or general medical condition
+ Borderline Personality Disorder: What is it?

DSM-IV:
“ A pervasive pattern of instability of interpersonal relationships, self-image, and affects,
and marked impulsivity that begins by early adulthood and is present in a variety of
contexts.”
+ Borderline Personality Disorder: DSM-IV
Criteria

Five or more of the following:

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Frantic efforts to avoid real or imagined abandonment
A pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization and
devaluation
Identity disturbance: markedly and persistently unstable selfimage or sense of self
Impulsivity in at least two areas that are potentially self-damaging
Recurrent suicidal behavior, gestures or threats, or self-mutilating
behavior
Affective instability due to a marked reactivity of mood
Chronic feelings of emptiness
Inappropriate, intense anger or difficulty controlling anger
Transient, stress-related paranoid ideation or severe dissociative
symptoms
+ Borderline Personality Disorder: Instability &
Impulsivity

Instability of:
 Mood
 Self-image and identity– overdetermined by the environment
 Interpersonal relationships

Marked impulsivity (5 S’s):
1. Spending
2. Sex
3. Substance use
4. Speeding (reckless driving)
5. Satiety (binge eating)
(6.) Suicidal/self-harm behavior (has its own criterion)
+ Borderline Personality Disorder:
Demographics & Course

Female > Male (3:1)

2% of community samples ; 15-25% of clinical populations; 1356% of hospitalized substance abusers

Completed suicide in ~8-10% (particularly high if comorbid
substance use)

High rates of functional deficits, mental health utilization costs

Rocky course during first decade of treatment (high drop out
rates); but many improve by second decade of treatment
+ Borderline Personality Disorder: Etiology
 Most researched is Marsha Linehan’s biosocial
theory
Biological:
Emotional
Vulnerability
Environmental:
Invalidating
Caregivers
• High sensitivity/reactivity
to emotional stimuli
• Indiscriminately rejects
internal emotional
experiences
• Slow return to baseline
• Punishes emotional
expressions and
intermittently reinforces
emotional escalation
Emotional
Dysregulation
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Anti-social Personality Disorder vs.
Psychopathic Personality Disorder
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“All psychopathic personalities are
anti-social but not all anti-social
personalities are psychopathic”
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
Derived from Greek

psych (soul, breath hence mind)

pathos (to suffer)

A constellation of affective, interpersonal, and behavioral characteristics
that include grandiosity, a callous disregard for others, a lack of empathy,
and highly impulsive and irresponsible behavior

Differentiation from Sociopathy and Antisocial Personality Disorder
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–
–
–
–
–
–
–
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Superficial charm & good
“intelligence”
Absence of delusions / irrational
thinking
Absence of “nervousness”
Unreliability
Untruthfulness and insincerity
Lack of remorse or shame
Inadequately motivated antisocial
behavior
Poor judgment / failure to learn by
experience
–
–
–
–
–
–
–
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Pathologic egocentricity / incapacity for
love
General poverty in major affective reactions
Specific loss of insight
Unresponsiveness in general interpersonal
relations
Fantastic and uninviting behavior with drink
& sometimes without
Suicide rarely carried out
Sex life impersonal, trivial, and poorly
integrated
Failure to follow any life plan
+

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Operationalized the construct of psychopathy in the PCL and PCL-R instruments

Factor 1: Interpersonal and affective characteristics

Factor 2: Impulsive and antisocial behaviors
Prevalence of psychopathy:
~ 1% of general population
~ 20-25% of prison population

Robust predictor of violent and non-violent criminal behaviors in adult male offenders
(e.g., Harris, Rice, & Cormier, 1991; Hemphill, Hare, & Wong, 1998; Salekin, Rogers, & Sewell,
1996)
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Psychopathy
Factor 1
Arrogant & Deceitful
Interpersonal Style
Factor 2
Deficient Affective
Experience
Factor 4
Antisocial Behavior
Factor 3
Impulsive & Irresponsible
Behavioral Style
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1. Glibness / Superficial Charm

Insincere and shallow interactional style

Charming, phony, or superficial
2. Grandiose Sense of Self-Worth

Inflated view of abilities and self-worth

Can appear domineering, opinionated, and arrogant
4. Pathological Lying

Deceitful, lying “just for kicks”
5. Conning/Manipulative

Uses deception to cheat, exploit, or manipulate others

Misrepresentation for personal gain
+
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6. Lack of Remorse or Guilt

Lack of concern for the consequences of their actions on others
7. Shallow Affect

Unable to experience a normal range and depth of emotion
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“Play acting” emotions
8. Callous/Lack of Empathy

Disregard for the feelings, rights, and welfare of others

Cynical and selfish
16. Failure to Accept Responsibility for Own Actions

Usually have excuses for behaviors that hurt others
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8. Need for Stimulation / Proneness to Boredom

Chronic and excessive need for novel and exciting stimulation; exciting
and risky activities; “on the go”
9. Parasitic Lifestyle

Exploitation of others for basic needs and obligations
13. Lack of Realistic, Long-Term Goals

Inability or unwillingness to formulate plans and commitments; living
“day to day” and changing plans frequently
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Factor 3-cont
14. Impulsivity
 Behaviors are unpremeditated and lacking in reflection; doing things on
the spur of the moment; opportunistic15. Irresponsibility
 Habitual failure to honor obligations and commitments to others
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10. Poor Behavioral Controls
12. Early Behavioral Problems
18. Juvenile Delinquency
19. Revocation of Conditional Release
20. Criminal Versatility
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11. Promiscuous Sexual Behavior
17. Many Short-Term Marital Relationships
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Best Practices for Treatment of
Borderline and Anti-social personality
disorder
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Dialectical Behaviour Therapy for
Borderline Personality Disorder
(Linehan, 2007)
Mindfulness
Interpersonal effectiveness
Distress Tolerance
Emotion Regulation
+
Best Practices for Psychopathy and
Anti-social Personality Disorder
“Nothing Works”
vs.
“What Works”?
+
Watch Dexter!
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“Most Best” Menu of Treatment
Strategies

Substance Use Treatment
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Pharmacological treatments for impulse control/cravings.
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I.M. medication for chronic non-adherence.
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Anger Management.
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Assertive outreach
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Crisis intervention
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Critical time intervention
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Volunteerism
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Most Best Treatment Options.

CTO’s, probation, bail orders as leverage points to
motivate recovery.

Drug Treatment Court/Mental Health Diversion in cases of
precontemplation/low motivation in terms of mental health
and addiction treatment.

Community placement should be in safe, pro-social
neighborhoods where exposure to criminal activities and
substance use is limited.

Re-training/Re-schooling
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Questions and Comments