Download Personality Disorders Continued

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Personality Disorders Continued
Carolyn R. Fallahi, Ph. D.
Obsessive-Compulsive Personality Disorder
 Similarities to Negativistic p.d. ( the old passive-aggressive p.d. lavel)
 Common themes include ambivalent & conflicted personality dynamics
that underlie presentation.
 Ambivalence is defined as a lack of certainty over the source of
reinforcement in one’s life.
 Ambivalent individuals = conflicted over whether they should follow what
others want them to do or follow their own needs and wishes.
 “Anxious – fearful” cluster with anxiety & tension prominent symptoms.
 OCPD: extreme rigidity, preoccupation with details & perfectionism.
 Interpersonal relationships lacking – seen as cold, distant, & authoritarian.
They have an excessive need to control others.
 The issue with subordinate relationships.
 Little motivation to become more flexible.
 OCPD: avoids unwelcome thoughts or impulses & frequently distracts
them by becoming unduly critical and judgmental of others.
 Rigid, perfectionist, & restricted emotional expressivity.
 Millon: intense ambivalence as the central feature.
Prevalence
 5-20% psychiatric patients
 Comorbidity: paranoid, histrionic, borderline, narcissistic, and avoidant
p.d.
 Issues with OCD Axis I.
Historically
 Psychoanalytic theory: intense conflict during the anal stage of
psychosexual development = “anal character”.
 Kraft-Ebing: “compulsion” = constricted thought processes in individuals
with severe depression. Then began to use the term to indicate hidden
emotions, incessant questioning, doubtfulness, & other characteristics.
 Anakastic (Schneider, 1923) = conceal feelings of insecurity, compensates
by adopting an overly correct or scrupulous demeanor, & uses control in
most relationships.
 Kretschmer = “sensitive” personality type.
 Kahn (1931) ambivalent tendencies = “ambitendency”.
 Reich (1949) extreme attention to order, circumstantiality, rumination,
indecision, self-doubt.
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Contemporary Theories
 Psychoanalytic: struggles over autonomy
 Erikson (1950): gain autonomy over one’s self & environment.
 Rado (1959) mother’s demandingness & intrusiveness into child’s bowel
patterns = defiance and anger.
 Mallinger (1984) parental rejection, authoritarian attitudes, & lack of
respect for privacy.
 Salzman (1980) & Storr (1980) pervasive threat to security.
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Behaviorial: very little in the literature.
Issues with the term OCPD.
Turkat & Maistro (1985): learns maladaptive emotional reactions in home
& emphasizes hard work & minimizes close interpersonal relationships.
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Cognitive Theory: Beck & Freeman (1990): OCPD clear distortions in
thinking = produce rigidity & perfectionism.
Cognitive disortions
Musts and shoulds
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Interpersonal Theory: Leary (1959) OCPD style defined by actions that
maintain conventionality and security.
Structural Analysis of Social Behavior (Benjamin, 1974): intense fears of
making a mistake / being viewed as imperfect.
Endler & Edwards (1988)
Pincus & Wiggins (1990)
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Biological perspective: limited attention
Issues with anxiety.
Clonginger’s (1987) neurobiological theory – novelty seeking, reward
dependence, harm avoidance.
Millon & Davis (1996) limbic system.
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Integrative Model: Millon (1996)
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Issues with Negativistic P.D.: stubbornness, passive resistance to fulfilling
routine demands, procrastination, and inefficiency. Also sullen & irritable.
Borderline Personality Disorder
Essential Symptoms:
 Impulsivity
 Affective Instability
 Cognitive Symptoms
Reliability & Validity Concerns
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Prevalence
 1-2% general population
 ¾ women. Why? Stone (1993)
Comorbidity
 Axis I mood disorders. Is it a form of depression?
 Gunderston & Phillips (1991)
 Trauma research: Kolk (1987)
 The “borderline child”
 Remits by early middle age.
 15 years = 75%
 1/10 commits suicide.
 Highest risk: substance abuse + borderline
 Stone (1993) less likely to marry or have children
Historically
 Problems with the term “borderline”
 Adolf Stern (1938)
 “hysteria” or “pseudo-neurotic schizophrenia”
 unstable personality disorder or emotionally unstable personality
Contemporary Theories
 Biological: relatives have impulse spectrum disorders and/or affective
disorders.
 No specific pattern of inheritance has been found.
 Torgersen (1984) twin studies – no MZ-DZ differences, but numbers
small.
 Torgersen (1996) BPD large heritable component.
 No adoption studies.
 No identifiable biological markers yet to be found. Similar markers to
depression, e.g. abnormal REM latency; serotonergic activity.
 Soft neurological signs, e.g. limbic activity issues.
 Siever & Davis (1991)
 Most likely = multiple receptors & multiple subsystems associated with
each NT.
 Linehan (1993) “emotional vulnerability”.
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Psychological Factors: psychoanalytic emphasis on early experience.
Large number of negative events in childhood.
Borderlines also report a high frequency of childhood sexual abuse, e.g.
50-70%.
Incest abuse with penetration.
Physical abuse, frequency, duration, & severity.
Gender issues.
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Herman et al (1989)
Zanarini et al (1989)
Van der Kolk et al (1991) & self-mutilation
Separation & loss b/f 16 (51%)
Parental psychopathology
Parental bonding issues; Gunderson et al (1980)
Adler (1985)
Linehan (1993)
Narcissistic Personality Disorder
 Normal narcissism versus pathological narcissism
 Definition: “a pervasive pattern of grandiosity, need for admiration, &
lack of empathy”
 Associated features: vulnerable self-esteem, sensitivity, intense reactions
of humiliation, emptiness or disdain to criticism or defeat, vocational
problems, feelings of shame, social withdrawal.
 Antisocial or borderline characteristics
 High achievement, promiscuity, excessive rage, suicidal behavior.
NPD Clinical Features
 The Arrogant Narcissist
 The Shy Narcissist
 NPD with Antisocial / Borderline Features
 Comorbid Axis I = depression or dysthymia
 Suicide
 Affect intolerance and vulnerability
 Discriminating behaviors: Ronningstam & Gunderston (1990) boastful &
pretentious behavior; self-centered & self-referential behavior; reactions
to the envy of others.
 Morey (1998): inflated self-esteem & marked affective reactions to
assaults of self-esteem; marked need for interpersonal control; hostility;
lack of overtly self-destructive behaviors.
Prevalence
 2-22%. Gender differences?
 Late teens & early 20s; middle age very critical.
Sociocultural Factors
 Lash (1979)
Comorbidity
 Dramatic cluster, e.g. histrionic, borderline, paranoid, avoidant, passiveaggressive, antisocial.
 Bipolar patients, substance abuse, major depression, anorexia nervosa.
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Differential Diagnosis
 Antisocial p.d.
 Borderline p.d.
 Histrionic p.d.
 Obsessive-Compulsive p.d.
 Paranoid p.d.
 Schizoid p.d.
 Mania & hypomania