What factors make it difficult for therapist to treat people with personality disorders? If you were a therapist, how might you attempt to overcome these difficulties?
Chapter 13 Personality disorders Chapter 13 Personality disorders Alice Cheng, Ph.D. University of Hartford Personality Disorders Personality disorders are characterized by chronic interpersonal difficulties problems with one’s identity or sense of self * Clinical Features of Personality Disorders The definition of personality disorders in DSM-IV-TR is based on five criteria Criterion A: The pattern must be manifested in at least two of the following areas: cognition affectivity interpersonal functioning impulse control * Clinical Features of Personality Disorders The definition of personality disorders in DSM-IV-TR is based on five criteria Criterion B: The enduring pattern must be inflexible and pervasive across a broad range of personal and social situations * Clinical Features of Personality Disorders The definition of personality disorders in DSM-IV-TR is based on five criteria Criterion C: This pattern leads to clinically significant distress or impairment of functioning * Clinical Features of Personality Disorders The definition of personality disorders in DSM-IV-TR is based on five criteria Criterion D: The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early childhood * Clinical Features of Personality Disorders The definition of personality disorders in DSM-IV-TR is based on five criteria Criterion E: The pattern is not better accounted for as a manifestation or consequence of another mental disorder * Difficulties Doing Research on Personality Disorders Difficulties in diagnosing personality disorders are caused by a number of factors, including diagnostic criteria are not as sharply defined as for other Axis I categories diagnostic categories are not mutually exclusive personality characteristics are dimensional in nature * Difficulties Doing Research on Personality Disorders Difficulties in studying the causes of personality disorders spring from The fact that such disorders have received consistent attention only since DSM-III was published in 1980 The fact that these disorders are less amenable to thorough study The fact that most studies to date are retrospective * Personality Disorders The DSM groups personality disorders into three clusters: Cluster A: People who are perceived as odd or eccentric. This cluster includes paranoid, schizoid, and schizotypal personality disorders. Cluster B: People whose behavior is overly dramatic, emotional, or erratic. This grouping consists of antisocial, borderline, histrionic, and narcissistic personality disorders. Cluster C: People who often appear anxious or fearful. This cluster includes avoidant, dependent, and obsessive–compulsive personality disorders. * Overview of Personality Disorders * Categories of Personality Disorders Provisional categories include passive-aggressive depressive * Paranoid Personality Disorder Paranoid personality disorder - A personality disorder characterized by undue suspiciousness of others’ motives, but not to the point of delusion. People who have paranoid personality disorder tend to be overly sensitive to criticism, whether real or imagined. Clinicians need to weigh cultural and sociopolitical factors when arriving at a diagnosis of paranoid personality disorder. * Diagnostic Criterion A) A pervasive distrust and suspicion of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her reads benign remarks or events as threatening or demeaning. persistently bears grudges, i.e., is unforgiving of insults, injuries, or slight sperceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counter attack has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. Schizoid Personality Disorder Schizoid personality disorder - A personality disorder characterized by persistent lack of interest in social relationships, flattened affect, and social withdrawal. Often described as a loner or an eccentric, the person with a schizoid personality lacks interest in social relationships. The person’s emotions usually appear shallow or blunted, but not to the degree found in schizophrenia. http://www.youtube.com/watch?v=niOEoRn3cA0 * A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: neither desires nor enjoys close relationships, including being part of a family most always chooses solitary activities has little, if any, interest in having sexual experiences with another person takes pleasure in few, if any, activities lacks close friends or confidants other than first-degree relatives appears indifferent to the praise or criticism of others shows emotional coldness, detachment, or flattened affect Schizotypal Personality Disorder Schizotypal personality disorder - A personality disorder characterized by eccentricities of thought and behavior, but without clearly psychotic features. Schizotypal personality disorder may be slightly more common in males than in females and is believed to affect about 3% of the general population. Investigators also find higher rates of the disorder among African Americans than among Caucasians or Hispanic Americans. http://www.youtube.com/watch?v=IJRQGxvTeT8 * A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, bizarre fantasies or preoccupations) Unusual perceptual experiences, including bodily illusions Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped) Suspiciousness or paranoid ideation Inappropriate or constricted affect Behavior or appearance that is odd, eccentric, or peculiar Lack of close friends or confidants other than first-degree relatives Social anxiety that tends to be associated with paranoid fears rather than negative judgments about self. Antisocial Personality Disorder Antisocial personality disorder - A personality disorder characterized by antisocial and irresponsible behavior and lack of remorse for misdeeds. They are not “antisocial” in the colloquial sense of seeking to avoid people. People with antisocial personalities also tend to be impulsive and fail to live up to their commitments to others. * * Antisocial Personality Mass murderer Henry Lee Lucas, a drifter and violent career criminal, fits the stereotype of an antisocial personality. * Lifetime prevalences of antisocial personality disorder by gender. Antisocial personality disorder is more than five times as common among men than women. However, the disorder has been rising more rapidly among women in recent years. * Antisocial Behavior and Criminality We tend to think of antisocial behavior as synonymous with criminal behavior. Although it is the case that antisocial personality disorder is associated with an increased risk of criminality, not all criminals have antisocial personalities nor do all people with antisocial personality disorder become criminals. Many people with antisocial personality disorders are law abiding and successful in their careers, even though they may treat others in a callous and insensitive manner. * Antisocial Personality and Psychopathy Individuals eighteen and over may be diagnosed with antisocial personality disorder if the following criteria are met: at least three behavioral problems occurring after age 15 at least three instances of deviant behavior before age 15 the antisocial behavior is not a symptom of another mental disorder * Borderline Personality Disorder Borderline personality disorder (BPD) - A personality disorder characterized by abrupt shifts in mood, lack of a coherent sense of self, and unpredictable, impulsive behavior. At the core is a pervasive pattern of instability in relationships, self-image, and mood, along with a lack of control over impulses. Pathological fear of real or imagined abandonment and rejection. People with borderline personality disorder tend to be uncertain about their personal identities—their values, goals, careers, and perhaps even their sexual orientations. * A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: Frantic efforts to avoid real or imagined abandonment. pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. Identity disturbance: markedly and persistently unstable self-image or sense of self. Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving) Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days). Chronic feelings of emptiness Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms Cutting. People with borderline personalities may engage in impulsive acts of self-mutilation, such as cutting themselves, perhaps as a means of temporarily blocking or escaping from deep, emotional pain. * Borderline Personality Disorder Self-mutilation is sometimes an expression of anger or a means of manipulating others. Such acts may be intended to counteract self-reported feelings of “numbness,” particularly in times of stress. Individuals with BPD often have very troubled relationships with their families and others Splitting - An inability to reconcile the positive and negative aspects of the self and others, resulting in sudden shifts between positive and negative feelings. * http://www.youtube.com/watch?v=eOphgCJX1FY Histrionic Personality Disorder Histrionic personality disorder - A personality disorder characterized by excessive need for attention, praise, reassurance, and approval. The term is derived from the Latin histrio, which means “actor.” People with histrionic personality disorder tend to be dramatic and emotional, but their emotions seem shallow, exaggerated, and volatile. The disorder was formerly called hysterical personality. * A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: is uncomfortable in situations in which he or she is not the center of attention interaction with others is often characterized by inappropriate sexually seductive or provocative behavior displays rapidly shifting and shallow expression of emotions consistently uses physical appearance to draw attention to self has a style of speech that is excessively impressionistic and lacking in detail shows self-dramatization, theatricality, and exaggerated expression of emotionis suggestible, i.e., easily influenced by others or circumstances considers relationships to be more intimate than they actually are. Narcissistic Personality Disorder Narcissistic personality disorder - A personality disorder characterized by adoption of an inflated self-image and demands for attention and admiration. They expect others to notice their special qualities, even when their accomplishments are ordinary, and they enjoy basking in the light of adulation. They are self-absorbed and lack empathy for others. http://www.youtube.com/watch?v=f9jRDHGabp8&feature=related * A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: has a grandiose sense of