CH13 Outline PDF

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CH13--Outline I. Personality Disorders A. Personality disorders are enduring, rigid patterns of inner experience and outward behavior that impair one’s sense of self, emotional experience, goals, and capacity for empathy and/or intimacy 1. The rigid traits of people with personality disorders often lead to psychological pain for the individual or others 2. A personality disorder typically becomes recognizable in adolescence or early adulthood a. These are among the most difficult psychological disorders to treat 3. Approximately 15 percent of all adults are believed to have a personality disorder at some point in their lives 4. Most individuals with a personality disorder also suffer from another disorder, a relationship called comorbidity a. Research has shown that the presence of a comorbid personality disorder complicates and greatly reduces the likelihood of a successful treatment outcome for any other psychological problem 5. DSM-5 identifies 10 personality disorders, which are separated into three groups or “clusters”: a. Odd or eccentric behavior: paranoid, schizoid, and schizotypal b. Dramatic, emotional, or erratic behavior: antisocial, borderline, narcissistic, and histrionic c. Anxious or fearful behavior: avoidant, dependent, and obsessive-compulsive 6. This DSM listing, which is called a categorical approach, assumes that: a. Problematic personality traits are either present or absent b. A personality disorder is either displayed or not c. A person who suffers from a personality disorder is not markedly troubled by personality traits outside of that disorder 7. These assumptions are frequently contradicted in clinical practice a. The symptoms of the personality disorders overlap so much that it can be difficult to distinguish one disorder from another b. In addition, diagnosticians sometimes determine that particular individuals have more than one personality disorder 8. This lack of agreement has raised concerns about the validity (i.e., accuracy) and reliability (i.e., consistency) of these diagnostic categories 9. As a result, many theorists have challenged the use of a categorical approach

a. They believe that these disorders differ more in degree than in type of dysfunction—called a dimensional approach b. In a dimensional approach, each trait is seen as varying along a continuum extending from nonproblematic to extremely problematic 10. Given the inadequacies of a categorical approach and the enthusiasm for a dimensional one, the framers of DSM-5 initially proposed significant changes a. This proposal was met with tremendous pushback and criticism in the clinical field, leading to a reversion back to the categorical approach b. The newly proposed dimensional approach is currently in DSM-5 as an alternative approach “for further study” II. “Odd” Personality Disorders A. People with these disorders display behaviors similar to but not as extensive as schizophrenia, including extreme suspiciousness, social withdrawal, and peculiar ways of thinking and perceiving things 1. Such behaviors leave the person isolated 2. Some clinicians believe that these disorders are actually related to schizophrenia and thus call them schizophrenia-spectrum disorders 3. While clinicians have learned much about the symptoms of these personality disorder, little is known about their causes or how best to treat them B. Paranoid Personality Disorder 1. This disorder is characterized by deep distrust and suspicion of others a. Although inaccurate, this suspicion usually is not delusional—the ideas are not so bizarre or so firmly held as to clearly remove the individuals from reality b. As a result of their mistrust, people with paranoid personality disorder often remain cold and distant c. They are critical of weakness and fault in others, particularly at work d. They are unable to recognize their own mistakes, and are extremely sensitive to criticism e. They often blame others for the things that go wrong in their lives, and they repeatedly bear grudges f. As many as 4.4 percent of adults are believed to experience this disorder, apparently more men than women 2. How do theorists explain paranoid personality disorder?

a. The proposed explanations of this disorder, like most of the personality disorders, have received little systematic research b. Psychodynamic theories trace the pattern back to early interactions with demanding parents c. Cognitive-behavioral theorists suggest that maladaptive assumptions, such as “People are evil and will attack you if given the chance,” are to blame d. Biological theorists propose genetic causes and have looked at twin studies for support of this model 3. Treatments for paranoid personality disorder a. People with paranoid personality disorder do not typically see themselves as needing help, so few come to treatment willingly i. Those who are in treatment often distrust and rebel against their therapists ii. As a result, therapy for this disorder, as for most of the other personality disorders, has limited effect and moves slowly b. Object relations therapists try to see past patient anger and work on the underlying wish for a satisfying relationship c. Cognitive-behavioral therapists try to help clients control anxiety and improve interpersonal skills while trying to restructure clients’ maladaptive assumptions and interpretations d. Antipsychotic drug therapy is of limited help C. Schizoid Personality Disorder 1. This disorder is characterized by persistent avoidance of social relationships and limited emotional expression a. People with this disorder do not have close ties with other people; they genuinely prefer to be alone i. People with schizoid personality disorder focus mainly on themselves and often are seen as flat, cold, humorless, or dull b. The prevalence of this disorder is estimated to be approximately 3.1 percent of the population i. It is slightly more common in men than in women 2. How do theorists explain schizoid personality disorder?

a. Many psychodynamic theorists, particularly object relations theorists, link schizoid personality disorder to an unsatisfied need for human contact i. The parents of those with the disorder are believed to have been unaccepting or abusive of their children ii. The schizoid individual is left unable to give or receive love and copes by avoiding relationships b. Cognitive-behavioral theorists propose that people with schizoid personality disorder suffer from deficiencies in their thinking i. Their thoughts tend to be vague and empty, and they have trouble scanning the environment for accurate perceptions ii. Their difficulties in perceiving emotional reactions in others renders them emotionally unresponsive 3. Treatments for schizoid personality disorder a. Their social withdrawal prevents most people with this disorder from entering therapy unless some other disorder makes treatment necessary b. Patients are likely to remain emotionally distant from the therapist, seem not to care about treatment, and make limited progress at best c. Cognitive-behavioral therapists have sometimes been able to help people with this disorder experience more positive emotions and more satisfying social interactions i. The cognitive end focuses on thinking about emotions ii. The behavioral end focuses on the teaching of social skills d. Group therapy apparently is useful when it offers a safe environment for social contact e. Drug therapy is of little benefit D. Schizotypal Personality Disorder 1. This disorder is characterized by a range of interpersonal problems, marked by extreme discomfort in close relationships; odd, even bizarre, ways of thinking; and behavioral eccentricities a. People with this disorder are uncomfortable around others, and they tend to have few friends b. They often have great difficulty keeping their attention focused; conversation is typically digressive and vague, even sprinkled with loose associations

c. They tend to drift aimlessly and lead an idle, unproductive life, choosing undemanding jobs in which they are not required to interact with other people d. An estimated 3.9 percent of all people, slightly more males than females, may have schizotypal personality disorder 2. How do theorists explain schizotypal personality disorder? a. Because the symptoms of this personality disorder so often resemble schizophrenia, researchers have hypothesized that similar factors are at work in both disorders i. Schizotypal symptoms are linked to family conflicts and to psychological disorders in parents ii. As in schizophrenia, problems with attention and short-term memory play a role in the disorder iii. Researchers also have begun to link schizotypal personality disorder to some of the same biological factors found in schizophrenia, such as high dopamine activity and abnormalities in brain structure b. The disorder has also been linked to mood disorders, especially depression and bipolar disorder 3. Treatments for schizotypal personality disorder a. Therapy is as difficult in cases of schizotypal personality disorder as in cases of paranoid and schizoid personality disorders b. Most therapists agree on the need to help clients “reconnect” and to recognize the limits of their thinking and powers c. Cognitive-behavioral therapists try to teach clients to objectively evaluate their thoughts and perceptions and provide speech lessons and social skills training d. Antipsychotic drugs have also been given, and appear to be somewhat helpful in reducing certain thought problems III. “Dramatic” Personality Disorders A. The behaviors of people with these problems are so dramatic, emotional, or erratic that it is almost impossible for them to have relationships that are truly giving and satisfying 1. These personality disorders are more commonly diagnosed than the others a. Only antisocial and borderline personality disorders have received much study 2. The causes of these disorders are not well understood 3. Treatments range from ineffective to moderately effective

B. Antisocial Personality Disorder 1. Sometimes described as “psychopaths” or “sociopaths,” people with antisocial personality disorder persistently disregard and violate others’ rights a. Aside from substance-related disorders, this is the disorder most linked to adult criminal behavior b. DSM-5 stipulates that a person must be at least 18 years of age to receive this diagnosis i. DSM-5 also requires that these individuals meet criteria for conduct disorder prior to age 15 c. People with the disorder are likely to lie repeatedly, be reckless, and act impulsively d. They have little regard for other individuals and can be cruel, sadistic, aggressive, and violent i. Surveys indicate that 3.6 percent of people in the United States meet the criteria for this disorder 1) The disorder is four times more common in men than women e. Because people with this disorder are often arrested, researchers frequently look for people with antisocial patterns in prison populations i. Approximately 35 percent of prison populations meet the diagnostic criteria ii. In these populations, a diagnosis of antisocial personality disorder is associated with a history of violent crime f. Studies indicate higher rates of alcoholism and other substance use disorders among this group 2. How do theorists explain antisocial personality disorder? a. Psychodynamic theorists propose that this disorder begins with an absence of parental love, leading to a lack of basic trust and emotional distancing b. Many cognitive-behavioral theorists have suggested that antisocial symptoms may be learned through modeling or unintentional reinforcement c. Another cognitive-behavioral explanation states that people with this disorder hold attitudes that trivialize the importance of other people’s needs d. A number of studies suggest that biological factors may play a role: i. Lower levels of serotonin, impacting impulsivity and aggression ii. Deficient functioning in the frontal lobes of the brain

iii. Lower levels of anxiety and arousal, leading people with this disorder to be more likely than other people to take risks and seek thrills iv. These different biological components may well be part of a larger dysfunctional brain circuit 3. Treatments for antisocial personality disorder a. Treatments are typically ineffective b. A major obstacle is the individual’s lack of conscience or desire to change i. Most have been forced to come to treatment c. Some cognitive-behavioral therapists try to guide clients to think about moral issues and the needs of other people, though this approach has proved largely ineffective d. Hospitals and prisons have attempted to create therapeutic communities, but most individuals do not respond to this intervention e. Atypical antipsychotic drugs also have been tried, but their effectiveness is limited C. Borderline Personality Disorder 1. People with this disorder display great instability, including major shifts in mood, an unstable self-image, and impulsivity a. Their interpersonal relationships are unstable b. People with this disorder are prone to bouts of anger, which sometimes result in physical aggression and violence i. Just as often, they direct their impulsive anger inward and harm themselves c. This disorder is complex, and is being seen more commonly in clinical practices i. More than 85 percent of individuals with borderline personality disorder have another, comorbid disorder d. This disorder is characterized by impulsive, self-destructive behavior that can include: i. Alcohol and substance abuse ii. Reckless behavior, including driving and unsafe sex iii. Self-injurious or self-mutilation behavior iv. Suicidal threats and actions 1) As many as 75 percent of people with this diagnosis attempt suicide at least once and 10 percent die from suicide e. People with the disorder frequently form intense, conflict-ridden relationships while struggling with recurrent fears of impending abandonment

f. Surveys find that as much as 5.9 percent of the general population has a form of this disorder, of whom three-fourths are women g. The course of the disorder varies i. In the most common pattern, the instability and risk of suicide reach a peak during young adulthood, then gradually wane with advancing age 2. How do theorists explain borderline personality disorder? a. Psychological factors—because a fear of abandonment tortures so many people with the disorder, psychodynamic theorists look to early parental relationships to explain the disorder i. Object relations theorists propose a lack of early acceptance or abuse/neglect by parents 1) Research has found some support for this view, including a link to early sexual abuse b. Biological factors—some features of the disorder have been linked to biological abnormalities, such as an overly reactive amygdala and an underactive hippocampus and prefrontal cortex i. Patients who are particularly impulsive apparently have lower brain serotonin activity ii. Evidence of a genetic contribution 1) Close relatives of those with borderline personality disorder are five times more likely than the general population to have the disorder iii. The different biological structures are possibly part of a larger, dysfunctional brain circuit that is characterized by poor interconnectivity (i.e., communication) between structures c. Sociocultural factors—some sociocultural theorists suggest that cases of borderline personality disorder are particularly likely to emerge in cultures that change rapidly d. Integrative explanations—both biosocial and developmental psychopathology explanations seek to explain this disorder in the context of interactions between biological and psychological factors i. The biosocial explanation proposes that borderline personality disorder arises because of internal factors, such as difficulty identifying and controlling one’s feelings, combined with external factors, such as parental punishment or trivializing of the child’s emotions ii. The developmental psychopathology model is similar, but suggests that early parent– child relationships are of particular importance

1) Early trauma, abuse, and parental inattentive, dismissive, uncaring, or threatening behavior leads to a disorganized attachment style 2) A major issue for these individuals is difficulty understanding their internal mental state and the mental state of others—a capacity known as mentalization 3) While studies have found such problems in the attachment styles of individuals with borderline personality disorder, and the theories have generated lots of interest, it is not clear if the parent–child relationship is the primary factor in this disorder 3. Treatments for borderline personality disorder a. Psychotherapy can eventually lead to some degree of improvement for people with this disorder i. It is extraordinarily difficult for a therapist to strike a balance between empathizing with a patient’s dependency and anger and challenging his or her way of thinking ii. It is difficult for therapists to establish a collaborative working relationship b. Contemporary psychodynamic therapy has been somewhat more effective than traditional psychodynamic approaches when it focuses on the patient’s central relationship disturbance, poor sense of self, and pervasive loneliness and emptiness c. Over the past two decades, an integrative treatment approach, called dialectical behavior therapy (DBT), has received more research support than any other treatment for this disorder i. This approach derives largely from the cognitive-behavioral treatment model and borrows heavily from humanistic and psychodynamic approaches ii. DBT is often supplemented by the clients’ participation in social skills-building groups d. Antidepressant, antibipolar, antianxiety, and antipsychotic drugs have helped some individuals to calm their emotional and aggressive storms i. Given the numerous suicide attempts by these patients, their use of drugs on an outpatient basis is controversial e. Many clients seem to have benefited from a combination of psychotherapy and drug therapy D. Histrionic Personality Disorder 1. People with histrionic personality disorder are extremely emotional and continually seek to be the center of attention a. They often engage in attention-getting behaviors and are always “on stage”

b. Approval and praise are the lifeblood of these individuals c. People with histrionic personality disorder often are described as vain, self-centered, and demanding i. Some make suicide attempts, often to manipulate others d. This disorder was once believed to be more common in women than in men i. Research has revealed gender bias in past diagnoses e. The latest statistics suggest that approximately 1.8 percent of adults have this personality disorder, with males and females equally affected 2. How do theorists explain histrionic personality disorder? a. Most psychodynamic theorists believe that, as children, people with this disorder experienced unhealthy relationships in which cold parents left them feeling unloved and afraid of abandonment i. To defend against their deep-seated fears of loss, these individuals learned to behave dramatically, inventing crises that would require people to act protectively b. Cognitive-behavioral theorists look at the lack of substance and extreme suggestibility seen in people with the disorder i. They view these individuals as less interested in the world around them because they are so self-focused and emotional ii. Some argue that people with histrionic personality disorder hold a general assumption that they are helpless to care for themselves, so they seek out others who will meet their needs c. Sociocultural and multicultural theorists believe the disorder is caused in part by society’s norms and expectations i. The vain, dramatic, and selfish behavior may be an exaggeration of femininity as our culture once defined it ii. Some argue that histrionic personality disorder is more commonly diagnosed in cultures that encourage or tolerate overt sexualization (e.g., Hispanic Americans) and less commonly diagnosed in cultures that discourage such behavior (e.g., Asian Americans) 3. Treatments for histrionic personality disorder a. Working with them can be difficult because of their demands, tantrums, seductiveness, and attempts to pl...