Chapter 12 summary - Abnormal Psychology: an Integrative Approach PDF

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Chapter 12 Personality Disorders  integrated model  individual vulnerabilities, mixed with these systems we have in placePersonality Disorders (PDs)  Characterized by enduring and relatively stable ways of relating and thinking o Inflexible and maladaptive, causing distress or impairment o Used t...

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Chapter 12 Personality Disorders  integrated model  individual vulnerabilities, mixed with these systems we have in place Personality Disorders (PDs)  Characterized by enduring and relatively stable ways of relating and thinking o Inflexible and maladaptive, causing distress or impairment o Used to be coded on Axis II of DSM-IV  Axis 1: acute  Axis 2: pervasive  Axis 3: medical  Axis 4: psychosocial  Axis 5: Global Affectiveness Function 0-100  A way to report what’s going on  When people are talking about Axis 2, they are talking about personality disorders  Categorical versus dimensional views of PDs o Categorical views suggest PDs are a difference in kind o Dimensional views suggest PDs are a difference in degree  People are too broad and varied to say there are “normal” and “not normal” people. Actually, it’s more dimensional. We all vary to some extent on different personality traits  It’s not saying here’s a clear line between normal and abnormal, it’s more of a difference in degree  60% of people with a personality disorder also has a substance disorder DSM 5 Personality Disorders  summary of changes from DSM-IV TR: o got rid of multiaxial system o no changes in diagnostic criteria … in section 2 of DSM 5 o however, section 3 describes an alternative model fro personality disorders DSM 5 Personality Disorders: Alternative Model in Section 3 (this is what we are STRIVING to use) A. moderate or greater impairment in personality functioning B. one or more pathological personality traits C. relatively inflexible and pervasive D. stable, with onset in adolescence or early adulthood E. not better explained by mental disorder F. not better explained by substance use or medical condition G. not better understood as normal for developmental stage or sociocultural environment

Five Factor Model of Personality  five factors can be remembered as OCEAN o openness to experience  psychoticism o Conscientiousness  disinhibition o Extraversion  detachment o Agreeableness  antagonism o Neuroticism  negative affectivity DSM 5 Personality Disorders  described in section II of DSM 5 A. enduring pattern of inner experience and behaviour that deviates markedly from the expetations of the individual’s culture – pattern manifested in two or more of the following areas: 1) cognition 2) affectivity 3)interpersonal functioning 4)…. SEE THIS SLIDE

Personality Disorders (PDs)  DSM5 personality disorder clusters o Cluster A – odd or eccentric cluster  Schizotypal  Schizoid  Paranoid o Cluster B – dramatic, emotional, erratic cluster  Borderline  Antisocial  Histrionic  Narcissistic o Cluster C – fearful or anxious cluster  OCPD  Avoidant  Dependent (characterized as pathological dependence on other people) Table 12.1 from textbook (relationship between each personality disorder and characteristics of the five-factor model of personality)

Personality Disorders (PDs)  prevalence rates o Canadian data on prevalence of personality disorders are generally lacking (health Canada, 2002) o Rates are higher in inpatient and outpatient settings  They are so disruptive and so impairing, these people seek help often in higher rates

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A lot of the cluster B  a lot of them are in your emergency rooms and crisis units o Comorbidity in PDs is high  E.g., about 60% of people with SUD also have PD  I work primarily with cluster B – they are very interesting people. Lovely people with traits who get them in trouble… impulsivity. Spontaneous, creative…

Cluster A: Paranoid PD  characterized by pervasive and unjustified mistrust and suspicion  biological and psychological contributions are unclear o may result from early learning that people and the world is a dangerous place  treatment o few seek professional help on their own o treatment focuses on development of trust  cognitive therapy to counter maladaptive thinking o there is a lack of good outcome studies showing that treatment is effective  you have to be aware of the systems in which people are working in order to accurately diagnose this We suspect for Paranoid PD, that at some point you were taught that the world is not a safe place  as you might imagine, people with paranoid PD wouldn’t necessarily seek out help  the treatment focuses on development of trust  both in therapy and outside of therapy  you might do CBT to counter maladaptive thinking… but when it comes to most of these disorders, we don’t have a lot of studies that tell us what works

Cluster A: Schizoid PD These are people who are not really connected, and who don’t miss it. They have a limited range of emotional responses. We aren’t really sure how it develops. Childhood shyness seems to be part of it.  characterized by a pervasive pattern of detachment from social relationships o very limited range of emotions in interpersonal situations  etiology is unclear o childhood shyness o childhood abuse or neglect o preference for social isolation in schizoid PD resembles autism  treatment o few seek professional help on their own o focus on the value of interpersonal relationships, empathy, and social skills o treatment prognosis is generally poor

o there is a lack fo good outcome studies showing that treatment is effective  these people are not interested in rapport – not interested in maintaining it Cluster A: Schizotypal PD  clinical features o behaviour and dress is odd and unusual o most people with schizotypal PD are socially isolated and may be highly suspicious of others o magical thinking, ideas of reference, and illusions are common o some develop schizophrenia o 30 to 50% with schizotypal PD also meet criteria for major depression  not quite full hallucinations, but distortions of perception  someone with full-on schizophrenia might believe that there is a person in the room that isn’t actually there. An illusion would be, I know that there isn’t somebody there, but I have a sense that there is somebody there Cluster A: Schyzotypal PD  etiology is also unclear o may be that schizoid personality is a phenotype of a schizophrenia genotype  treatment o main focus is on developing social skills o treatment also addresses comorbid depression o medical treatment is similar to that used for schizophrenia  antipsychotic medication o treatment prognosis is generally poor o seeing a therapist for a few sessions isn’t necessarily going to alter that Personality Disorders (PDs)  DSM 5 personality disorder clusters… Cluster B: Histrionic PD  characterized by excessive emotionality and attention seeking o overly dramatic, sensational, and sexually provocative o often impulsive and need to be centre of attention o thinking and emotions are perceived as shallow o common diagnosis in women etiology is largely unknown  histrionic personality may be a sex-typed variant of antisocial personality o there’s this idea that there’s not a lot of real deep emotional connection, the connections are kind of shallow – more utilitarian  treatment o few good treatment outcome studies

o treatment focuses on reducing attention seeking behaviours and long-term negative consequences o treatment targets may also include problematic interpersonal behaviours o little evidence that treatment is effective o acting seductively in an impulsive way, or making quick promises to people that are grandiose… you see that in histrionic PD Cluster B: Narcissistic PD  characterized by grandiosity, need for admiration, and lack of empathy o preoccupation with receiving attention o lack sensitivity and compassion for other people o high sensitivity to criticism o tendency to be envious and arrogant  Dr. Johnson’s work ;) pretty interesting  etiology o associated with failure to learn empathy as a child o sociological perspectives see narcissism as a product of the “me” generation Cluster B: Narcissistic PD  treatment o cognitive therapy around grandiosity, lack of empathy, unrealistic thinking o extremely limited research o treatment may also address co-occurring depression o little evidence that treatment is effective  treatment may work, we just don’t have a lot of evidence Cluster B: Antisocial PD  characterized by failure to comply with social norms and by violation of the rights of others o irresponsibility, impulsiveness, and deceit o lack conscience, lack empathy, and lack remorse  many with ASPD have early histories of behaviour problems, including conduct disorder o many come from families with inconsistent parental discipline and support o families often have a ….. see this ASPD and Psychopathy  related but not interchangeable  antisociality may be one facet of psychopathy o antisociality may include: early behavioural problems o see this slide ASPD and Psychopathy

 other facets of psychopathy may include: o arrogant interpersonal style  superficial charm, grandiosity, lying o deficient affect  shallow emotions, lack of remorse, failure to accept responsibility o irresponsible behaviour  need for stimulation, impulsitivy, parasitic lifestyle, lack of realistic goals ASPD, Psychopathy and Criminality  there is some overlap in these constructs, but they can and do exist independently VENN DIAGRAM with three circles: criminality (the biggest circle on bottom) psychopathy, antisocial personality disorder

ASPD and Substance Use Disorders  up to 4/5 people with ASPD also have SUD o problematic treating this population – it’s easy to get roped in o guys will find ways to hook you o they will often ask for a favour right away  can I borrow a pen, can I use your phone Neurobiological Theories  underarousal hypothesis o antisocial behaviours serve to increase arousal  cortical immaturity hypothesis o antisocial behaviours result from impulsiveness due to lack of cortical activation  fearlessness hypothesis o higher threshold for experiencing fear o when you do measure of skin conductance, they don’t seem to sweat under stress the same way others do. Psychological Dimensions  failure to abandon unattainable goals  coercive parenting  inconsistent parenting  trauma, particularly childhood trauma Treatment of Antisocial PD  few with ASPD seek treatment on their own  antisocial behaviour is indicator of poor prognosis, even in children  treatment emphasizes prevention and rehabilitation o e.g., relapse prevention, prevention of recidivism  incarceration is often the only viable alternative

 KNOW HOW TO DIFFERENTIATE THIS FROM PSYCHOPATHY April 4, 2016 Cluster B: Borderline PD  BPD is characterized by: o Patterns of unstable moods and relationships o Impulsivity, fears of abandonment, very poor self-image o Self harm and suicidality are common o Most common PD in psychiatric settings o Comorbidity rates are high  Trauma  Mood disturbance  Up to ¼ of people with bulimia have BPD  Up to 2/3 or people with BPD have SUD  Their moods last hours or days, but not typically a week. You can differentiate them by timeline Borderline PD  frantic efforts to avoid abandonment  unstable intense relationships  identity disturbance  impulsivity (potentially self-damaging)  recurrent suicidal or self mutilating behaviour  affective instability  chronic emptiness  anger – inappropriate, intense  transient paranoid ideation or dissociation o occurs under stress, goes away when stress goes away o they can endorse psychotic-like symptoms, but only under stress. Is resolved when stress is resolved o Borderline refers to being on the border between neurotic and psychotic  Not a good classification system anymore Cluster B: Borderline PD  etiology o BPD runs in families o Early trauma and abuse seem to play some etiologic role  Up to ¾ may report childhood sexual abuse  Complex PTSD?  There is an idea out there – perhaps this is just a kind of PTSD that expresses itself in a particularly problematic way  o Linehan’s biosocial model of BPD

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Somebody that comes in whose therapist told them they must have been abused as a child. That said, lots of people with BPD do have a history of abuse. Just not all of them. Implanted memories…

Transactional Model of the Etiology of BPD  emotionally vulnerable person with BPD o the sensitivity shows up as  they have a low threshold for emotional stimuli o they react very intensely, and it takes them a long time to cool off o you’ve got somebody who might be born that way o what kinds of brain situations might lead them to this? Frontal lobe?  We know that trauma changes the brain  Quite likely that there are brain-related changes that might occur that could account for that brain activity  Invalidating environment o Your private experience isn’t something to be counted o “you’re acting crazy”, “this shouldn’t bother you” o they are told that their behaviour isn’t acceptable and doesn’t make sense to people  Behaviourally dysregulated person with BPD o You end up with somebody who is behaviourally dysregulated because they are trying to find ways to modify their emotions  Sex, spending, drinking, self-harm… these things can modify how you feel.  Borderline PD is a result of all of these interactions Emotion Vulnerability  0-100 real quick  see this slide Emotion Dysfunction High emotion vulnerability  emotion regulation deficits  problem behaviours  functions of self-harm  affect regulation o physical pain overcomes emotional pain o control of feelings o express anger o suicide prevention  this doesn’t mean that you should go ahead and do it.  punish self for being “bad” o they are under the impression that punishment will modify behaviour o not a good long-term solution for behaviour change  exert control over environment

o environmental reinforcement o sometimes the environment only takes you seriously when you engage in self-harm  overcome numbness or dissociation o to feel something o chronic emptiness. Self-harm is sometimes a way to re-orient you to the present moment, and to feel something at all, rather than nothing/numbness Biosocial model  BPD is not anybody’s fault. It’s the transaction between the person and the environment that produces the behaviour

Invalidating Environment  the predominant response of the environment is characterized by the denial and rejection of the individual’s behaviour  expressions of private experience are punished or trivialized  painful emotions are disregarded DBT - - there is no one truth Dialectical Behaviour Therapy  emphasizes dialectics as btoh a world view and an approach to therapy o e.g., balances acceptance strategies and change strategies  structure includes: o individual sessions for clients o skills training groups for clients o consultation team for therapists April 5, 2016 Personality Disorders (Ds)  DSM 5  Cluster A –  Cluster B –  Cluster C: Avoidant, Dependent & Compulsive PD Cluster C: Avoidant PD  characterized by extreme sensitivity to the opinions of others o avoidant most interpersonal relationships o anxious in interpersonal settings and fearful of rejection  possible etiologies o overactive behavioural inhibition system o difficult temperament resulting in rejection early in development  treatment o several well-controlled treatment outcome studies exist

o treatment is similar to that used for social phobia o treatment targets include social skills and anxiety Avoidant – they don’t necessarily WANT to be different  if you’re more reserved, let them come to you. That style works better Cluster C: Dependent PD  characterized by excessive reliance on others to make major and minor life decisions o unreasonable fear of abandonment o clingy and submissive in relationships  possible etiologies o still largely unclear o linked to early disruptions in learning independence  treatment o treatment outcome research is generally lacking o therapy typically progresses gradually o treatment targets include skills that foster independence

Inventing Mental Illness  mental illness is not real, it is a fiction of psychiatry  DSM categories are a result of voting by psychiatrists o “no statistics in DSM” o DSM codes are required for insurance billing  No lab test for mental illness o No diagnostic biological marker  No understanding of the etiology of mental illness  Diagnosis is unreliable o Unreliable between clinicians o “I can find five diagnoses that would fit you or anybody else” Not a real science  psychiatry = learning which drug to use for which diagnosis o its about marketing, not science o brain scans  changes in brain function do not mean we have discovered anything with its origin in the brain  no specific blood flow patterns associated with specific disorders o that’s all true

The Citizens Commission on Human Rights (CCHR)  CCHR is affiliated with the Church of Scientology

http://www.vancewoodward.com/journal/2012/10/22/this-is-scientology-part-1introduction...