Personality Disorders 101

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Personality Disorders 101

• Mike Pett MSWRSW
• Advanced Practice Clinician
• Complex Mental Illness Program

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Objectives for the Presentation

• -Common Pathways of Offending for SMI population
• -Personality Disorders Defined
• -Cluster B personality disorders
• Borderline, Narcissistic, and Anti-social/Psychopa
  thic
• -Treatment of Personality Disorders
• -Question Period

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Conventional Path to Offending Part 1.
Biological Temperament Family history Cognitive
ability
Psychological Antisocial attitudes
Social Poor parent-child relns Social learning
of antisocial behaviour
Conduct Disorder
Substance Use
ASPD/ Psychopathy
Andrews Bonta 2006
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Conventional Path to Offending Part 2

• Proximal motivations (the weather)

Motives material gain, sexual, power, jealousy,
revenge
Instrumental
Motives anger, intoxication, perceived threat,
emotional stressor
High Risk Individual
Reactive
Substances
Motives obtain drugs of abuse
Disadvantaged
Motives minor crimes for food, shelter
Peterson et al. 2010
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Paths to Offending in SMI
Positive Symptoms

• SMI vs. Gen Pop
• Higher rate of Conduct dis.
• Higher rate of ASPD
• Higher rate of substance
• Higher rate of poverty
• The direction of these relationships is unclear
• The proportion of each motivation is unclear

Serious Mental Illness
Disorganization
High Risk Individual (ASPD)
Instrumental
Reactive
Substances
Disadvantaged
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The False Dichotomy
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Personality Disorders 101
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Personality Disorder Clusters

• Cluster C (sad)
• Obsessive-Compulsive
• Avoidant
• Dependent

• Cluster A (mad)
• Schizoid
• Schizotypal
• Paranoid
• Cluster B (bad)
• Borderline
• Antisocial
• Narcissistic
• Histrionic

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Activity Personalities R Us

• Corporate Structure
• President ?
• Vice President ?
• Personnel ?
• Advertising ?
• Legal Department ?
• Research ?
• Customer Service ?

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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 individuals 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

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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.

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Borderline Personality Disorder DSM-IV Criteria

• Five or more of the following
• 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 self-image 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

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Borderline Personality Disorder Instability
Impulsivity

• Instability of
• Mood
• Self-image and identity overdetermined by the
  environment
• Interpersonal relationships
• Marked impulsivity (5 Ss)
• 1. Spending
• 2. Sex
• 3. Substance use
• 4. Speeding (reckless driving)
• 5. Satiety (binge eating)
• (6.) Suicidal/self-harm behavior (has its own
  criterion)

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Borderline Personality Disorder Demographics
Course

• Female gt Male (31)
• 2 of community samples 15-25 of clinical
  populations 13-56 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

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Borderline Personality Disorder Etiology

• Most researched is Marsha Linehans biosocial
  theory

Environmental Invalidating Caregivers
Biological Emotional Vulnerability

• High sensitivity/reactivity to emotional stimuli
• Slow return to baseline

• Indiscriminately rejects internal emotional
  experiences
• 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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What is Psychopathy?

• 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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Psychopaths in History

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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

• 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 4 Antisocial Behavior
Factor 1 Arrogant Deceitful Interpersonal Style
Factor 2 Deficient Affective Experience
Factor 3 Impulsive Irresponsible Behavioral
Style
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Factor 1 Arrogant Deceitful Interpersonal Style

• 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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Factor 2 Deficient Affective Experience

• 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
• 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
• Rationalize or minimize past transgressions

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Factor 3Impulsive Irresponsible Behavioral
Style

• 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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Factor 4 Antisocial Behavior

• 10. Poor Behavioral Controls
• 12. Early Behavioral Problems
• 18. Juvenile Delinquency
• 19. Revocation of Conditional Release
• 20. Criminal Versatility

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Other Items

• 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

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Best Practices for Psychopathy and Anti-social
Personality Disorder

• Nothing Works
• vs.
• What Works?

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Watch Dexter!
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Most Best Menu of Treatment Strategies

• Substance Use Treatment
• Pharmacological treatments for impulse
  control/cravings.
• I.M. medication for chronic non-adherence.
• Anger Management.
• Assertive outreach
• Crisis intervention
• Critical time intervention
• Volunteerism

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Most Best Treatment Options.

• CTOs, 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