PERSONALITY DISORDERS

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PERSONALITY DISORDERS

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• Personality Disorders
• Summary

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• The core concept of the Personality Disorders
  group is the presence of a pervasive and enduring
  pattern of maladaptive spontaneous behaviors,
  responses, and modes of thought that begin by
  early adulthood, often interfere with normal
  interpersonal relationships, and produce
  functional impairment or subjective distress.
• Exaggerated normal personality characteristics
• General Diagnostic Criteria p. 689

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Types

• Paranoid
• Schizoid
• Schizotypal
• Antisocial
• Borderline
• Histrionic

• Narcissistic
• Avoidant
• Dependent
• Obsessive-Compulsive
• NOS

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Cluster A

• Characterized by odd, eccentric, isolative, or
  suspicious behavior.
• (Paranoid, Schizoid, Schizotypal)

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PARANOID PERSONALITY DISORDER

• Characterized by pervasive distrust and
  suspiciousness of others and interpretation of
  others motives as malevolent.
• P. 694

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SCHIZOID PERSONALITY DISORDER

• Characterized by a pervasive pattern of
  detachment from social relationships and a
  restricted range of expression of emotions in
  interpersonal settings
• P. 697

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SCHIZOTYPAL PERSONALITY DISORDER

• Characterized by a pervasive pattern of deficits
  marked by discomfort with, and reduced capacity
  for, close relationships, as well as cognitive
  or perceptual distortions and eccentricities of
  behavior
• P. 701

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Cluster B

• Distinguished by dramatic, emotional, erratic, or
  impulsive behavior, or a reduced capacity for
  empathy
• (Antisocial, Borderline, Histrionic,
  Narcissistic)

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ANTISOCIAL PERSONALITY DISORDER

• Diagnosis requires that the client be at least 18
  years old, have evidence of Conduct Disorder
  occurring before age 15 years, and have a
  pervasive pattern of disregard for and violation
  of the rights of others.
• p. 706

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BORDERLINE PERSONALITY DISORDER

• Characterized by a pervasive pattern of
  instability in interpersonal relationships,
  self-images, affects, and control over impulses.
• P. 710

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HISTRIONIC PERSONALITY DISORDER

• Characterized by a pervasive pattern of excessive
  emotionality and attention seeking.
• P. 714

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NARCISSISTIC PERSONALITY DISORDER

• Distinguished by a pervasive pattern of
  grandiosity, need for admiration, and lack of
  empathy.
• p. 717

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CLUSTER C

• Characterized by anxious, fearful, or
  perfectionistic behavior
• (Avoidant, Dependent, Obsessive-Compulsive)

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AVOIDANT PERSONALITY DISORDER

• Pervasive pattern of social inhibition, feelings
  of inadequacy, and hypersensitivity to negative
  evaluation
• P. 721

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DEPENDENT PERSONALITY DISORDER

• Pervasive and excessive need to be taken care of,
  leading to submissive and clinging behavior and
  fears of separation.
• P. 725

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OBSESSIVE COMPULSIVE PERSONALITY DISORDER

• Pervasive pattern of preoccupation with
  orderliness, perfectionism, and mental and
  interpersonal control, at the expense of
  flexibility, openness, and efficiency.
• P. 729

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PERSONALITY DISORDER NOS

• Disturbance of personality functioning that does
  not fit the criteria for any specific Personality
  Disorder.
• P. 729

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Key Diagnostic Points

• Fear of rejection is the key personality trait in
  patients who have Avoidant Personality Disorder.
• Patients with Schizoid Personality Disorder
  prefer isolation. Patients with Avoidant
  Personality Disorder desire close relationships
  but are fearful of them.

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• Patients with Schizotypal P.D. have peculiar or
  odd behavior, thinking, perception, and speech
  that is generally more bizarre than that of
  patents with Schizoid P.D.
• A sense of entitlement and a lack of empathy are
  the hallmarks of Narcissistic P.D.
• Dependency is common in patients with Borderline
  P.D., Histrionic, and Dependent P.D.
• Excessive anger and brief, intense, unstable
  relationships are characteristic of Borderline
  P.D.

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• A 41-year-old office clerk complains that she has
  unfairly been passed over for promotion by a boss
  and a civil service system that are, in her
  words, "incredibly stupid." She has sought
  information from others about why she hasn't
  gotten bonuses or promotions, even though her
  department is quite productive. She resents and
  belittles their observations that she is always
  late with her work and slows down office projects
  by always being the last person finished. She
  feels she is last because she is always given the
  hardest, most odious tasks her co-workers
  disagree. She is intelligent and truly feels she
  is doing a very good job, but she has received
  mediocre performance ratings from every
  department in which she has worked. The managers
  of the government agency for which she works
  would prefer to fire her, but are reluctant to do
  so since she has worked in the same, obstructive,
  way for longer than any of them has been with the
  agency.

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Diagnosis

• Axis I
• Axis II

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• For as long as the local residents can remember,
  this 56-year-old, single high-school graduate has
  lived alone a couple of miles outside of town.
  Although often seen along the road, and
  occasionally in town, he doesn't frequent the
  local bars or cafes and has never been known to
  socialize. He makes his living fixing things, at
  which he is quite adept, but chooses not to open
  a shop in town. He seems indifferent to praise,
  advice, or complaints from his customers,
  generally answering with a nondescript shrug and
  continuing his work. He has never been married
  and did not attend either his sister's wedding or
  his parents' funerals, all of which occurred
  within the county. When passersby offer
  greetings or friendly conversation, he remains
  aloof, barely acknowledging their comments. He
  has no complaints or psychiatric symptoms which
  trouble him. He has never been in trouble with
  the law and has had no known hallucinations,
  delusions, or psychiatric treatment

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Discussion

• Axis I
• Axis II

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• Susan is a 26-year-old teacher's aide who came to
  the center for counseling. For six months she
  had been feeling increasingly lonely and "lost"
  since her sister, who is two years older, was
  married and moved out of town. This sister had
  been Susan's only real social contact otherwise
  she had no girlfriends to speak of and was
  extremely afraid of men. Because she felt that
  she had very little to offer, she always
  anticipated that men, even if attracted, would
  quickly find fault with her and she would be
  "dropped." Although she wanted to get married,
  she never dated a man beyond three dates. While
  her sister encouraged her to join several clubs
  and organizations or go back to school, Susan
  never wanted to be the focus of attention as the
  "new person." Susan also noted that advanced
  education was "scary" and would detract from work
  and hobbies so she "couldn't." This was her first
  attempt to get professional help.

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Diagnosis

• Axis I
• Axis II

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• A 41-year-old man was referred to a community
  mental health center's activities program for
  help in improving his social skills. He had a
  lifelong pattern of social isolation, with no
  real friends, and spent long hours worrying that
  his angry thoughts about his older brother would
  cause his brother harm. He had previously worked
  as a clerk in civil service, but had lost his job
  because of poor attendance and low productivity.
  On interview the patient was distant and somewhat
  distrustful. He described in elaborate and often
  irrelevant detail his rather uneventful and
  routine daily life. He told the interviewer that
  he had spent an hour and a half in a pet store
  deciding which of two brands of fish food to buy,
  and explained their relative merits. For two
  days he had studied the washing instructions on a
  new pair of jeans- Did "Wash before wearing" mean
  that that the jeans were to be washed before
  wearing the first time, or did they need, for
  some reason, to be washed each time before they
  were worn? He did not regard concerns such as
  these as senseless, though he acknowledged that
  the amount of time spent thinking about them
  might be excessive. When asked about his
  finances, he could recite from memory his most
  recent monthly bank statement, including the
  amount of every check and the running balance as
  each check was written. He knew his balance on
  any particular day, but sometimes got anxious if
  he considered whether a certain check or deposit
  had actually cleared. He asked the interviewer
  whether, if he joined the program, he would be
  required to participate in groups. He said that
  groups made him very nervous, and he was unsure
  if he could "stand" participating in them.

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Diagnosis

• Axis I
• Axis II

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• Leon is a 45-year old postal employee who was
  evaluated at a clinic specializing in the
  treatment of depression. He claims to have felt
  constantly depressed since the first grade,
  without a period of "normal" mood for more than a
  few days at a time. His depression has been
  accompanied by lethargy, little or no interest or
  pleasure in anything, trouble concentrating, and
  feelings of inadequacy, pessimism, and
  resentfulness. His only periods of normal mood
  occur when he is home alone, listening to music
  or watching TV. On further questioning, Leon
  reveals that he cannot ever remember feeling
  comfortable socially. Even before kindergarten,
  if he was asked to speak in front of a group of
  family friends, his mind would "go blank." He
  felt overwhelming anxiety at children's social
  functions, such as birthday parties, which he
  either avoided or, if he went, attended in total
  silence. He could answer questions in class only
  if he wrote down the answers even then, he
  frequently mumbled and couldn't get the answer
  out. He met new children with his eyes lowered,
  fearing their scrutiny, expecting to feel
  humiliated and embarrassed. He was convinced
  that everyone around him thought he was "dumb" or
  "a jerk."

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Continued

• As he grew up, Leon had a couple of neighborhood
  playmates, but he never had a "best friend." His
  school grades were good, but suffered when oral
  classroom participation was expected. As a
  teen-ager, he was terrified of girls, and to this
  day has never gone on a date or even asked a girl
  for a date. This bothers him, although he is so
  often depressed that he feels he has little
  energy or interest in dating. Leon attended
  college and did well for a while, then dropped
  out as his grades slipped. He remained very
  self-conscious and "terrified" of meeting
  strangers. He had trouble finding a job because
  he was unable to answer questions in interviews.
  He worked at a few jobs for which only a written
  test was required. He passed a Civil Service
  exam at age 24, and was offered a job in the post
  office on the evening shift. He enjoyed this job
  since it involved little contact with others. He
  was offered, but refused, several promotions
  because he feared the social pressures. Although
  by now he supervises a number of employees, he
  still finds it difficult to give instructions,
  even to people he has known for years. He has no
  friends and avoids all invitations to socialize
  with co-workers. During the past several years,
  he has tried several therapies to help him get
  over his "shyness" and depression. Leon has never
  experienced sudden anxiety or a panic attack in
  social situations or at another times. Rather,
  his anxiety gradually builds to a constant high
  level in anticipation of social situations. He
  has never experienced any psychotic symptoms

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Diagnosis

• Axis I
• Axis II

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• The patient did well in school until he reached
  high school, then he started to cut classes and
  dropped out of the tenth grade. He worked for
  two years as a security guard. He is now
  unemployed, but wants to go back to school and
  become an auto mechanic. The patient is the
  third in a family of eight children. His parents
  separated when he was 14 years old. He lives
  with his mother and siblings. He argues with his
  siblings about doing household chores and, as a
  result, doesn't spend much time with his family
  he just comes and goes and spends time with
  friends. He restrains himself from telling his
  friends not to comment on his "mug," preferring
  to "keep it inside." He hopes that if the
  operation is successful, his friends will stop
  remarking on his looks. When examined, the young
  man was noted to have mild acne and a very
  visibly protruding jaw with an under bite. His
  manner was somewhat awkward. There were no gross
  abnormalities of thinking, perception, or overt
  behavior. He denied ever having any problems
  with mood, sleeping, eating, or the use of
  alcohol or other drugs.

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Diagnosis

• Axis I
• Axis II

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• A wealthy and attractive 34-year-old woman
  presented with a "marital problem." She was an
  heiress of a wealthy European family, and her
  husband was the president of a small importing
  company. She felt he was being insensitive and
  demanding and he, apparently, accused her of
  being self-centered, impulsive, and a
  "compulsive" liar. Over the course of their
  ten-year marriage, each had had numerous affairs,
  most of which eventually came out into the open.
  Both would resolve to deal with their marital
  frustrations and to stop having affairs, and a
  brief period of reconciliation would follow but
  soon one or the other would again surreptitiously
  begin an affair. The patient also described a
  special problem that worried her and that she had
  never disclosed to her husband. Periodically she
  experienced the urge to walk into one of the more
  elegant department stores in the city and steal
  an article of clothing. Over the course of the
  previous three or four years she had stolen
  several blouses, a couple of sweaters, and a
  skirt. Since her husband's income alone was over
  250,000 a year and her investments worth many
  times that, she recognized the "absurdity" of her
  acts. She also indicated that what she stole was
  rarely very expensive and sometimes not even
  enough to her liking for her to wear. The patient
  would become aware of the desire to steal
  something several days before she actually did
  so.

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Continued

• Once out the door, she would experience a sense
  of relaxation and satisfaction but at home she
  would feel anxious and guilty when she realized
  what she had done. She was caught on one
  occasion, but gave a long, involved story about
  intending to pay after she had gone elsewhere in
  the store and then "forgetting" to do so. She
  was released by the store security officers with
  a warning and suspiciously raised eyebrows. She
  spent considerable time describing her own
  accomplishments, talents, and abilities. Her
  affairs, she said, proved that she was indeed
  beautiful and of superior "stock." She thought
  that she and her husband, who was handsome,
  aggressive, and successful, should be a perfect
  match. According to her, the problems with her
  husband stemmed from the little attention he paid
  her and the expectations he seemed to have that
  she should be at his beck and call. The frequent
  arguments they had upset her greatly, and thus it
  was her idea that they seek professional help.
  Regarding the charge that se was a compulsive
  liar, she admitted that she often found it easier
  to tell "white lies" than to face up to something
  "stupid" that she had done.

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Diagnosis

• Axis I
• Axis II

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Semester Summary

• Course content and purpose Psychobehavioral
  Diagnosis
• The DSM IV
• Mental Disorders