UNDERSTANDING PSYCHOPATHOLOGY: PERSONALITY DISORDERS

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UNDERSTANDING PSYCHOPATHOLOGY PERSONALITY
DISORDERS DISORDERS OF CHILDHOOD
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• Paranoid
• Schizoid
• Schizotypal

CLUSTER A
odd, eccentric

• Histrionic
• Narcissistic
• Borderline
• Antisocial

CLUSTER B
dramatic, erratic

• Avoidant
• Dependent
• Obsessive/Compulsive

CUSTER C
fearful
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HOW COMMON ARE PDs?
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BORDERLINE PERSONALITY DISORDER (BPD)

• Definition
• Pervasive pattern of instability of
  interpersonal relationships, self-image, and
  affects, and marked impulsivity beginning by
  early adulthood and present in a variety of
  contexts as indicated by 5 or more of 9 symptom
  categories.
• Treatment Marsha Linehan (1995) Dialectical
  Behavior Therapy

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THE CHALLENGES OF BORDERLINE PERSONALITY DISORDER

• Most commonly diagnosed PD among patients in
  treatment
• Represents a particularly challenging disorder to
  treat
• High rates of suicidal or other self-harm
  behaviors, and of hostile behaviors
• High rates of drop-out or treatment failure

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THE DIALECTICAL APPROACH

• Dialectics stresses the basic interconnectedness
  of reality to fully understand a person you have
  to understand his/her context.
• Reality is composed of opposing forces (thesis
  and antithesis) (there can be no function without
  dysfunction distortion without accuracy).

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THE DIALECTICAL APPROACH

• The fundamental nature of reality is change.
  Resolution of the tension between polarities
  produces a new reality which, in turn, creates
  another set of polarities, and so on.
• An implication of this premise is that people
  and their environment are in constant transition
  and need to adapt to inconsistency and
  change.

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BORDERLINE BEHAVIOR AS THE RESULT OF DIALECTICAL
FAILURES

• Polarization (splitting) Persons with BPD
  often view themselves and others in extremes
  (e.g., good, bad), and are unable to accept that
  both qualities can reside within the same person.
  
• Unstable identity Lack of sense of
  interconnectedness renders it difficult to hold
  on to a stable sense of self.

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THE DIALECTICS OF BORDERLINE BEHAVIOR

• Emotional Vulnerability -vs- Self-Invalidation
• Active-passivity -vs- Apparent Competence
• Unrelenting Crises -vs- Inhibited Grieving

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TREATMENT FOR BORDERLINE PD
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From Personality Disorders to Disorders of
Childhood (or the other way around??!!)
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ENDURING PATTERN

• B. is inflexible and pervasive across a broad
  range of situations
• C. leads to clinically significant distress or
  impairment in important areas of functioning
• D. is stable and onset can be traced back at
  least to adolescence or early adulthood
• E. is not better accounted for by another mental
  disorder/ or
• F. by physiological effect of a substance or
  general medical condition

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Case Conference
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CRITICISMS OF PD DIAGNOSES

• Thresholds are not adequately justified
• The thresholds vary for the 10 PDs, and the
  disorders likely vary in terms of the associated
  levels of impairment
• PD criteria are gender biased
• Application of PD criteria is open to gender bias

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CRITICISMS OF PD DIAGNOSES

• Many experts do not regard personality disorders
  disorders or illnesses
• Kendell (2002)
• A. Sociopolitical definition
• B. Biomedical definition
• C. Combination of sociopolitical and biomedical
• Little relationship between DSM IV PD categories
  and major personality theories

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CRITICISMS OF PD DIAGNOSES

• Polythetic classification - heterogeneous
  categories core features not clearly defined.
  Examples
• BP diagnosis requires 5 of 9 features to be
  present
• Antisocial PD diagnosis requires 3 of 7 features
• Related, PD are difficult to measure
• Sokol et al. (1991) administered two standard
  interviews to diagnose PD in 100 patients.
  Despite good inter-rater reliability of each
  interview, the interviews classified patients
  accurately only 50 better then when diagnoses
  were made completely at random.

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CRITICISMS OF PD DIAGNOSES

• Low reliability of diagnoses
• High degree of overlap between PDs
• 85 of individuals with one PD also meet criteria
  for a second PD
• Of those with only one PD diagnosis, only 1-2
  are described as representing the prototype of
  the particular PD (Clark et al., 1995).
  Prototypic cases are supposed to be the
  majority of the category (I.e., they DEFINE the
  category), not the exception.

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CRITICISMS OF PD DIAGNOSES

• The most common PD diagnosis is not one of the
  ten described in the DSM the most common PD is
  PD-NOS
• Example Study of 18,000 clinic patients found
  that PD-NOS was the most common PD diagnosis
  (30).

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CRITICISMS OF PD DIAGNOSES

• Overlap between axis I and axis II diagnoses

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PD and Axis I disorders with high degrees of
comorbidity

• Schizotypal PD - Schizophrenia
• Borderline PD - Anxiety Disorders
• Antisocial PD - Substance Use Disorders
• Avoidant PD - Social Phobia Fabrega et
  al. (1991) almost 80 of individuals with a PD
  also received an axis I diagnosis.

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Common diagnoses Number with dx with at
least 1 comorbid dx
Somatization D. 67 100 Antisocial
PD 628 93 Panic 304
91 Schizophrenia/Schizophreniform D. 340
91 Dysthymia 703 86 Agoraphobia 1,281
84 Obsessive-compulsive D. 571 79 Drug
abuse/dependence 1,316 75 Depressive
episode 1,258 75
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ECA DATA ON ANTISOCIAL PD

• Reliability or Stability of diagnosis
  (enduring)?
• Gender?
• Age phenomenon?

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ANTISOCIAL PERSONALITY DISORDER
Lifetime One-Year One-Month
Men 4.5 2.1 0.9 Women 0.8 0.4 0.2
Whites 2.6 1.2 0.5 Blacks 2.3 1.1 0.
4 Hispanics 3.4 1.6 0.7 lt
30 3.8 2.3 0.9 30-44 3.7 1.5 0.8 45-
64 1.4 0.2 0.1 p lt .001 Source
Robins, Tipp, Przybeck, 1985 ECA
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ANTISOCIAL PERSONALITY DISORDER AND INCARCERATION
White Black Hispanic
Total incarcerated 0.3 1.8 0.3 ASPD
no 0.2 1.1 0.2 ASPD yes 2.7 14.6 1.8
Source Robins, Tipp, Przybeck, 1985 ECA