Personality Disorders

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Personality Disorders
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Bo r d e r l i n e

• Neurotic Beh
• Anxiety-based
• No distortions in reality
• Recognizes problem
• No great personality disorganization

• Psychotic
• Gross distortions in reality (e.g., perception)
• Some personality disorganization
• Does not recognize problem

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Neurotic Behaviour

• Doing the same thing over and over
  expecting a different outcome
• You yourself produce the thing you fear the
• most
• Deals with anxiety-based disorders including
• Generalized Anxiety
• Panic
• Obsessive Complusive
• Phobias
• Others that have anxiety as a basis

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Neurotic Behaviour

• Maladaptive behaviour pattern that does not
  involve gross distortions in reality or marked
  personality disorganization
• Person recognizes that behaviour is unacceptable
  or irrational (ego dystonic ? apart from the ego)

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Neurotic Anxiety

• Central component of anxiety disorders and
  anxiety-based disorders
• No obvious danger or threat
• Event or stimulus is, objectively, minor or
  insignificant (e.g., mouse, thunder, shopping
  mall, etc.)

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Neurotic Paradox I

• Neurotic evaluates innocuous events as anxiety
  provoking ? inordinate anxiety response
• Deals with anxiety in defensive fashion, usually
  avoidance ? reduces anxiety in short term

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Neurotic Paradox II

• This defensive behaviour results in
  self-defeating behaviour
• Does exactly opposite of what is healthy or
  adaptive

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Neurotic Paradox Outcomes

• Blocks personal growth
• Relationship problems (especially intimacy)
• Anxiety focus of life
• Lack of energy and enthusiasm
• Egocentric concerns

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Neurotic Paradox Process

• Maximize pleasure
• Minimize pain
• Immediate Effect Reduce Anxiety
• Long Term Dont resolve the actual problem
• E.G. Doug, the Graduate Student

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Neurotic Styles Characteristics

• Deficit in behavioural repertoire (Inhibition)
• Behaves in an inflexible and exaggerated manner
  opposite to the deficient behaviour
• Behaviour does not fully contain the anxiety

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Neurotic Styles

• Aggression/Assertion Inhibition
• Responsibility/Independence Inhibition
• Compliance/Submission Inhibition
• Intimacy/Trust Inhibition

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Aggression/Assertion Inhibition

• Person uncomfortable with aggression and/or
  assertion and avoids situations where need to
  engage in this behaviour
• Irrationally clings to cooperative stance
• Thought to result in problems such as
  hypertension,ulcers, migraines, other
  stress-related disorders
• Potential sudden aggressive outbursts

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Responsibility/Independence Inhibition

• Person has aversion to autonomy
• Avoids situations where they are in charge or in
  control other others or themselves
• Appear incompetent in simple tasks to pull
  direction by others
• Poor relationships, helplessness, depression

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Compliance/Submission Inhibition

• Neurotic is often the rebel and avoids
  submission to authority
• Need to be non-compliant (i.e., self-reliant,
  independent, free-thinking, to a fault)

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Intimacy/Trust Inhibition

• Retreats from closeness and withdraws from people
  who want deeper relationships
• All relationships short-term to avoid intimacy
• End relationships at crucial points in the
  establishment of intimacy (not just romantic
  relationships, friendships too)

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Interpersonal Consequences

• Some will result in depending too much on others
  that results in others feeling used and
  manipulated
• Unpredictable demands on others that results in
  others feeling angry, frustrated, guilty, etc.

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Interpersonal Aspects of Neurotic Styles I

• Extremely sensitive to acts, opinions, feelings
  of others
• Lack of spontaneity (stilted, controlled,
  mechanical)
• Superficial relationships if any
• Relationships often stormy
• Private life is one of turmoil and inner torment

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Interpersonal Aspects of Neurotic Styles II

• Dont have large networks of enduring
  relationships
• Speculation that some complementary hooking up
  is match made in hell
• Two people with aggression/assertion inhibition
• One with responsibility/independence style and
  one with compliance/submsission style

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Personality Disorders

• When behaviour patterns become inflexible and
  maladaptive to the point of causing distress or
  social/occupation impairment can say have
  Personality Disorder

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Personality Disorders

• Dont stem from reactions to stress but from
  gradual development of inflexible and distorted
  personality
• Maladaptive ways of perceiving, thinking,
  relating to world

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Personality Disorders

• Excessively rigid patterns of behaviour or ways
  to relating to others that prevents people from
  adjusting to external demands and, thus, become
  self-defeating.
• Have always been there for an individual

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Personality Disorders

• Mild Function reasonably well, viewed as
  troublesome, eccentric, etc.
• Severe Extreme or unethical behaviour, may be
  incarcerated.

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Quote From Lorna Benjamin (1996)

• A great way to come down with a case of medical
  student disease (syndrome) is to read a survey
  of personality disorders

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Some Trait Pattern Example

• Suspiciousness
• Self-regard
• Fear of Rejection
• Come to dominate reactions to new situations
• Repetitive maladaptive behaviour

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Difference between DSMs Clinical Syndromes PD

• Clinical Syndrome? specific symptom clusters,
  time limited, ego-distonic (viewed as separate
  from self, unacceptable, objectionable and alien)
• E.g., depression, anxiety disorders, psychotic
  disorders

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Continued

• Personality Disorder? Individual with PD are
  perceived as ego-syntonic (e.g., personality
  issues are acceptable, unobjectionable and part
  of the self). Tend to blame others for problems
  in their lives.

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Difficulties with Diagnosis of Personality
Disorder

• Need to infer traits to make diagnosis, do not
  have specific behaviours clinician can judge
• Disorders and criteria are relatively new,
  therefore not as much research has been done on
  them
• Great deal of overlap among the disorders
• Hard to draw a line between disorder and normal
  behaviour

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Personality Disorder Clusters

• Cluster One Odd-Eccentric
• Behaviours similar to schizophrenia,
  suspiousness, withdrawal, peculiar thinking

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The Odd Eccentric PD Group

• 1. Paranoid Personality Disorder
• 2. Schizoid Personality Disorder
• 3. Schizotypal Personality Disorder

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Paranoid Personality Disorder
Reverend Jim Jones Peoples Temple
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Paranoid Personality Disorder

• suspicious of others motives
• interprets actions of others as deliberately
  demeaning/threatening
• expectation of being exploited
• see hidden messages in benign comments
• easily insulted/ bears grudges
• appear cold and serious

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Paranoid Personality Disorder Example

• Undergraduate student/patient who followed

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Schizoid Personality Disorder
Theodore Kaczynski Unabomber
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Schizoid

• indifferent to relationships
• limited social range (some are hermits)
• aloof, detached, called loners
• no apparent need of friends, sex
• solitary activities
• seem to be missing the human part

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Schizotypal

• peculiar patterns of thinking and behaviour
• perceptual and cognitive disturbances
• magical thinking
• not psychotic
• perhaps a distant cousin of schizophrenia

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Personality Disorder Clusters

• Cluster Two Dramatic-Emotional
• Behaviours are so dramatic, emotional, or erratic
  that it is almost impossible to have truly giving
  and satisfying relationships
• More commonly diagnosed than other PDs

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The Dramatic-Emotional PD Group

• 1. Antisocial Personality Disorder (Dissocial)
• 2. Borderline Personality Disorder
• 3. Histrionic Personality Disorder
• 4. Narcissistic Personality Disorder

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Antisocial Personality Disorder

• pattern of irresponsibility, recklessness,
  impulsivity beginning in childhood or adolescence
  (e.g., lying, truancy)
• adulthood
• criminal behaviour
• little adherence to societal norms,
• little anxiety
• conflicts with others
• callous/exploitive

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• Difficulties in establishing secure identity
• Distrust
• Impulsive and self-destructive behavior
• Difficulty in controlling anger and other emotions

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Borderline Personality Disorder

• marked instability of mood, relationships,
  self-image
• intense, unstable relationships
• uncertainty about sexuality
• everything is good or bad
• chronic feeling of emptiness
• recurrent threats of self-harm/ slashers

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• Single White Female (Jennifer Jason Leigh) or
  Fatal Attraction (Glen Close).

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Narcissistic Personality Disorder

• grandiose, sense of self-importance
• lack of empathy
• hyper-sensitive to criticism
• exaggerate accomplishments/ abilities
• special and unique
• entitlement
• below surface is fragile self-esteem

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Armand Hammer

• There has never been anyone like me, and my
  likes will never be seen again.

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Armand Hammer - Again
The brilliance of my mind can only be described
as dazzling. Even I am impressed by it.
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Focus on Borderline PD
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Borderline Personality Disorder

• Therapist killers (not really killers)
• Very difficult to treat
• Tend to be avoided by many clinicians
• Takes lots of training and experience to treat
  effectively
• Lots of turmoil in treatment

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Borderline Personality Disorder Four Core
Elements

• Difficulties in establishing secure
  self- identity
• Distrust Splitting
• Impulsive and Self Destructive Behaviour
• Difficulty in controlling anger and other
  emotions

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Borderline Examples From Therapist

• First experience with BPD under my supervision

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Identity Disturbance

• In terms of identity disturbance, she relied
  heavily on a sort of reflected identity from
  others and saw herself as she believed others saw
  her.
• With respect to her poor ego boundaries and the
  melding of her identity with my own, one
  particularly surprising thing she said to me was
  that she had googled my name on the internet and
  found out that I had won a presitious academic
  award. She said she felt really sad because she
  did not have an award herself.

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Distrust and Splitting

• She vascillated quite wildly between idealizing
  me (including telling me that she loved me and at
  times wanted us to sit together on the couch so I
  could hold her) and devaluing me (lots of anger
  in session, and a fairly caustic email that said
  "Ain't it so nice and easy. Tell you what M,
  go out and get ourself abused, loose that
  charming smile of yours and come back and tell me
  who's mentally ill", which was followed shortly
  after by an apologetic one.)

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Continued

• It was difficult for me to predict from week to
  week whether she would tell me I was dirt  or
  idealized. She was a good example of someone who
  used splitting defenses where she saw other
  people (me in particular) in all good or all bad
  terms and made rapid shifts between these two
  positions.

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Affective Instability

• Affective instability (went along with the wild
  swings between this sort of coy, coquettish
  behavior and the pronounced anger in session),
  but also exhibited shallow affect and incongruent
  affect.
• For example, she often smiled or giggled when she
  told me about her difficulties and began to
  ocassionally exhibit sadness in session by
  crying. However, a little later in therapy she
  told me that in fact the tears were fake and that
  she was using them because she felt closer to me
  when I responded to her tears.

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More on Distrust

• She had a long history of interpersonal problems
  and difficulty connecting with people. She was
  quite paranoid about what others thought of her
  and this was quite evident in her comments about
  her co-workers whom she felt were against her
  (and, frankly, she may have been right) and in
  her desire to see her chart in the hopes that it
  would finally reveal the intense dislike for her
  that she imagined I felt.

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Termination Always difficult

• We spent about 2 months preparing for and
  discussing termination and it still went poorly.
  She was angry and her parting gift to me was a
  plant that contained a set of tiny clay pots
  (sort a decorative thing) partially submerged in
  the soil. She gave the clinic secretary the same
  thing, but she was careful to say "this one is
  for the secretary, and this one is for you", when
  I looked at the two later, the one that she gave
  me had the tiny clay pots smashed, while
  Geraldine's were intact. A final parting message.

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Self-Destructive Behaviour

• Drug abuse
• Suicide threats
• Lots of promiscuity

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