PSYCHIATRY

Personality Disorders
Lecturer: Dr. Jerez | September 21, 2017
Transcribed by: KJDP|NBO|RLM|KIM|AWP

OUTLINE
 Dramatic, emotional, or erratic – antisocial, borderline,
1. DSM Axis II – What is a personality disorder?
histrionic, narcissistic
2. Clusters of personality disorders – 3 main types
 Anxious and fearful – dependent, obsessive-
a) Cluster A- Odd, Eccentric
i. Paranoid compulsive (one thing is missing here you probably
ii. Schizoid know why)
iii. Schizotypal
b) Cluster B-Dramatic, Emotional Prevalence
i. Antisocial  6-9% of population have one or more personality
ii. Histrionic disorder
iii. Borderline  prevalence higher among people with other mental
iv. Narcissitic disorders
c) Cluster C-Anxious, Fearful  most people with personality disorders never come to
i. Avoidant the attention of mental health professionals
ii. Dependent Historical perspective
iii. Obsessive-Compulsive  Roots in psychoanalysis – narcissism, masochism, etc.
3. Prevalence  Karl Abraham – first theorist to focus on personality
4. Historical perspectives disorders
5. Diagnostic issues
6. Etiology – Theoretical perspectives 19th century German psychiatrist Krafft-Ebing named
7. Clusters of PD in Detail
sadism for Marquis de Sade the autor of Justine, ou les
8. The Big 5 Personality Traits
Malheurs de la Vertu (Justine, or The Misfortunes of Virtue)
9. Summary
and Leopold von Sacher-Masoch, author of Venus in Furs.
Uniquely important elements in Psychiatric History Taking
 Sensitivity (patients will have different level of Diagnostic issues
sensitivity and that depends on their personality)  poor understanding of etiology of most personality
 Confidentiality (It is utmost important for psychiatric disorders
patients)  comorbidity and diagnostic overlap
 Collaboration (this is done between patient’s friends,  gender and cultural issues
family, records and the physician)  reliability of diagnosis
 categorical vs. dimensional approach – Big 5
Others like rapport and empathy are more general. Though personality traits
these are important especially in hostile situations.
The BIG 5 Personality Traits are: OCEAN or CANOE
What is a personality disorder? The five-factor model was claimed to significantly predict all
 maladaptive personality traits ten personality disorder symptoms. However, most
 traits are relatively enduring features of a person that predictions related to an increase in Neuroticism and a
are persistent over time and situations decrease in Agreeableness, and therefore did not
 people with personality disorders tend to be: rigid and differentiate between the disorders very
inflexible, show a restricted range of traits, have a well.
dominant single trait
 personality disorders are egosyntonic, more than
egodystonic

Patients with PD are egosyntonic even up to the point they

try to cover up or deny that do not have the condition or
disorder. When it is egosyntonic and it brings anxiety (not to
the point it brings significant distress and affect normal
functioning) to the person, it is more of just a trait.

Clusters of Disorders
 Odd and eccentric – paranoid, schizoid, schizotypal

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Etiology- Theoretical Perspectives
 Psychodynamic theory (id, ego, superego)
 Attachment theory – particularly for dramatic,
emotional, erratic
 Cognitive-behavioural perspectives
 Biological – particularly for odd, eccentric and
dramatic, emotional, erratic
Cluster A: Odd and Eccentric
 Paranoid – suspicious, argumentative (no delusions or
hallucinations)
 Schizoid – withdrawn, reserved, reclusive
 Schizotypal – eccentricity of thought and behaviour
Schizoid are the loners and do not like or enjoy sex.
Schizotypal likes magical thinking and have perceptual
disturbances.
Cluster B: Dramatic, Emotional, Erratic
Antisocial, Histrionic, Borderline, Narcissitic
Antisocial Personality
 Defining feature is pervasive disregard for and
violation of rights of others
 Begins in childhood
 Must meet 3 of the following criteria – violation of
rights of others, nonconformity, callousness,
deceitfulness, irresponsibility, impulsivity,
aggressiveness, recklessness
 Lifetime prevalence rates for APD – 3% for men, 1%
for women, lower rates for psychopathy
 40% of those in Canadian prisons have APD
APD vs. Psychopathy
 Defining feature is APD focuses more on
behaviour
 Robert Hare, UBC – Psychopathy Checklist
Revised – focuses on both personality traits and
behaviour (lifestyle instability)
Personality traits Lifestyle instability
lack of remorse antisocial (lying, stealing, cheating)
callousness impulsive
selfishness social deviant lifestyle
exploitation of others
APD Etiology
 Family and parenting factors – disruptive family life,
harsh and inconsistent discipline, lack of monitoring
 Genetics – concordance rates for criminality are 51%
for MZ twins, 21% for DZ; runs in families
 Fearlessness hypothesis – deficient emotional arousal
and conditioning is associated with a lack of empathy,
thrill-seeking; In the face of punishment, psychopaths
increase the frequency of punished behavior, rather
than decrease it; defiance/opposition (the juvenile
form of APD is conduct disorder)
PSYCHIATRY- Personality Disorders
 Lykken’s (1957) research- In a lever pressing task,
people with psychopathy did not learn the association
between particular lever presses and shocks; in
contrast, people without psychopathy learned this
association quickly.
 Schmauk’s (1970) research- repeated this experiment,
but compared different types of punishers – physical,
tangible (loss of money), social (reprimands); He found,
like Lykken, that those with psychopathy learned
poorly when physical and social punishers were used,
but they learned as well as controls when tangible
punishment was used.
 Stewart’s (1972) research- sentence completion task
involving physical punishment for aggressive
responses; Controls stopped aggressive responses
very quickly, but those with psychopathy increased
aggressive responses; They acted in opposition to and
defiance of the researcher
 Implication of this research
 Punishment of offenders not likely to be
very effective for rehabilitation
 Programs like “Scared Straight,” boot camps
make kids with APD worse rather than
better
 “Getting tough” with this population not
likely to work
APD Course
 A progression or career of deviancy - oppositional
defiant disorder, conduct disorder, APD
 Burnout response – as they age, people with APD
become less involved in criminal activity
APD Treatment
 difficulty establishing therapeutic alliance
 need to focus on specific behaviours, such as anger
management
 treatment approaches not very successful
 probably more success with prevention and early
intervention
Borderline Personality
 fragile identity and instability in relationships
 unpredictability, impulsiveness, irritability,
argumentative
 more prevalent in women
 low reliability of this diagnosis
 experience of child abuse and neglect
Histrionic Personality
 attention-seeking, flirtatious, flamboyant, difficulty
with relationships
Reminds us of Sharon Stone on her movie “Basic Instinct.”
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 PSYCHIATRY- Personality Disorders

Narcissism Personality
 grandiosity, egocentricity, vengeful, but low self-
esteem

Cluster C: Anxious and Fearful Disorders

 Avoidant personality – extreme sensitivity to criticism
and disapproval, avoidance of intimacy
 Dependent personality – constantly seeks reassurance,
advice, direction from others
 Obsessive-compulsive personality – inflexibility and
desire for perfection, absence of obsessional thoughts
and compulsive behaviours

Treatment of PD
 Object relations psychodynamic therapy – Kernberg,
Kohut
 Cognitive-behavioural
 Pharmacological (more on symptoms and comordities)
Kernberg and Kohut are for narcissitic PD: Kernberg
recommends challenging the patient’s defense; while Kohut
recommends exploration of therapist’s empathic failure
BIG 5- OCEAN (Costa and McRea, 1992)
High Personality trait Low
Curious Openness Conventional
Reliable Conscientiousness Unreliable
Sociable Extraversion Shy-quiet
Good natured Agreeableness Uncooperative
Nervous Neuroticism Calm

 Dimensional analysis of types: Where would (Schizoid

/Paranoid /Antisocial /Narcissism /Avoidant
/Dependent) personality fit on the 5 dimensions?

Summary
 Personality disorders are maladaptive personality
traits
 3 broad clusters
 Problem of overlap of categories
 Etiology for many personality disorders not well
understood
 Treatments have not been very successful for many of
these disorders.