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Summary 4.2 Personality disorders week 1
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WEEK 1 LITERATURELECTURE 1
o To identify the characteristics of a personality disorder (PD)
o To distinguish between personality traits vs. personality disorders
o To identify the various etiologies of PD
o To compare and distinguish the different PDs and their characteristics, including:
o Three clusters
o Diagnostic criteria and (associated) features
o Prevalence, development and course
o Risk and prognostic factors
o Culture- and gender-related diagnostic issues
o Differential diagnosis
o To apply knowledge of PDs and their characteristics to clinical examples
DSM 5 PERSONALITY DISORDERS
- definition: “A personality disorder is an enduring pattern of inner experience and
behavior that deviates markedly from the expectations of the individual’s culture, is
pervasive and inflexible, has an onset in adolescence or early adult- hood, is stable
over time, and leads to distress or impairment.”
Overall included in the DSM 5 (good summary):
- general personality disorder
- paranoid PD: distrust and suspiciousness, motives interpreted as malevolent
- schizoid PD: detachment from social relationships and restricted emotional
expression
- schizotypal PD: acute discomfort in close relationships, cognitive or perceptual
distortions, eccentricities of behavior
- antisocial: disregard for and violation of the rights of others
- borderline PD: instability in interpersonal relationships, self-image, affects and
marked impulsivity
- histrionic PD: excessive emotionality and attention seeking
- narcissistic PD: grandiosity, need for admiration and lack of empathy
- avoidant PD: social inhibition, feelings of inadequacy, hypersensitivity to negative
evaluation
- dependent PD: submissive and clinging behavior related to excessive need to be
taken care of
- OCPD: preoccupation with orderliness, perfectionism and control
- personality change due to another medical condition
- other specified personality disorders and unspecified personality disorder
o either: person meets general criteria for PD and traits of several PDs are
present but criteria for any specific PD is not met
o or: person meets general criteria for PD but the person has a PD not included
in the DSM e.g. passive-aggressive personality disorder
,Clustering:
- A: paranoid, schizoid, schizotypal odd and eccentric
o 5.7%
- B: antisocial, borderline, histrionic, narcissistic dramatic, emotional, erratic
o 1.5%
- C: avoidant, dependent and obsessive compulsive anxious or fearful
o 6%
- this clustering has limitations and is not 100% validated
- 15% of adults have at least 1 PD
Dimensional model
- DSM 5 uses the categorical perspective, PDs are qualitatively distinct clinical
syndromes
- alternative is dimensional perspective: PDs represent traits that merge imperceptibly
into normality and into one another
- clusters can also be seen as dimensions representing spectra on a continuum with
other mental disorders
GENERAL PERSONALITY DISORDER:
Criteria:
- a) an enduring pattern of inner experience and behavior that deviates markedly from
expectations of the person’s culture
- pattern is manifested in 2 (or more) of the following areas:
o cognition, affectivity, interpersonal functioning, impulse control
- b) enduring pattern is visible and pervasive across a broad range of situations
- c) enduring pattern leads to clinically sig. distress or impairment in important areas of
functioning
- d) pattern is stable and of long duration, onset can be tracked back to at least
adolescence or early adulthood
- e) pattern is not better explained by another mental disorder
- f) pattern is not attributable to substance use and another medical condition
Diagnostic features:
- personality traits must be different that the characteristics that emerge to specific
situational stressors or more transient mental states (e.g. bipolar, depression etc.)
- often necessary to conduct more than one interview
- disorders characteristics may not be considered problematic to be person (ego-
syntonic), to overcome this, additional info is useful
Development and course
- becomes recognizable during adolescence or early adulthood
- some types become less evident with age (antisocial, borderline) and some don’t
- for a PD to be diagnosed for someone younger than 18, the features must be present
for at least 1 year
o exception for antisocial PD: cannot be diagnosed if you’re under 18
- PDS require onset no later than early adulthood, but some people may not come to
clinical attention until later
,Culture-related issues
- PDs should not be confused with problems related to immigration or expression of
habits, customs, religion or political values
Gender-related issues
- some more in males (e.g. antisocial)
- some more in females (e.g. borderline, histrionic, dependent)
- cautious not to over- or underdiagnose bc of social stereotypes
Differential diagnosis
- other mental disorders and personality traits:
o characteristics (e.g. suspiciousness, dependency etc.) must appear before
early adulthood, be typical of the person’s long-term functioning, and don’t
occur during an episode of another mental disorder
o might be difficult to distinguish from persistent mental disorders e.g.
depressive disorder
o some disorders may have a spectrum relationship (schizotypal with SCZ,
avoidant with antisocial anxiety)
o traits should only be diagnosed as PDs when they are inflexible, maladaptive,
persistent and cause sig. impairment or distress
- psychotic disorders:
o for paranoid, schizoid, and schizotypal PDs there is an exclusion criterion:
behavior must not occur during the course of SCZ, a bipolar or depressive
disorder with psychotic features or another psychotic disorder
- anxiety and depressive disorder:
o cautious of cross-sectional symptom features that mimic personality traits
- PTSD:
o cautious if personality changes emerge after extreme stress
- SUDs:
o don’t make diagnosis based on behaviors that are consequences of
intoxication or withdrawal, or associated with activities to sustain substance
use
- personality change due to another medical condition:
o e.g. brain tumor
CLUSTER A PDs
PARANOID PD:
Criteria:
- a) pervasive distrust and suspiciousness of others that their motivated are
interpreted as malevolent, beginning by early adulthood, present in a variety of
context, with 4 (or more) of the following:
o suspects, without sufficient basis, that others are exploiting, harming or
deceiving him/her
o preoccupied with unjustified doubts about the loyalty or trustworthiness of
friends or associated
, o is reluctant to confide in others bc of unwarranted fear that info will be used
maliciously again him/her
o reads hidden or threatening meanings into benign remarks or events
o persistently bears grudges
o perceives attacks on his/her character or reputation that are not apparent to
others and is quick to react angrily or to counterattack
o has recurrent suspicions, without justification, regarding fidelity of spouse or
sexual partner
- b) does not exclusively occur during the course of SCZ, a bipolar or depressive
disorder with psychotic features, or another psychotic disorder and is not
attributable to another medical condition
- if criteria are met before the onset of SCZ, add “premorbid”
Diagnostic features:
- they often feel deeply and irreversibly injured by another person even when there is
no objective evidence for this
- they are amazed when a friend/associate shows loyalty that they can’t trust or
believe it
- they may refuse to answer personal questions
- they may misinterpret an honest mistake or a humorous remark as a deliberate
attack, compliments are often misinterpreted too
- they may try to gather evidence to support their jealous beliefs
- they want to maintain control of intimate relationships to avoid being betrayed
Associated features supporting diagnosis:
- generally difficult to get along with and have problems with close relationships
- criteria can be expressed as overt argumentativeness, recurrent complaining, hostile
aloofness
- they may act guarded, secretive, cold, lacking tender feelings
- they appear objective and rational but really, they are hostile, stubborn, and sarcastic
- their combative nature may elicit hostile responses which confirm their original
expectations
- excessive need to be self-sufficient
- desire of high control of those around them
- difficulty accepting criticism, may blame others for their shortcomings
- bc of quick counterattacks they may be involved in legal disputes
- unrealistic grandiose fantasies attuned to issues of power and rank
- negative stereotypes of others, especially groups different from them
- may be perceived as fanatics and form tightly knit cults or group with the same
paranoid belief systems
- may experience brief psychotic episodes in response to stress
- paranoid PD may appear premorbid to delusional disorder or SCZ, they may develop
MDD, and may be at increased risk for agoraphobia and OCD
- alcohol and other substance use are frequent
- most common co-occurring PDs are schizotypal, schizoid, narcissistic, avoidant, and
borderline
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