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PIP - Personality Disorders - Y2 - Coggle Diagram
PIP - Personality Disorders - Y2
Adult attachment, personality traits and borderline personality features in young adults (Scott, Levy and Pincus, 2011):
Attachment anxiety in insecure attachment is significantly associated with negative affect and impulsivity, which attachment avoidance did not
This favours the model that adult attachment anxiety and features of BPD are fully mediated by trait negative affect and impulsivity
The role of identity in the DSM-5 classification of personality disorders (Schmeck et al, 2013):
Alternative model for diagnosing personality disorders where the construct identity has been integrated as a central diagnostic criterion for personality disorders is in section III in the DSM-5
Pathological personality traits are assessed in five broad domains divided into 25 trait facets (Level of Personality Functioning Scale)
This allows more detail to be given in describing the patient, as each facet can be examined
The relevance of identity problems in understanding personality pathology is illustrated in using the new classification system - identity diffusion is key to many severe personality disorders, and treatment can be more unique if each facet is understood
Suggested that in adolescents, thresholds should be higher so diagnosis is more restrictive
Plate tectonics in the classification of personality disorder (Widiger and Trull, 2007):
Suggestion that diagnostic criteria should shift to a dimensional classification of personality disorder that would address issues with current categories and contribute to an integration of the DSM-5 with research on general personality structure
Most mental disorders appear to be the result of a complex interaction of an array of interacting biological vulnerabilities and dispositions with environmental, psychosocial events exerting effects (Rutter, 2003) over time
Personality disorders are responsive to a variety of biological, cognitive, interpersonal and other moderating variables that shape the psychopathological profile
Therefore, single diagnostic categories are too reductionist, by trying to be discrete with continuous dimensions
Criteria for validity of personality disorder diagnostic categories - -> Heritability, temporal stability, and discriminant validity
A dimensional model would address many of the severe limitations and handicaps of existing categories, including tackling heterogeneous presentations, unstable diagnostic boundaries, excessive co-occurrence, weak scientific base and inadequate coverage
Although the FFM is seen as limited, its 30 facets for the 5 traits provide enough detail of both adaptive and maladaptive traits and could reduce stigma by conceptualising it as a variant of personality rather than a separate trait - they are not distinct, just extremes
An FFM dimensional model of personality disorders would describe abnormal functioning using the same language as normal personality structures, bringing methods of assessment and well-validated research tools, allowing more universal diagnosis and integrating psychiatry and psychology
Gender differences -
Men tend to show more aggressive, structured, self-assertive and attached traits
Women tend to show more submissive, emotional and insecure traits (Torgersen, 2012)
ASPD more common in men, histronic personality disorder in women
However, this has been debunked - there are cultural and social reasons based on stereotyping for this discrepancy
Clusters of personality disorders
Cluster A - odd or eccentric disorders -
Paranoid personality disorder - pervasive distrust and suspicion of others so that their motives are seen as malevolent
Schizoid personality disorder - detachment from social relationships and restricted range of expression of emotions
Schizotypal personality disorder - pervasive pattern of social and interpersonal deficits marked by acute discomfort and reduced capacity for close relationships, and cognitive or perceptual distortions
Causes of Cluster A
Paranoid personality disorder -
Biological contributions to PPD is limited, but there is a strong genetic role (Kendler et al, 2015) and some relationship with schizophrenia
Early mistreatment or trauma has been linked to this disorder, but this is studied retrospectively and so bias can be an issue
Schemas have also been implicated - they follow basic mistakes in assumptions about people, and is maladaptive in viewing the world
-> No cause for this has been identified, but it is linked to early upbringing with parents teaching them strongly about a worldview, causing a vigilance about other people being malicious if they do not match this
Cultural factors - unique experiences such as imprisonment, refugees and those with hearing impairments can make people more susceptible (Iacovino et al, 2014)
Symptoms associated with PPD are also precursors to conditions like Alzheimer’s
Experiences of discrimination can reinforce the paranoia felt by immigrants, for example
Cultural and cognitive factors can therefore cause misinterpretation of events, leading to paranoia
Tend to be treated with therapy to restructure schemas (Kelly et al, 2007)
Schizoid personality disorder -
Very little research on causes, but some implication of brainstem inhibitory dysfunction (Wang et al, 2020)
Childhood shyness has also been suggested to be a precursor, as is abuse and neglect
There is also a suggestion of a genetic cause
There is overlap between SPD and ASD, and it could be that combining these two with early learning or issues with interpersonal relationships produces the social deficits that define SDP (Hopwood and Thomas, 2012)
Therapy often focuses on improving social relationships
Schizotypal personality disorder -
May have schizophrenia genes (polygenic) but not the correct environmental cues to produce this, and so schizotypal PD develops alternatively (phenotype differs but genotype is the same)
In men, childhood maltreatment is implicated, but this tends to become PTSD in women
Some cognitive deficit in memory and learning is also linked, suggesting left hemisphere damage could cause the disorder
Treatment often bears resemblance to anxiety and depression, as this is what treatment is sought for
-> Research is growing because it is a precursor to schizophrenia
-> Combining community treatment, psychotic medication and social skills training seemed to be effective in delaying onset or reducing symptoms (Nordentoft et al, 2006)
Cluster B - dramatic, emotional or erratic disorders
Antisocial personality disorder - disregard and violation for rights of others
BPD - instability in interpersonal relationships, self-image, affects and impulse control
Histronic personality disorder - excessive emotion and attention seeking
Narcissistic personality disorder - grandiosity, need for admiration and lack of empathy
Antisocial personality disorder -
Glibness / superficial charm
Grandiose sense of self worth
Pathological lying
Conning / manipulative
Lack of remorse or guilt
Callous / lack of empathy
Also linked to criminality and conduct disorder
Genetic influence is suggested as being a cause in this, with Crowe (1974) finding that adopted children had higher rates of criminality if they had a criminal biological parent
-> There is also a gene-environment interaction of attachment issues - adopted children of mothers who were felons and also spent more time in interim orphanages were more likely to be ASPD
-> Epigenetic cause of the disorder, with criminality requiring deficits in high-quality, early contact with caregivers not just the genetic influence (Cadoret et al, 1995)
-> Neglect, abuse and trauma in early years all contributed to this disorder
Neurobiological influences - general brain damage does not seem to constitute ASPD
Arousal theories - underarousal hypothesis and the fearlessness hypothesis
Suggestion that cortical arousal that is either high or low causes negative affect and perform poorly (Yerkes-Dodson law)
-> Underarousal hypothesis suggests that abnormally low cortical arousal is the primary cause of psychopathy, as they seek stimulation to boost this
-> Raine, Venables and Williams (1990) - found future criminals to have low skin conductance, lower heart rate, and more slow-frequency brain wave activity, indicating low arousal
Fearlessness hypothesis suggests that psychopaths have a higher threshold for experiencing fear
Attempted to link Gray’s BIS and BAS theory - suggested an imbalance between the two, with more BAS than BIS; this may explain why psychopaths are not anxious about their acts (Chen, 2020)
Cortisol, testosterone and serotonin have been linked to callousness, superficial charm, lack of remorse and impulsivity - integrative theories link the genetic and environmental influences to make better treatment (Hare et al, 2015)
Psychological and social dimensions -
Psychopaths are more likely to not be deterred despite signs of a goal no longer being achievable as they have set their sights on it (Patterson and Kosson, 1987)
Aggression in children with this may escalate, partly as a result of interaction with their parents, as parents often given in to the problem behaviours displayed by their children
-> This is a coercive family process which can maintain aggressive behaviours, combined with parental depression, genetic vulnerability and less parental involvement can result in psychopathy
Shared environment factors have been linked to the disorder, with parental social status and inconsistent parenting causing ASPD
Developmental influences - the behaviour decreases around the age of 40 - however, the cause of this is unknown (Hare et al, 2012)
Integrative model - paired with biological factors, abnormal responses to fear conditioning can lead to the fearlessness shown in the disorder; they have deficits in amygdala functioning
May point to a genetic influence that weakened the amygdala and interacts with the environment to reduce the effects of conditioning
May also interact with childhood adversity - antisocial and impulsive behaviour caused by difficult temperament pushes them away from good role models, leading to more frustration at life circumstances and feeding the behaviours
Treatment - attempting to address cognitive deficits and examine states of minds to encourage prosocial behaviour
Most common strategy is parent training
Proper prevention when problematic behaviours are spotted in home and education is vital - introducing behavioural supports and social competence skills (Reddy et al, 2009) helps prevent development of poor behaviour
Given treatment is ineffective mostly, prevention is the best strategy
Borderline personality disorder -
Genetic influence - linked to mood disorders (Streit et al, 2020) - MZ twins have high concordance
Emotional reactivity, the central symptom, led to inspection of endophenotypes - genetic studies on serotonin have been linked to this, and this suggests genetic differences impact the development of BPD
The limbic system is also implicated - sensical as it is the emotion regulation and serotonin centre, and low serotonergic activity in this group leads to poor regulation and impulsivity
Shame is an emotion that has been highlighted in this disorder (Buchman-Wildbaum et al, 2012), leading to self harm and low self-esteem
Cognitive factors of memory bias - remembering things despite being instructed to forget them (Baer et al, 2012) meaning that they remember negative information
Environment risk factors - sexual and physical abuse, which is particularly causative in women and girls, along with neglect, parental styles also have an impact with encouraging poor behaviour
-> However, abuse is a risk factor for many personality disorders, and so specific development may involve other factors more importantly
Rapid cultural changes have also been implicated - supports idea that prior trauma can cause the disorder
Intergrative model of triple vulnerability theory - general psychological and biological vulnerability and the specific vulnerability learned from early experience of abuse and trauma leads to more threat sensitivty and thus emotional instability (Barlow, 2002)
Treatment - dialectical behavioural therapy - coping with stressors that trigger maladaptive behaviours (Lynch and Cuper, 2012)
-> Brain imaging revealed that women who benefitted from treatment
Histronic personality disorder -
One hypothesis involves a possible relationship with ASPD - high cooccurrance (Lilienfield et al, 1986) of around 66%
Suggestion that they may be sex-typed expressions of the same underlying condition - women show histronic patterns, men show antisocial ones
However, more evidence is needed - however, the theory also exists for the dimensions of BPD (female) and psychopathy (male)
Treatment - therapy is often used, which involves improving problematic interpersonal relationships and are taught more appropriate ways of negotiating wants and needs
Narcissistic personality disorder -
Caused by a failure of parents to teach empathy and altruism to balance self-centeredness and demand which is innate (Kohut, 1977) - involved in finding someone who is able to cope with their fixation on grandiose and able to meet their empathic needs
Sociological theory - Western societies have an emphasis on hedonism, individualism, competitiveness and success - this has led to an increase in NPD
Cognitive training and coping strategies have been used to treat their approach to interpersonal relationships, along with their grandiosity and hypersensitivity and empathy, but it is unsure how effective they are
Cluster C - anxious or fearful disorders -
Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorder
Avoidant personality disorder - sensitive to the opinions of others, and although they desire social relationships, their anxiety leads them to avoid associations and they experience low self-esteem, reducing their relationships
Lerner et al, 2020 - some links to subschizophrenia disorders
Millon (1981) - genetic difficult temperament or personality characteristics; this leads to rejection from parents and this can lead to low self-esteem and social alienation, which persists into adulthood
Also describe childhood neglect, isolation, rejection and conflict with others (Eikenaes et al, 2015)
Use behavioural intervention as treatment
Dependent personality disorder - rely on others to make decisions, causing an unreasonable fear of abandonment
Disruptions to early caregiving can lead to poor transitions from dependency to independent living, and also cause a fear of abandonment
However, submissiveness makes treatment difficult - therefore, it tends to focus on developing the confidence of the patient in their ability to make decisions independently (Maccaferri et al, 2020)
Obsessive-compulsive personality disorder -
Moderate genetic contribution, and some people may be predisposed to favour structure in their lives (Stein and Lochner, 2020)
Therapy focuses on attacking the fears that underlie the need for orderliness, helping the individual relax and teach them the ability to reappraise their compulsive thoughts
Key features and causes of personality disorder
Personality disorders -
Personality traits - enduring yet flexible characterstics
Personality disorder -
-> Enduring inflexible and pervasive patterns
-> Differs from social expectation in at least two of -
--> Cognition
--> Affectivity
--> Interpersonal functioning
--> Impulse control
-> Clinically significant distress of impaired functioning
-> Long-standing, stable - intrinsic part of someone's personality and identity
How can a personality be disordered - Different theories:
A particular form of trait structure - failure to develop certain components of personality such as remorse
Development primitive trait structure - Klein; a disordered personality remains at the paranoid-schizoid level of development and does not achieve the 'depressive position' (psychoanalysis)
Socially deviant or statistically abnormal levels of given trait e.g. extreme introversion traits
Where is the line between normal and disordered - classification even harder
They have a prevalence of 10-15% - however, many people do not seek treatment so actual prevalence is unclear
Onset - usually recognisable from adolesence
Assessment -
-> Self-report questionnaires e.g. PDC-IV; reliable, efficient and valid but requires insight to self which can be biased
-> Semi-structured interview e.g. SCID-II; good inter-rater reliability and validity, but suffers from potential bias and is time consuming
Is often comorbid with order disorders, especially depression and anxiety, making those disorders harder to treat
Classification in DSM - Cluster B
Antisocial - violation of rights
Antisocial PD involves two key features -
Disregard and violation of others' rights and feelings, with 3 or more of:
Repeated unlawful behaviour
Deceitfulness
Impulsivity
Aggression and physical fights
Reckless disregard for safety
Consistent irresponsibility
Lack of remorse
Over 18 but evidence of conduct disorder before age of 15
Previously called psychopathic / sociopathic, but now emphasises behaviours over underlying psychology
Overlaps with, but not the same as sublinical psychopathy
Aetiology -
More prevalent in men than women
Genetics - 41% heritable (meta-analysis; Rhee et al, 2002)
Biology -
-> Smaller brain (Barkataki et al, 2006)
-> Lack of response to distress and punishment (Birbaumer et al, 2005; Blair et al, 1997)
--> Failure to learn from punishment and lack of constraint on behaviour as a result
-> Impaired prefrontal cortex functioning (Dinn & Harris, 2000)
Environment - low SES, family conflict, physical abuse, inconsistent parenting, father APD - Cohen et al, 2005
Issues with aetiology -
-> Childhood conduct problems - could be APD showing
-> Difficult to study - do not seek help, as they succeed by not being caught
Borderline - unstable
Pervasive instability and impulsivity, with 5 or more of:
Frantic effort to avoid abandonment
Very unstable relationships (idealised <-> devalued)
Very unstable self image
Impulsive in at least 2 damaging areas
Recurrent self harm or suicidal behaviour / threats
Extremely reactive mood
Chronic empty feelings
Intense, inappropriate or uncontrolled anger
Stress-related paranoid or severe dissociative symptoms
Comorbid with depression, anxiety and addiction disorders - dissociation as a coping mechanism, severe abuse leading to poor coping strategies
Aetiology -
More women than men present for treatment
Genetics (42-69%) heritable in both sexes (Distel et al, 2008; Torgersen et al, 2000)
Biology - poorly developed:
-> Frontal lobe - poor impulse control
-> Amygdala functioning - emotion regulation
Environmental risk factors - Cohen et al, 2005:
-> Childhood verbal, emotion or sexual abuse (60-90%)
-> Extended separations from mother before age of 5
-> Inconsistent parenting
BPD is persistent across the lifespan supposedly but 73.5% of a BPD sample remitted over 6 years (Zanarini et al, 2007; Gunderson et al, 2011)
-> However, this could be an issue of diagnosis
-> People fluctuate in remission and relapse - depression also shows a fast relapse of 60% by 3 years, and some BPD eventually meet diagnostic criteria again
-> Clearly symptoms of BPD can go into remission - however, even after some remission, problems in adaptive functioning are more stable than diagnoses
--> Diagnosis criteria may not be met but emotional functioning still suffers
Anxious or disorganised attachment (Steele and Siever, 2010)
-> Role of emotion regulation and negative model of self
-> BPD correlates with attachment anxiety in non-clinical samples (Nickell et al, 2002)
-> BPD patients report preoccupied or fearful attachment (Levy et al, 2005)
Scott et al (2009) - BPD in a non-clinical sample
-> Similar patterns found by Fossati et al, 2005, in a clinical sample
--> Significant = Attachment anxiety -> negative affect + impulsivity -> BPD features
--> Not significant = Attachment avoidance -> negative affect + impulsivity -> BPD
--> As a result, anxious attachment styles more significantly predict BPD
Histrionic - attention seeking:
Aetiology -
Genetics - 67% heritable (Torgersen et al, 2000)
Environment -
-> Psychodynamic theories - parental coldness or attitudes to sex, but little evidence
-> Evidence for maternal overinvolvement (Cohen et al, 2005)
Excessive emotionality + attention seeking, with more of -
Needs to be centre of attention; concerned with appearance; theatrical exaggeration; sexually provocative
Shallow and rapidly shifting emotions; impressionistic speech and suggestible
Considers relationships more intimate than they are
Narcissistic - admiration seeking
Grandiosity, need for admiration + lack of empathy, with 5 or more of:
Grandiose self-importance
Fantasies of unlimited success
Believes self is special / unique
Requires admiration
Sense of entitlement
Exploitative
Lacks empathy
Envy (self or others)
Arrogant
Aetiology -
More prevalent among men than women
Genetics - significant heritable component (up to 79%; Torgersen et al, 2000)
Psychodynamic approach - permissive or rejecting parenting can result in self not developing in healthy way
Environmental risk factors - parental verbal abuse (Cohen et al, 2005) - but little research
Most research is on subclinical narcissism (overlaps with NPD but relates to better psychological health; Miller and Campbell, 2008)
Other types -
Paranoid - distrust
Schizoid - detached
Schizotypal - distortions
Avoidant - socially inhibited
Dependent - clingy
Obsessive-compulsive - perfectionist
Personality disorders and relation to personality models and attachment
Integrative models -
Biopsychosocial - additive effects of genes, personality and environmental risk factors
Diathesis-stress -
-> Maladaptive personality traits (inherited or formed in early experience) might form diathesis
-> Life stress could tip over the edge into disorder
-> High IQ or social support might be protective factors (Cohen et al, 2005)
Issues in PD diagnosis -
Treatment rarely sought for PD itself but for resulting impairment or distress
PDs overlap and are difficult to distinguish - leads to high comorbidity -> validity and reliability issues
Many permutations of symptoms for each PD
'Not otherwise specified' is a common diagnosis
-> Forces categorical distinction onto naturally dimensional individual differences
Personality disorders and gender -
Is there a sexist bias inherent in the concept of PD?
-> Histrionic and borderline are more reported in females
Perception of gender may affect how diagnoses are handed out
Distributions of PD diagnoses may reflect underlying distributions of personality traits in men and women - men generally have lower agreeableness and conscientiousness
Does this reflect gendered reactions to the same underlying traumas - BPD and ASPD run in families
May be that problems with emotion regulations are coped with by self-harm in females and alcohol and drugs or violence in males
Personality disorders and culture -
PD prevalence varies across cultures and over time within the same culture
-> Substance misuse and parasuicide more common in Western societies (Paris, 1991)
-> APD highest in the US and lowest in Japan and Taiwan - rates increased since WWII (Kessler et al, 1994)
Mismatch of person / culture (Caldwell-Harris & Aycicegi, 2006)
Traits present differently in different cultures
Does social media foster narcissism?
Dimensions or categories -
There are at least 18 alternative dimensional models of PDs
O'Connor et al, 2002 - same factors emerge in clinical / non-clinical samples for both clinical / non-clinical measures
Livesely et al (1989) - validated by Kushner et al, 2011 -
-> Factor analysis of PD symptoms - 18 facets, 5 higher order factors
--> Emotion dysregulation
--> Need for approval
--> Dissocial behaviour
--> Compulsivity
--> Inhibitedness
-> DAPP - Dimensional Assessment of Personality Pathology
Are PDs related to the Big Five?
Continuity hypothesis - PDS are just extreme combinations of normal personality traits
Widiger and Trull (2007) - five-factor model can be used to assess PDs
-> Identify extreme facet scores
-> Identify likely resulting impairments
-> Assess global functioning
Most PDs related to high neuroticism, low extraversion, low agreeableness and low conscientiousness
Facets can help distinguish different PDs or clusters (Samuel and Widiger, 2008)
Issues in predicting PDs with FFM -
-> FFM does not capture extremes found in PDs - ceiling effects (Clark et al, 2002)
-> FFM does not cover relevant PD dimensions (Tromp & Koot, 2010) - cognitive distortions, self-harm etc
-> FFM based on lay concepts of personality - does not reflect the complexity of clinical cases (Shedler & Westen, 2004) - e.g. NPD = inflated self-worth + inadequacy
DSM-5 - Alternative hybrid models -
Included in section III - focus of further study
-> Long-term, stable, pervasive impairment of functioning (self/interpersonal)
-> High score on 1/5 pathological trait domains (negative affectivity, detachment, antagonism, disinhibition v compulsivity and psychoticism - 25 facets)
-> PD diagnosis if match specific patterns of impairment and traits - avoidant, antisocial, borderline, narcissistic, OC, schizotypal etc
-> Otherwise - personality disorder - trait specified
Evaluation -
Would remove comorbidity and not otherwise specified
Can also be used to describe pathological personality of non-PD clients
Helps identify areas to focus treatment
4/5 traits are unipolar and do not map perfectly onto FFM or other theoretical models
Could be useful for heterogenous presentations and unique behavioural displays
Can PDs be treated?
Medical - medication used to treat comorbid problems
Psychodynamic - some evidence that achieving insight into problems is helpful (Svartberg et al, 2004)
Behavioural - Dialectical Behaviour Therapy (Linehan, 1987)
-> Accept and understand maladaptive behaviours, replace with more helpful ones
-> Learn alternative emotional / coping skills
-> Effective for reducing BPD behaviours but not identity / emotions - Robins and Chapman, 2004
Cognitive-behavioural -
CBT - identify dysfunctional cognitions
-> Adapted to help client trust therapist, avoid direct challenges
Schema therapy - focus on early maladaptive schemas
-> Similar to CBT but also aims to identify childhood origins, accept and manage associated emotions
Preliminary RCT evidence for BPD (Giesen-Bloo et al, 2006)
-> 3 years schema therapy v psychodynamic therapy
Cognitive schemas -
-> Beck et al, 2004 - theorised that each personality disorder has a specific associated belief or cognitive schema, which affects attention, memory and interpretation of experiences
Schemas -
Paranoid - I cannot trust people
Schizoid - relationships are messy and undesirable
Schizotypal - It’s better to be isolated from others
Histrionic - people are there to serve or admire me
Narcissistic - since I am special, I deserve special rules
Borderline - I deserve to be punished
Antisocial - I am entitled to break rules
Avoidant - If people know the real me, they will reject me
Dependent - I need people to survive and be happy
Obsessive-compulsive - people should do better and try harder
Summary
PDs involved Persistent, Pervasive and Problematic personality patterns -
-> 4 PDs focused on - instability, focus on self at detriment of others
PDs are partly genetic, but environmental factors such as abuse, insecure attachment and stress may increase risk or trigger a diathesis-stress pattern
Classifications of PDs in flux - they are underlain by dimensions, relate to the Big Five, dark triad and insecure attachment, but no system yet captures natural variation alongside diagnostic usefulness
PDs are present challenge for treatment, but BPD symptoms can be improved through DBT or CBT/Schema therapy