Lecture 17 Personality Disorders Lecture Outline I. Introduction II. Differentiation between personality disorders and Axis I disorders A. Anxiety and Mood Disorders B. Psychotic Disorders III.DSM-III-R Diagnostic Categories IV. A note on "Sex Bias" V. Proposed DSM-III-R Categories VI. Conclusion ------------------------------------------- I. Introduction Up to this point we have been looking at "Axis I disorders" - disorders recorded on Axis I of the DSM-III diagnostic system. Most of the diagnoses are made on this axis. However, DSM-III also has Axis II: Here are recorded the so-called Personality Disorders. DSM-III-R definition of "Personality Traits": "Enduring patterns of perceiving, relating to, and thinking about the environment and oneself." These patterns or traits "are exhibited in a wide range of important social and personal contexts" (APA, 1987, p.335). DSM-III-R definition of "Personality Disorders": When personality traits "are inflexible and maladaptive and cause either significant impairment or subjective distress" (APA, 1987, p.335). In other words, we are talking about deeply ingrained, basic patterns of relating to the world and oneself; patterns that characterize the person's long-term functioning. Such personality disturbances are often seen early in the person's life, and they continue through adulthood. Individuals with personality disorders exhibit recurrent maladaptive behaviors in a wide range of areas, especially in their interpersonal relationships. These people are often quite dissatisfied with their lives. Not surprisingly, anxiety and depression are common complications. II. Differentiation between personality disorders and Axis I disorders A. Anxiety and Mood Disorders The symptoms experienced by individuals suffering from anxiety or mood disorders tend to be "ego-dystonic". That is, the problems and difficulties they experience are unacceptable, objectionable, and alien to the self. In contrast, the problems experienced by a person with a personality disorder are often perceived as "ego- syntonic": acceptable, unobjectionable, and part of the self. When they do confront problems in their lives, people with personality disorders will blame others (Marmar, 1987). B. Psychotic Disorders It is true there can be severe social and occupational impairments associated with the personality disorders, but persistent psychotic features, delusions and hallucinations do not occur. There can be transient psychotic states in certain personality disorders (esp.: borderline) - but these episodes are short-lived and normally do not require medication or hospitalization (Marmar, 1987). Individuals with personality disorders are (usually) in touch with reality. III. DSM-III-R Diagnostic Categories The DSM-III-R groups the personality disorders into three clusters: Cluster A: disorders marked by odd or eccentric behaviors. paranoid schizoid schizotypal Cluster B: disorders characterized by dramatic, emotional or erratic behaviors. antisocial borderline histrionic narcissistic Cluster C: disorders characterized by anxious or fearful behaviors. avoidant dependent obsessive compulsive passive aggressive A. Paranoid Personality Disorder [on overhead: DSM-III-R diagnostic criteria] Case study: see attached When in a new situation, the person will actively search for any "confirmation" of his/her paranoid beliefs: a nice self- fulfilling prophecy. This is how the person always operates. Individuals with this disorder thus have significant problems in their relationships. Indeed, they shun intimacy. They are rigid and uncompromising; hostile, stubborn, and defensive (Marmar, 1987). Prevalence: Unknown - these people rarely seek help (which is to be expected, given the nature of the disorder). Sex ratio: More common in men B. Schizoid Personality Disorder [on overhead: DSM-III-R diagnostic criteria] Case study: see attached These are "loners". They are excessively self-absorbed and detached, both socially and emotionally. They do better at work (especially when contact with others in not necessary) than they do in interpersonal relationships. While these patterns typically begin in childhood, that is not to suggest that all shy children go on to develop a schizoid personality disorder. Prevalence: Not yet established (Marmar, 1987), although it is low in clinical settings (APA, 1987). But again, these people also rarely seek help. Sex ratio: Unknown C. Schizotypal Personality Disorder [on overhead: DSM-III-R diagnostic criteria] Case study: see attached This disorder is apparently related to Schizophrenia, both in symptomatology and etiology. Symptoms: peculiar and bizarre thoughts, beliefs, behaviors, emotions, perceptions, etc. However, these symptoms are much less severe than that found in schizophrenia. Etiology: Schizotypal Personality Disorder seems to share a genetic relationship with schizophrenia: relatives of Schizophrenic persons are more likely to exhibit schizotypal symptoms than are genetically unrelated persons (Kendler, 1985). Some researchers even suggest that schizotypal personality disorder is actually a milder or "borderline" form of schizophrenia (Kendler, 1985). Prevalence: about 3% of the population (APA, 1987). Sex Ratio: unknown D. Antisocial Personality Disorder [on overhead: excerpts from DSM-III-R criteria] Case study: see attached Unlike the other personality disorders, where the individual usually harms him/herself more than he/she harms others, the person with an antisocial personality disorder harms others: chronic indifference and violation of others' rights (Cadoret, 1986), what colloquially we call the "psychopath". This personality disorder is the most widely researched personality disorder, and the most reliably diagnosed. This is why your text (indeed, most introductory texts!) emphasize this disorder. Prevalence and sex ratio: males - 3% females - less than 1% E. Borderline Personality Disorder [on overhead: DSM-III-R diagnostic criteria] Case study: see attached Instability is the hallmark here. There is thus often considerable interference with social and occupational functioning. We will discuss this disorder in more detail next lecture. Prevalence: Apparently common, although this may be because the diagnosis is currently "fashionable". This disorder also tends to co-occur with many of the other personality disorders - it has fuzzy boundaries Sex ratio: more common in females, with a 2:1 to 9:1 ratio, depending on the sample. F. Histrionic Personality Disorder [on overhead: DSM-III-R diagnostic criteria] Case study: see attached People with this disorder are lively and dramatic, always drawing attention to themselves. While they may be attractive and appealing initially, relationships with them are superficial. They are sometimes described as excessively flirtatious. Prevalence: Apparently common. There is some evidence of increased familial incidence (Marmar, 1987). Sex Ratio: much more common in females than males. (Note: this disorder can be seen as an exaggerated stereotype of women. Should this concern us? More on this in a moment). One hypothesis is that HPD and Antisocial PD are closely related - the former is merely the female expression of the disorder, and the latter the male expression. G. Narcissistic Personality Disorder [on overhead: DSM-III-R diagnostic criteria] Case study: see attached Here is the person who is "full of themselves": grandiose, unempathetic, exploitative... Narcissistic individuals attempt to sustain an image of perfection and personal invincibility for themselves and others (Marmar, 1987). Depression and chronic intense envy are common. While they may run into all sorts of problems in their relationships and on the job, certain individuals may be quite successful in occupational spheres as they are driven to succeed. Prevalence: Appears to be common, although this has not always been so. Perhaps the increased rates recently noted are due more to professional interest than to actual increases. Sex Ratio: Unknown. H. Avoidant Personality Disorder [on overhead: DSM-III-R diagnostic criteria] Case study: see attached Unlike Schizoid Personality Disorder, in Avoidant Personality Disorder there is a desire for social involvement. The individual yearns for affection and acceptance, but is immobilized by his/her timidity and hypersensitivity, especially regarding fear of rejection. Difference with Social Phobia: Social phobia is usually of a specific situation, not interpersonal relationships. Prevalence: Apparently common Sex ratio: Unknown I. Dependent Personality Disorder [on overhead: DSM-III-R diagnostic criteria] Case study: see attached The key features are excessive dependent, submissive and passive behavior patterns. The individual seems incapable of making his/her own decisions or living independently. The individual will belittle what skills he/she does have. Being alone is painful; the individual is frequently depressed and anxious. Prevalence: Apparently common Sex ratio: More common in females (Again, stereotypic behavior patterns..?) J. Obsessive Compulsive Personality Disorder [on overhead: DSM-III-R diagnostic criteria] Case study: see attached This is different from the anxiety disorder known as obsessive compulsive disorder. In the anxiety disorder, there are intrusive and unwanted thoughts and possible accompanying compulsive behaviors. In Obsessive Compulsive Personality Disorder, there are no true obsessions or compulsions. Rather, there is the pervasive general drive for perfectionism and inflexibility. The two disorders can, however, coexist. Prevalence: Unknown Sex ratio: Frequently diagnosed in men (Marmar, 1987) (another stereotypic bias?) K. Passive Aggressive Personality Disorder [on overhead: DSM-III-R diagnostic criteria] Case study: see attached An individual with this disorder is thus indirect in his/her communications and actions. Rather than just saying "no, I don't want to", he/she engages in all sorts of indirect resistances. S/he finds ways of not doing what s/he is supposed to, but never through direct refusal; rather s/he procrastinates, dawdles, makes mistakes, etc. The name of this disorder implies that the passive behaviors are a cover for feelings of resentfulness and hostility. So, rather than directly expressing the anger, the person passively expresses it through indirect means. Prevalence and sex ratio: Unknown IV. A note on "Sex Bias" The pattern of "sex bias" that we have noted is a curious one indeed. FEMALES MALES borderline paranoid histrionic antisocial dependent obsessive compulsive When we look at the characteristics of these different disorders, it looks like they are being defined in terms of stereotypic male/female behavior patterns. There has been considerable debate from feminist writers that many of these disorders are based on behavior patterns which our culture expects from women - so women are overly represented in these categories because that's how they've been taught to act. In essence, what the critics argue is that we have turned typical female behavior patterns into a psychopathology. Similarly, women who attempt to break out of these patterns by being assertive and independent are also diagnosed as having other disorder - borderline perhaps. It's a no win situation. And it's a situation that has little to do with science, and more to do with politics. The story doesn't stop here, by any means... as we shall see in the next section. VI. Proposed DSM-III-R categories Two new Personality Disorders have been proposed in the DSM-III-R: Sadistic personality disorder and Self-defeating personality disorder. These are placed in an appendix, and described as needing more study before the validity of the disorders is established. It has been argued that such diagnoses are needed to account for a not uncommon subset of patients seen in therapy: those who are unusually cruel and violent in their relationships, and those who seem to go out of their way to engage in self-defeating behaviors. Some therapists argue that these two personality types might account for some of the domestic violence that occurs, and especially for why the violent relationships continue. [on overhead: the DSM-III-R diagnostic criteria for both disorders] There is, however, much debate over the scientific validity of these proposed categories. Some people are arguing that these categories ignore the social realities that abused women find themselves in. Critics argue that by diagnosing the woman we focus on the wrong thing. If we start diagnosing abused women (and their abusers), will the real economic and social injustices that give rise to this abuse be obscured and ignored? Such is the concern of the critics. We end up "blaming" the woman, and obscuring the more important social problems. Extremely heated debates ensued when the authors of the DSM-III proposed these new categories for the revised version of the manual. As a compromise, the categories are in an appendix. Nevertheless, there is still a lot of controversy over the political nature of the manual. Indeed, as we noted, some of the other personality disorders also seem to be merely stereotyped descriptions of male and female sex roles (Kaplan, 1983). The personality disorders are some of the most controversial and debated diagnostic categories in the DSM-III. We will return to other controversies next lecture. V. Conclusion We have looked at the various Personality Disorders as defined by the DSM-III-R. These people are very difficult to relate to on a personal level. People diagnosed with some of these disorders (esp: borderline, dependent, narcissistic and passive-aggressive) have even been described as the "hateful patients" (Groves, 1978) because of the manipulative and rejecting behaviors common with these people.