Personality Disorders and Impulse Control Disorders Personality ...

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Chapter 13

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Personality Disorders and Impulse Control Disorders

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Personality Disorders

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The DSM groups personality disorders into three clusters: Cluster A: People who are perceived as odd or eccentric. This cluster includes paranoid, schizoid, and schizotypal personality disorders. Cluster B: People whose behavior is overly dramatic, emotional, or erratic. This grouping consists of antisocial, borderline, histrionic, and narcissistic personality disorders. Cluster C: People who often appear anxious or fearful. This cluster includes avoidant, dependent, and obsessive–compulsive personality disorders.

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Paranoid Personality Disorder

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Paranoid personality disorder - A personality disorder characterized by undue suspiciousness of others’ motives, but not to the point of delusion.

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Schizoid personality.

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People who have paranoid personality disorder tend to be overly sensitive to criticism, whether real or imagined.

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Overview of Personality Disorders

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Ego dystonic - Referring to behaviors or feelings that are perceived to be alien to one’s self-identity.

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Ego syntonic - Referring to behaviors or feelings that are perceived as natural parts of the self.

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Personality disorders - Excessively rigid behavior patterns, or ways of relating to others, that ultimately become self-defeating.

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Sheila K. Grant, Ph.D. Professor

Personality Disorders

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Clinicians need to weigh cultural and sociopolitical factors when arriving at a diagnosis of paranoid personality disorder.

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Schizoid Personality Disorder

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Schizoid personality disorder - A personality disorder characterized by persistent lack of interest in social relationships, flattened affect, and social withdrawal.

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Antisocial Personality Disorder Antisocial personality disorder - A personality disorder characterized by antisocial and irresponsible behavior and lack of remorse for misdeeds.

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Antisocial Personality

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People with antisocial personalities also tend to be impulsive and fail to live up to their commitments to others.

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Investigators also find higher rates of the disorder among African Americans than among Caucasians or Hispanic Americans.

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Schizotypal personality disorder may be slightly more common in males than in females and is believed to affect about 3% of the general population.

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They are not “antisocial” in the colloquial sense of seeking to avoid people.

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Schizotypal personality disorder - A personality disorder characterized by eccentricities of thought and behavior, but without clearly psychotic features.

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The person’s emotions usually appear shallow or blunted, but not to the degree found in schizophrenia.

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Schizotypal Personality Disorder

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Often described as a loner or an eccentric, the person with a schizoid personality lacks interest in social relationships.

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Antisocial Personality Disorder

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Lifetime prevalences of antisocial personality disorder by gender.

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Criminality or antisocial personality disorder?

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The Case of Liz

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Antisocial Behavior and Criminality We tend to think of antisocial behavior as synonymous with criminal behavior. Although it is the case that antisocial personality disorder is associated with an increased risk of criminality, not all criminals have antisocial personalities nor do all people with antisocial personality disorder become criminals. Many people with antisocial personality disorders are law abiding and successful in their careers, even though they may treat others in a callous and insensitive manner.

Borderline Personality Disorder Borderline personality disorder (BPD) - A personality disorder characterized by abrupt shifts in mood, lack of a coherent sense of self, and unpredictable, impulsive behavior. At the core is a pervasive pattern of instability in relationships, self-image, and mood, along with a lack of control over impulses. People with borderline personality disorder tend to be uncertain about their personal identities—their values, goals, careers, and perhaps even their sexual orientations.

Cutting.

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“I have problems with anger management.”

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Borderline Personality Disorder

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Such acts may be intended to counteract self-reported feelings of “numbness,” particularly in times of stress.

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Individuals with BPD often have very troubled relationships with their families and others

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Splitting - An inability to reconcile the positive and negative aspects of the self and others, resulting in sudden shifts between positive and negative feelings.

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Histrionic Personality Disorder Histrionic personality disorder - A personality disorder characterized by excessive need for attention, praise, reassurance, and approval. The term is derived from the Latin histrio, which means “actor.” People with histrionic personality disorder tend to be dramatic and emotional, but their emotions seem shallow, exaggerated, and volatile. The disorder was formerly called hysterical personality.

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Over the top?

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Self-mutilation is sometimes an expression of anger or a means of manipulating others.

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Not all people who dress outrageously or flamboyantly have histrionic personalities.

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What other personality features characterize people with histrionic personality disorder?

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Narcissistic Personality Disorder Narcissistic personality disorder - A personality disorder characterized by adoption of an inflated selfimage and demands for attention and admiration. They expect others to notice their special qualities, even when their accomplishments are ordinary, and they enjoy basking in the light of adulation. They are self-absorbed and lack empathy for others.

Narcissistic Personality Disorder

Interpersonal relationships are invariably strained by the demands that people with narcissistic personality impose on others and by their lack of empathy with, and concern for, other people. They seek the company of flatterers and, although they are often superficially charming and friendly, their interest in people is one-sided: They seek people who will serve their interests and nourish their sense of selfimportance. They have feelings of entitlement that lead them to exploit others.

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Avoidant Personality Disorder Avoidant personality disorder - A personality disorder characterized by avoidance of social relationships due to fears of rejection. They may have few close relationships outside their immediate families. They also tend to avoid group occupational or recreational activities for fear of rejection. They prefer to lunch alone at their desks.


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Obsessive–Compulsive Personality Disorder

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Obsessive–compulsive personality disorder A personality disorder characterized by rigid ways of relating to others, perfectionistic tendencies, lack of spontaneity, and excessive attention to detail.

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Persons with obsessive–compulsive personality disorder are so preoccupied with the need for perfection that they cannot complete work on time.

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Their efforts inevitably fall short of their expectations, so they redo their work.

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Sexist Biases The construction of certain personality disorders may have sexist underpinnings. The diagnostic criteria seem to label stereotypical feminine behaviors as pathological with greater frequency than stereotypical masculine behaviors. Take the example of histrionic personality, which seems a caricature of the traditional stereotype of the feminine personality: flighty, emotional, shallow, seductive, attention-seeking.

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Dependent Personality Disorder Dependent personality disorder - A personality disorder characterized by difficulty making independent decisions and overly dependent behavior. Dependent personality disorder has been linked to other psychological disorders, including major depression, bipolar disorder, and social phobia, and to physical problems, such as hypertension, cancer, and gastrointestinal disorders like ulcers and colitis. There also appears to be a link between dependent personality and what psychodynamic theorists refer to as “oral” behavior problems, such as smoking, eating disorders, and alcoholism.

Problems with the Classification of Personality Disorders Problems Distinguishing Personality Disorders from Anxiety and Mood Disorders Overlap Among Disorders Difficulty in Distinguishing Between Normal and Abnormal Behavior Confusing Labels with Explanations

Are there sexist biases in the conception of personality disorders?

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Psychodynamic Perspectives Traditional Freudian theory focused on problems arising from the Oedipus complex as the foundation for abnormal behaviors, including personality disorders. Freud believed that children normally resolve the Oedipus complex by forsaking incestuous wishes for the parent of the opposite gender and identifying with the parent of the same gender. As a result, they incorporate the parent’s moral principles in the form of a personality structure called the superego.


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Hans Kohut

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To Kohut, early childhood involves a normal stage of healthy narcissism.

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Infants also normally perceive their parents as idealized towers of strength and wish to be one with them and to share their power.

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Empathic parents reflect their children’s inflated perceptions by making them feel that anything is possible and by nourishing their self-esteem (e.g., telling them how terrific and precious they are).

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Infants feel powerful, as though the world revolves around them.

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Margaret Mahler Margaret Mahler, another influential modern psychodynamic theorist, explained borderline personality disorder in terms of childhood separation from the mother figure. Mahler and her colleagues believed that during the first year infants develop a symbiotic attachment to their mothers. Symbiosis, or interdependence, is a biological term derived from Greek roots meaning “to live together.” In psychology, symbiosis is a state of oneness in which the child’s identity is fused with the mother’s.

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Hans Kohut One of the principal shapers of modern psychodynamic concepts is Hans Kohut, whose theory is labeled self psychology because of its emphasis on processes in the development of a cohesive sense of self. Freud believed that the resolution of the Oedipus complex was central to the development of adult personality. Kohut disagreed, arguing that what matters most is how the self develops—whether the person is able to develop self-esteem, values, and a cohesive and realistic sense of self as opposed to an inflated, narcissistic personality

Otto Kernberg Otto Kernberg (1975), a leading psychodynamic theorist, views borderline personality in terms of a failure in early childhood to develop a sense of constancy and unity in one’s image of oneself and others. From this perspective, borderline individuals cannot synthesize contradictory (positive and negative) elements of themselves and others into complete, stable wholes. Rather than viewing important people in their lives as sometimes loving and sometimes rejecting, they shift back and forth between pure idealization and utter hatred.

Learning Perspectives Learning theorists focus on maladaptive behaviors rather than disorders of personality. They are interested in identifying the learning histories and environmental factors that give rise to maladaptive behaviors associated with diagnoses of personality disorders and the reinforcers that maintain them. Learning theorists suggest that childhood experiences shape the pattern of maladaptive habits of relating to others that constitute personality disorders.

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What are the origins of antisocial personality disorder?

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Biological Perspectives Much remains to be learned about the biological underpinnings of personality disorders. Most of the attention in the research community has centered on antisocial personality disorder and the personality traits that underlie the disorder, which is the focus of much of our discussion.

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Lack of Emotional Responsiveness When people get anxious, their palms tend to sweat. This skin response, called the galvanic skin response (GSR), is a sign of activation of the sympathetic branch of the autonomic nervous system (ANS). In an early study, Hare (1965) showed that people with antisocial personalities had lower GSR levels when they were expecting painful stimuli than did normal controls. Apparently, the people with antisocial personalities experienced little anxiety in anticipation of impending pain.


Family Perspectives Many theorists have argued that disturbances in family relationships underlie the development of personality disorders. Consistent with psychodynamic formulations, researchers find that people with borderline personality disorder (BPD) remember their parents as having been more controlling and less caring than do reference subjects with other psychological disorders. When people with BPD recall their earliest memories, they are more likely than other people to paint significant others as malevolent or evil.

Genetic Factors We have learned that first-degree biological relatives (parents and siblings) of people with certain personality disorders, especially antisocial, schizotypal, and borderline types, are more likely to be diagnosed with these disorders than are members of the general population. Genetic factors appear to play a role in the development of certain psychopathic personality traits, such as callousness, impulsivity, and irresponsibility. Investigators find that a variant on a particular gene is associated with antisocial behavior in adult men, but only in those who were maltreated in childhood.

The Craving-for-Stimulation Model People with antisocial or psychopathic personalities appear to have exaggerated cravings for stimulation. Perhaps they require a higher-than-normal threshold of stimulation to maintain an optimum state of arousal. In other words, they may need more stimulation than other people to maintain interest and function normally.

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The Brain Abnormalities Model

Brain-imaging techniques link borderline personality disorder and antisocial personality disorder to dysfunctions in parts of the brain involved in regulating emotions and impulsive aggressive behavior, specifically the prefrontal cortex of the frontal lobes and the deeper brain structures comprising the limbic system.

The prefrontal cortex is responsible for such functions as controlling impulsive behavior, weighing consequences of our actions, and problem solving. Brain abnormalities could help account for many features of antisocial personality disorder, including lack of conscience, failure to inhibit impulsive behavior, low arousal states, poor problem-solving efforts, and failure to think about the consequences of one’s behavior

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Treatment Of Personality Disorders People with personality disorders usually see their behaviors, even maladaptive, selfdefeating behaviors, as natural parts of themselves.

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Despite these obstacles, evidence supports the effectiveness of both psychodynamic therapy and cognitive-behavioral therapy in treating personality disorders

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Sociocultural Perspectives Social conditions may contribute to the development of personality disorders. Because antisocial personality disorder is reported most frequently among people from lower socioeconomic classes, the kinds of stressors encountered by disadvantaged families may contribute to antisocial behavior patterns. Many inner-city neighborhoods are beset by social problems such as alcohol and drug abuse, teenage pregnancy, and disorganized and disintegrating families.

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Even when unhappy and distressed, they are unlikely to perceive their own behavior as causative.

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Behavioral Approaches Behavior therapists see their task as changing clients’ behaviors rather than their personality structures. Many behavioral theorists do not think in terms of clients’ “personalities” at all, but rather in terms of acquired maladaptive behaviors that are maintained by reinforcement contingencies. Behavioral therapists therefore focus on attempting to replace maladaptive behaviors with adaptive behaviors through techniques such as extinction, modeling, and reinforcement.


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Psychodynamic Approaches Psychodynamic approaches are often used to help people diagnosed with personality disorders become aware of the roots of their self-defeating behavior patterns and learn more adaptive ways of relating to others. However, people with personality disorders especially those with borderline and narcissistic personality disorders, often present particular challenges to the therapist. For example, people with borderline personality disorder tend to have turbulent relationships with therapists, sometimes idealizing them, sometimes denouncing them as uncaring.

Biological Approaches Drug therapy does not directly treat personality disorders. Antidepressants or antianxiety drugs are sometimes used to treat associated depression or anxiety in people with personality disorders, especially borderline personality disorder. Antidepressants of the SSRI class (e.g., Prozac) may also help temper anger and rage in people with borderline personality disorder and help them control anger and impulsive and aggressive behaviors, including selfmutiliation. Researchers suspect that impulsive and aggressive behavior may be related to serotonin deficiencies.

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Impulse Control Disorders

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Impulse control disorders - A category of psychological disorders characterized by failure to control impulses, temptations, or drives, resulting in harm to oneself or others.

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Compulsive gambling (called pathological gambling in the DSM) is a type of impulse control disorder, as is kleptomania (compulsive stealing), pyromania (compulsive fire setting), trichotillomania (compulsive hair-pulling resulting in noticeable bald patches), and intermittent explosive disorder (failure to resist aggressive impulses, leading to serious assault or property destruction).

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Other impulse control problems, such as compulsive Internet use and compulsive shopping, are presently under consideration for inclusion in the diagnostic manual.

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Pathological Gambling Pathological gambling - A type of impulse control disorder characterized by a pattern of habitual gambling and impaired control over the behavior. Pathological gamblers often report they had experienced a big win, or a series of winnings, early in their gambling careers. Eventually, however, their losses begin to mount, and they feel driven to bet with increasing desperation to reverse their luck and recoup their losses.

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Gambling and other Nonchemical Addictions We can think of pathological gambling as a kind of nonchemical addiction. It shares with chemical dependence (addiction) a loss of control over the behavior, a state of high arousal or pleasurable excitement experienced when the behavior is performed, and withdrawal symptoms, such as headaches, insomnia, and loss of appetite, when the person cuts back or stops the compulsive behavior. Personality characteristics of pathological gamblers and chemical abusers also overlap, with psychological test profiles of both groups showing such traits as selfcenteredness, anxiety, low tolerance for frustration, impulsivity, and manipulativeness.

Kleptomania Kleptomania - A type of impulse control disorder characterized by a pattern of compulsive stealing. The stolen objects are typically of little value or use to the person. The person may give them away, return them secretly, discard them, or just keep them hidden at home. In most cases, people with kleptomania can easily afford the items they steal.


Treatment of Pathological Gambling Many treatment programs involve peer support programs, like Gamblers Anonymous (GA), which models itself on Alcoholics Anonymous. This program emphasizes personal responsibility for one’s behavior and ensures anonymity of group members so as to encourage participation and sharing of experiences. Within a supportive group setting, members gain insight into their self-destructive behaviors.

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QUESTIONS?

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