Live Lecture: Personality Disorders

What is a personality disorder?

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in > 2 of the following areas:

- Cognition
- Affectivity
- Interpersonal functioning
- Impulse control

B. Inflexible and pervasive across a broad range of personal and social situations

C. Significant distress or impairment in social, occupational, or other important areas if functioning

D. Stable and long duration, and early onset (at least adolescence)

E. Not better explained by another mental disorder

F. Not attributable to a substance or another medical condition

The three P’s are important:

- Persistent
- Pervasive
- Pathological

→ Personality traits are diagnosed as a personality disorder only when they are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress.

Personality disorders:

1. Cluster A:
- Paranoid personality disorder
- Schizoid personality disorder
- Schizotypal personality disorder

→ Individuals in this cluster often display odd or eccentric behavior, exhibit social withdrawal, and may have unusual beliefs or perceptual experiences.

2. Cluster B:
- Borderline personality disorder (instability in a range of things, more impulsivity)
- Narcissistic personality disorder
- Histrionic personality disorder (excessive emotionality and attention-seeking)
- Antisocial personality disorder (disregard and violation of the rights of others)

→ Individuals in this cluster tend to have dramatic, emotional or erratic behavior, often struggle with impulse control, and may have difficulty forming and maintaining relationships

3. Cluster C:
- Avoidant personality disorder
- Dependent personality disorder
- Obsessive-compulsive personality disorder

→ Individuals in this cluster typically exhibit anxious or fearful behavior, are preoccupied with fears of rejection or abandonment, and may have a strong need for control and perfectionism

How do personality disorders develop?

→ They arise from a complex interplay between genes, temperament, and environment

→ A significant number of BPD patients report experiences of sexual, physical, and/or emotional abuse.

- Meta-analysis showed that patients with BPD are over 13 times more likely to report childhood adversity (traumas) than non-clinical controls (particularly emotional abuse and neglect)

Schema therapy:

→ A schema is a framework through which we interpret certain things/events. The emotions, thoughts, behaviors, and bodily senses are colored by our schemas. Most of the time, you are not aware of your own schemas, but they have a lot of influence on your life and the way you experience things.

→ Events can trigger our schemas

An early maladaptive schema is’:

- A broad, pervasive theme or pattern
- Comprised of memories, emotions, cognitions, and bodily sensations
- Regarding oneself and one’s relationships with others
- Developed during childhood or adolescence
- Elaborated throughout one’s lifetime and dysfunctional to a certain degree

Core psychological needs (according to schema therapy):

- Secure attachments to others (includes safety, stability, nurturance, and acceptance)
- Autonomy, competence, and a sense of identity
- Realistic limits and self-control
- Freedom to express valid needs and emotions
- Spontaneity and play

→ These needs can be satisfied during childhood. But when they are not, this can lead to maladaptive behavior, schemas, and disorders.

> Different schemas and the emotions compared to it

Two examples of maladaptive schemas’:

1. Abandonment: the belief that somehow you will always be abandoned.

- Strong negative reactions - such as anger or depression - to actual or perceived loss (for example, partner comes home a little bit later, they can explode with anger)
- Act clingy, needy, jealous, and controlling in relationships
- Fear abandonment but choose partners that are likely to leave them
- Often seen in BPD

2. Entitlement/grandiosity:

- Feel superior to others
- Belief that one does not have to follow the rules that apply to others
- Related to NPD and ASPD

An example of BPD, with clips about Elton John.

Borderline personality disorder:

→ A pervasive pattern of instability of interpersonal relationships, self-image, and affect, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by >5 of the following:

1. Frantic efforts to avoid real or imagined abandonment
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
3. Identity disturbance: markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two areas that are potentially self-damaging (spending, sex, substance abuse, reckless driving, binge eating, etc.)
5. Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior
6. Affective instability due to a marked reactivity of mood
7. Chronic feelings of emptiness
8. Inappropriate intense anger or difficulty controlling anger
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Empirical evidence of abuse and PDs:

→ Different forms of abuse may be related to different types of disorders

What about the brain and PDs?

→ Different issues and the extent of grey matter in different parts of the brain (the more blue, the more grey matter)

→ But it’s not this simple. A lot of issues share similar patterns. You cannot conclude that if someone has less grey matter in the prefrontal cortex, someone must have ADHD, for example.

Brain structure and function in BPD: smaller/less grey matter in amygdala

Another study: again smaller volumes found in the amygdala with BPD, and also the hippocampus

Brain and clinical diagnosis:

- Neuroscience cannot be used for diagnosis
- The brain is not deterministic
- The brain is not unchangeable
- The brain is not genetic

→ The brain is shaped by a complex interplay of genes and experiences

→ Study of cab drivers who have to learn the map of London by heart.

→ This study shows that the hippocampus can evolve. After studying the whole map of London, the hippocampi of the cab drivers have grown.

→ This shows that the brain responds to environmental changes. So our genes set some pathways, but it’s a use-it-or-lose-it principle. If we don’t use the genes or some pathways/functions etc., the activity/volume/presence of it will fade.

Social exclusion:

→ People with BPD felt excluded in the cyber ball game, even when they got the ball every now and then (so got included sometimes). This suggests they have some kind of baseline of feeling excluded.

→ In healthy controls, the brain activity changes. But with BPD patients, the line is flatter and does not change as much.

Social evaluation experiment:

→ Different words (negative/positive) and after that the question is how do you feel right now.

→ Control vs. low self-esteem, vs. BPD

→ The patients don’t feel as good as controls with positive words

→ TPJ (important for switching perspective and putting yourself in someone else's shoes): healthy controls activate the TPJ relatively more to positive words, and less to negative words. But this was reversed in people with borderline, so they had more TPJ activity in negative feedback.

Summary:

- Personality disorders: persistent, pervasive,