Persoonlijkheidsproblematiek - een samenvatting
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The Oxford Handbook of Personality Disorders
Chapter 26
Obsessive-compulsive personality disorder
Early psychoanalytical perspectives
Freud hypothesized that orderliness, parsimony and obstinacy were either sublimations of. Or reaction formations against, anal-erotic instincts of childhood. This is without empirical support.
Early psychoanalysts provided rich clinical descriptions of what would later become known as compulsive or obsessive-compulsive personality disorder. Several of the traits were incorporated into later diagnostic criteria.
The diagnostic and statistical manual of mental disorders and revisions
DSM-IV and DSM-IV-TR specified the essential feature of obsessive-compulsive personality disorder as ‘preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. An individual must have at least four of the eight criteria in order to meet the diagnosis.
Obsessive-compulsive personality traits in moderation may be especially adaptive, particularly in situations that reward high performance.
International classification of diseases
The equivalent of obsessive-compulsive personality disorder in the ICD-10, is anankastic personality disorder. Criteria are: 1) preoccupation with details, rules, list, order, organisation or schedule 2) perfectionism that interferes with task completion 3) excessive conscientiousness and scrupulousness 4) undue preoccupation with productivity to the exclusion of pleasure an interpersonal relationships 5) rigidity and stubbornness 6) unreasonable insistence by the individual that others submit to exactly his or her way of doing things 7) feelings of excessive doubt and caution 8) excessive pedantry and adherence to social conventions.
Epidemiology
Estimates about the prevalence of obsessive-compulsive personality disorder range from 1.6-2.5%.
The prevalence in men and women is similar. The prevalence s greater in older age groups.
Comorbidity
Anxiety and mood disorders
Patients with OCPD had higher prevalences of anxiety disorder, social phobia, obsessive-complusive anxiety disorder and mood disorder.
Obsessive-compulsive disorder
Neuroticism and OCPD may be alternative expressions of the same underlying vulnerability in at least some families with OCD.
Eating disorders
OCPD has been found to be the most common personality disorder in patients with eating disorders.
Co-occurrence with other personality disorders
There is considerable diagnostic overlap between OCPD and other personality disorders. There are significant correlations with: avoidant PD, dependent PD, paranoid PD and borderline PD.
More than half the patients with OCPD had a co-occurring personality disorder.
Functional impairment
A substantial proportion of patients with OCPD show evidence of functional impairment.
The traditional treatment approach is intensive psychoanalyses. It is hoped that the patient will become aware of the defences (s)he marshals to control anxiety and how these interfere with a satisfying interpersonal life.
Cognitive-behavioural therapies aim to identify and change patients’ maladaptive interpretations and meanings that they associate with experience. Behavioural therapy aims to increase adaptive and decrease maladaptive behaviour patterns, by using behavioural techniques such as 1) graded exposure to increase the patient’s rewards and tolerance for novelty 2) increase emotional awareness and expression 3) decrease avoidance tendencies.
Stability
OCPD has a relatively stable trait structure, but with fluctuation in the severity or amount of features present at each point in time. Over a 2-year period, the most prevalent and least changeable OCPD criteria are rigidity and problems delegating. The least prevalent and most changeable criteria are distress and inflexibility about morality.
Interrater agreement
Studies do not support the convergent validity of the OCPD diagnosis.
The five-factor model
The five factor model proposes that the personality disorders should be described and understood as extreme or maladaptive variants of underlying dimensions of personality structure.
Differentiating extreme form maladaptive variants of general personality traits
Very extreme scores on the taxonomic dimensions of the FFM are likely to be maladaptive. Not every very extreme score is necessary going to express or reflect pathology or maladaptivity or lead to impairment or dysfunction. Situational or contextual factors are powerful determinants of what is a good or bad fit of a trait.
Other facets or traits in the person’s particular personality profile may buffer, constrain, modify, or otherwise influence how the trait is expressed concretely in particular situations.
But, one should not consider ‘OCPD to be simply a disorder of excessive conscientiousness’.
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Personality disorders
Chapter 1
Description of personality disorders
Personality is the individual differences in usual tendencies to think, feel and behave. Abnormal personality or pathology refers to maladaptive traits that are overly rigid and/or extreme. Constellations of such pathologically amplified personality traits may constitute personality disorders.
A personality disorder is a chronic psychiatric disorder with onset in adolescence continuing into adulthood, characterized by pathological personality traits that lead to a disruption in the development and maintenance of mutual interpersonal relationships. This is to an extent that leads to prolonged subjective distress of self and/or others.
Personality disorders concern how people matured into adult personalities, and the building blocks are often referred to as traits. Associated problems don’t typically fall into circumscribed specific categories. They involve personal identity and dissatisfaction and dysfunction in interpersonal relationships. It is about difficulties related to how people typically experience and respond to themselves, others, and the world around them (ego-syntonic pathology).
The hallmark of personality disorders is disturbed relationships.
The DSM defines personality disorder as an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two or more of the following areas: cognition, affectivity, interpersonal functioning and impulse control. This is inflexible and pervasive across a broad range of personal and social situations and present for a long duration.
Personality disorder is a longstanding, pervasive and persistent pattern of experience and behaviour. This is different from cultural expectation and problematic in terms of personal suffering and/or impairment in functioning.
Most patients manifest personality pathology that is a combination or mix of the various personality disorders identified in the DSM.
Cluser A
Cluster A consists of: paranoid, schizoid and schizotypical disorders.
This is the odd or eccentric cluster.
Paranoid personality disorder
The criteria are variations of profound mistrust and suspiciousness regarding the motives of other persons. Patients are hypervigilant to hidden meanings and threats, but in a contentious hostile way.
DSM-IV criteria:
Comorbiditeit van ‘common mental disorders’
Bocking, Ruhe, Spijker & Spinhoven
Comorbiditeit van syndroomstoornissen en persoonlijkheidsstoornissen
Fenomenologie en begeleidende verschijnselen van persoonlijkheidsstoornissen
Persoonlijkheidsstoornissen zijn psychische problemen die zijn ontstaan in de jeugd, en zich in een veelheid van situaties voordoen, waarbij de persoon of diens omgeving leed wordt aangedaan. Dit is persistent, pervasief en pathologisch.
Het denken, voelen en doen van de persoon is egosyntoon.
Persoonlijkheid kan nog veranderen in volwassenheid. De verandering van persoonlijkheidstrekken vind gemiddeld genomen plaats in de richting van betere adaptatie.
Persoonlijkheidsstoornissen zijn geassocieerd met een verlaagde kwaliteit van leven, lager dan bij veel syndroomstoornissen.
Comorbiditeit is meer de regel dan uitzondering bij persoonlijkheidsproblematiek.
Behandelmodellen (sequentieel/parallel/geïntegreerd) voor deze comorbiditeit
Modellen bij de behandeling van comorbide syndroom- en persoonlijkheidsstoornissen zijn: 1) klassieke psychodynamisch, elke syndroomstoornis is het gevolg van onderliggende persoonlijkheidsproblematiek. De behandeling dient zich op de persoonlijkheid te richten 2) Klassieke CGT-denken, ontkende persoonlijkheidsstoornissen aanvankelijk. De behandeling diende zich louter op de syndroomstoornis te richten 3) Stepped care, er wordt begonnen bij de syndroomstoornis. Als deze behandeling niet goed aanslaat of er complicaties ontstaan wordt de patiënt doorverwezen naar een gespecialiseerd behandelprogramma. 4) Geïntegreerde en parallelle behandeling, komen minder voor.
Detectie
Er zijn geen (vroeg)detectie instrumenten voor persoonlijkheidsstoornissen bekend met voldoende sensitiviteit en specificiteit om individueel toe te passen. De hulpverlener moet letten op langdurige dysfunctionele patronen van denken, voelen en doen, die zich ook buiten de syndroomstoornissen manifesteren.
Diagnostisch systeem
Persoonlijkheidsstoornissen zijn in de DSM-5 hetzelfde als in de DSM-IV. Dit is in drie clusters: A, het vreemde, bizarre cluster, gekenmerkt door merkwaardige ideeënvorming. B, het dramatische, impulsieve en emotionele cluster, gekenmerkt door excessieve uitingen van emoties en impulsen. C, het angstige cluster, gekenmerkt door overmatige vrees en vrees-gedreven coping als vermijding, aanklamping en perfectionisme. En er is nog een rest-categorie.
Gespecialiseerde assessment
Voor valide diagnostiek is het noodzakelijk om klinische interviews te gebruiken. Hiermee worden systematisch de criteria van de diagnoses nagegaan. Ze helpen clinici om niet te snel tot een oordeel te komen.
De diagnostiek van persoonlijkheidsstoornissen dient vooraf te gaan door diagnostiek van syndroomstoornissen.
Twee fouten moeten worden vermeden: een syndroom stoornis aan te zien voor een persoonlijkheidsstoornis en een persoonlijkheidsstoornis aanzien voor een syndroomstoornis.
Planning van de behandeling
Bij een comorbide syndroom- en persoonlijkheidsstoornis is het van belang een goed diagnostisch beeld te vormen.
De behandeling wordt meestal vooral gericht op de primaire diagnose. Uit klinische interviews blijkt echter niet altijd welke diagnose primair is.
Om te bepalen waarde behandeling primair op
.....read morePsychoanalyse in vogelvlucht
Wouter Gomperts (2015)
Dynamisch onbewust
Mensen zijn zich maar voor een deel bewust van wat er in hen omgaat.
Censuur is het mechanisme dat verhindert dat bepaalde wensen, gevoelens en gedachten bewust worden. Dit huist in de persoon zelf. Hij of zij verdringt bepaalde dingen omdat ze onverdraaglijk en ondenkbaar zijn. Enkel na vervorming door de censuur kan wat onbewust is tot uitdrukking komen.
Freud spreekt van dynamisch onbewust vanwege het krachtenspel tussen conflictueuze innerlijke krachten. Volgens hem is een neurotisch symptoom een compromisformatie tussen conflictueuze krachten. In het symptoom wordt zowel voldaan aan een onbewuste wens als aan de afkeer hiervan.
Impliciet weten
Onbewuste processen en geheugenprocessen hangen nauw samen.
In de neurocognitieve geheugentheorie wordt er onderscheid gemaakt tussen 1) expliciet, maakt gebruik van talige symbolen en heeft betrekking op feiten, ideeën en autobiografische gebeurtenissen. Heeft betrekking op de hippocampus en de frontale schors. Doordat dit zich pas later ontwikkeld kan het zijn dat meerdere ervaringen in het niet expliciete geheugen worden opgeslagen. 3) impliciet geheugen. In de eerste jaren is dit het enige werkende systeem In de amygdala Komt tot uiting in automatismen in denken, voelen en doen die hun oorsprong hebben in pre-verbale ervaringen
Onbewuste processen manifesteren zich in overdracht. Dit is de (non-verbale) houding van de patiënt tegenover de behandelaar. Tegenoverdracht is de houding van de behandelaar tegenover de patiënt.
Overdracht
Freud had het idee dat in de relatie met de behandelaar wensen, fantasieën, emoties die betrekking hebben op andere personen onbewust worden herhaald en vaak met grote intensiteit worden beleeft aan de persoon van de behandelaar.
Overdracht is zowel weerstand tegen, als manifestatie van het herleven van verdrongen wensen en conflicten. Het is een middel waarvan de weerstand zich bedient én is een krachtig therapeutisch instrument om het ongeweten verleden in het hier en nu van de therapeutische relatie te leren kennen en begrijpen.
De interactie met de therapeut draagt bij aan het creëren van nieuwe betekenissen in het psychisch leven van de patiënt. De therapeut is een nieuw ervaringsobject. Hierdoor kan de patiënt beleven dat er in een relatie andere ervaringen mogelijk zijn dan dat die tot dan toe had. Hierdoor ontstaan nieuwe manier van denken, voelen en doen die ook
.....read more “The Neurobiology of Personality Disorders: Implications for Psychoanalysis”
Siever, Larry J, and Lissa N Weinstein (2009)
Journal of the American Psychoanalytic Association 57, no. 2 361–98. doi:10.1177/0003065109333502
A low threshold for impulsive aggression, as observed in borderline and anti-social personality disorders, may be related to excessive amygdala reactivity, reduced prefrontal inhibition, and diminished serotonergic facilitation of prefrontal controls.
Affective instability may be mediated by excessive limbic reactivity in gabaminergic/glutamatergic/cholinergic circuits. This results in an increased sensitivity or reactivity to environmental emotional stimuli.
Disturbances in cognitive organization and information processing may contribute to detachment, desynchrony with the environment and cognitive/perceptual distortions.
A low threshold for anxiety may contribute to the avoidant, dependent and compulsive personality disorders.
Alterations in critical regulatory domains will influence how representations of self and others are internalized. Aspects of neurobiological functioning become cognized through the medium of figurative language into an ongoing narrative of the self.
Temperamental abnormalities lie at the basis of the personality disorders emerging in the context of a specific experiential developmental trajectory.
Most personality characteristics are influenced by the underlying variability in biological endowments.
Individual differences in temperament along dimensions of affect regulation, impulse control, cognitive organisation, modulation of anxiety, and social information processing may contribute to the unique characterological constellation of each individual.
Temperament influences how an individual internalizes experiences.
This paper is based on a continuum model in which personality is seen as organized around basic psychological dimensions.
Four broad psychological dimensions based on disturbances are: Mood/affect, impulse/action, attention/cognition and anxiety.
These dimensions can be formulated as affective dysregulation or instability, impulsivity, cognitive disorganization and anxiety. Vulnerability to the development of personality disorders is patterned by genes expressing themselves in these dimensions, which are shaped by the environment. Difficulties in some of these domains cluster together and are associated with specific personality disorders.
Within the normal range, individual variations on the four domains will form the template for character traits.
Impulse aggression
Impulsivity/aggression is a lowered threshold for the activation of motoric responses to external stimuli without reflection or appropriate constraint.
Aggression expressed clinically must be understood form the perspective both of the more primitive limbic systems involved in its generation and of the
.....read moreMind, Brain, and Personality Disorders
Gabbard, Glen O.
Am J Psychiatry 162, no. 4 (2005)
648–55. doi:10.1176/appi.ajp.162.4.648
Genes and environment are inextricably connected in shaping human behaviour. Experience shuts down the transcriptional function of some genes, while turning on that of others.
Psychosocial stressors have profound effects of a biological nature by changing the functioning of the brain.
A genetic diathesis acted on by adverse environmental experience is necessary for the development of antisocial personality disorder.
Early psychotherapeutic interventions might serve to influence the expression of genes that lead to antisocial behaviour. Genes and environment are inextricably connected in the pathogenesis of antisocial behaviour.
Early trauma is associated with greater symptoms of borderline personality disorder.
The hippocampus is vulnerable to the effects of stress, in part because it has many glucocorticoid receptors. Adult patients with borderline personality disorder have reduced hippocampal volume.
Early trauma may promote hemispheric lateralization and adversely affect integration of the right and left hemispheres. This may be reflected in the use of splitting as a major defence mechanism in borderline personality disorder.
A consequence of early childhood trauma is persistent sensitization of the hypothalamic-pituitary-adrenal (HPA) axis. This is related to hypersecretion of corticotropin releasing factor (CRF).
The hyperreactive physiological state is relevant to a subgroup of borderline personality disorder patients, but not all.
The capacity to mentalize or have a theory of mind involves being able to recognize that someone else has a different mind from one’s own. Inherent in mentalization are an appreciation and recognition that the perceived state of one’s self and others are fallible and subjective and are representations of reality that reflect only one of a range of possible perspectives.
Mentalization refers to the capacity to represent mental states of the self and other.
Mentalization is created in the context of secure attachment with a caregiver who ascribes mental states to the child, treats the child as a mental agent, and helps the child to create internal working models.
Early childhood trauma leads to
.....read moreHandbook of personality disorders
Chapter 8
Cognitive structures and processes in personality disorders
It is assumed that cognitive structures underlie personality disorders (PDs). These have a more pervasive and permanent character. They are assumed to emerge early in development from the interaction between temperament and environmental influences.
Schemas can be defined as generalized knowledge structures that is represented in memory and governs information processing. They consists of verbal and nonverbal knowledge.
Schemas and information processing constitute the basis for our subjective experience.
Three layers of the beliefs that are part of schemas central to PDs are: 1) unconditional beliefs, represent basic assumptions about the self, others, and the world. 2) conditional assumptions, beliefs about conditional relationships 3) instrumental beliefs, beliefs about how to act to avoid bad things and acquire good things
Patients with PD report elevated levels of specific maladaptive beliefs.
Early maladaptive schemas (EMSs) are thought to arise form experiences during early childhood when basic needs are not met. They are not considered to be related to specific DSM-5 PDs.
Coping styles reflect the way individuals deal with activation of a schemas. Early maladaptive schema-related copings styles are thought to be built on primitive responses that animals exhibit under high levels of threat. Coping responses are grouped into three clusters: 1) overcompensation, fight. The person behaves and thinks in a way that is the opposite of the triggered schema. 2) avoidance, flight. Prevent triggering of the schema, or avoiding the emotions and thoughts that are aroused. 3) surrender, freeze, submitting to what the schema dictates.
Schema mode is the emotional-cognitive-behavioural state of the person. Some schema modes show a specific relationship to certain PDs. A schema mode is a combination of an activated specific EMS and a specific coping style. Sudden switches in schema modes are ‘mode switches’.
In schema therapy, therapist and patient make an idiosyncratic case conceptualization that explains the problems with which the patient is struggling and link these, through these models, to the early experiences that lie at their root. Through the session, the therapist tries to detect what mode is activated, and next chooses among a specific set of techniques developed to deal with that mode.
Schemas that are central to PDs are assumed to develop during childhood from the interaction of biological and environmental influences. Children differ in their innate sensitivity to environmental influences and in how they response to stressors. These
.....read moreIdentifying the Lost Generation of Adults with Autism Spectrum Conditions
Meng-Chuan Lai, and Simon Baron-Cohen (2015)
The Lancet Psychiatry 2
Autism spectrum conditions comprise a set of neurodevelopmental syndromes. They are characterized by early-onset difficulties in social communication and usually restricted repetitive behaviour and narrow interests.
Early diagnosis tend to be made more readily in individuals with severe symptoms and current developmental difficulties. Autism spectrum conditions in people with obvious developmental delay and with more subtle difficulties tend to be recognized later. It might not be recognized until adulthood.
Characteristics of autism spectrum disorder have to be present in early childhood. Interviewing informants who can provide reliable and valid information about the patient’s developmental history is essential to confirm a diagnosis. The quality of such a recall in adulthood might be inaccurate or not detailed enough. Generation effects should be taken into account.
Where informants who were present in childhood are not available, clinicians must rely on current clinical assessments, self-reported history by the patient, school or employment reports, and the observations of an information who has known the patient in adulthood.
Developmental changes complicate recognition of symptoms in adults. Developmental trajectories and outcomes of social communication are far more varied in adolescence and adulthood than in childhood. In adults, judging impairments might be arbitrary, and cultural factors and the fit of the person in his or her environment have important roles.
Under long-term social pressure to fit in, adults with autism spectrum conditions might have developed coping or camouflaging strategies.
Individuals with autism spectrum conditions have high rates of co-occurring psychiatric disorders in childhood, adolescence and adulthood. They also tend to have high rates of co-occurring medical disorders.
Assessment should be considered if an adult shows possible autistic features. This is at least one of the following: 1) difficulty in obtaining or sustaining employment or education 2) difficulty in initiating or sustaining social relationships 3) previous or current contact with mental health or learning disability services 4) a history of a neurodevelopmental or mental health disorder.
Diagnosis is also about how something affects a person’s life. Formal assessment should only be recommended if there is also a clinical indication.
Careful understanding of the individual’s difficulties as perceived by the patient and informants, and a clear delineation of coping strategies that
.....read moreTemperament, Character, and Personality Disorders in Adults with Autism Spectrum Disorder: a Systematic Literature Review and Meta-Analysis
Vuijk, Richard, Mathijs Deen, Bram Sizoo, and Arnoud Arntz. (2018)
doi:10.1007/s40489-018-0131-y.
Autism spectrum disorder (ASD) is associated with an introvert, rigid, passive-dependent temperament with low novelty seeking, high harm avoidance, low reward dependence and high persistence. It Is associated with an immature and poorly developed character with low self-directedness, low cooperativeness, and high self-transcendence.
There is a positive correlation between ASD severity and neuroticism. There is a negative correlation between ASD severity and extraversion, openness to experience, agreeableness and conscientiousness.
There is a positive correlation between ASD and paranoid, schizoid, schizotypal, avoidant, and obsessive-compulsive PDs.
ASD is an impairing neurodevelopmental disorder with social problems as a key symptom. People with ASD show persistent deficits in social communication and social interaction and restricted, repetitive patterns of behaviour, interests and activities.
ASD is associated with cognitive limitations and deficits in social cognition and social perception, executive functions, and bottom-up and top down information processing.
Personality is a complex pattern of deeply embedded psychological characteristics that are largely unconscious, cannot be eradicated easily, and express themselves automatically in almost every facet of functioning. These traits emerge from a complicated matrix of biological dispositions and experiential learnings.
Temperament is close to biological substrates. Character is influenced by social-cultural factors.
Temperament is those aspects of an individual’s personality that are often regarded as the result of biological evolution, initially constitutionally based rather than learned. It is a combination of 1) a certain level of activity 2) a tolerance for feelings 3) a certain degree of vitality 4) a certain degree of extraversion/introversion.
A baby shapes his environment with his temperament and this temperament is influenced by the environment.
The interaction between temperament and social environment influences the formation of character.
Character is theorized as less heritable, later developing, influenced by processes of maturation, and representing individual differences in self-object relationships.
Character includes the following: self-directedness, cooperativeness and self-transcendence.
Personality disorders are associated with ways of thinking and feelings about oneself and others,
.....read moreHandbook of personality disorders
Chapter 23
Clinical features of borderline personality disorder
The borderline personality disorder suffers from heterogeneity and fuzzy boundaries.
Critics of borderline personality disorder would like to define it as a variant of mood disorder. This is based on symptoms of affective instability. But this is not consistent with research literature. Patients with borderline personality disorder experience continually abnormal mood for years, may in a different mood from hour to hour, are likely to have every mood, and have a different neurobiological profile than bipolar disorder. Mood symptoms are only one of the primary symptoms of borderline personality disorder.
Patients with borderline personality disorder do not have manic or hypomanic episodes.
One-third of people with borderline personality disorder develop symptoms without experiencing serious childhood adversity.
In the DSM-5, nine criteria for borderline personality disorder are listed, with five required to make a diagnosis. These criteria include 1) affective symptoms 2) impulsive symptoms 3) interpersonal problems 4) an unstable identity 5) cognitive symptoms
The most characteristic symptom of borderline personality disorder is affective instability. Hypersensitivity to the environment leads to rapid changes of mood in response to interpersonal events, with slow recovery from distress. This doesn’t fully account for the disorder.
Other characteristic behaviours are chronic and recurrent overdoses and/or self-harm. These are usually precipitated by interpersonal conflict.
Suicidality in borderline personality disorder is a way of being heard when one does not see any other way for a message to get through.
Patients with borderline personality disorder have a pattern of unstable close relationships that involve clinging attachment, fear of abandonment, and intense conflict with intimate partners.
Some patients with borderline personality disorder experience hallucinations. They do not develop delusional elaborations of these experiences.
Borderline personality disorder can best be understood in the light of diathesis-stress theory. Temperamental vulnerability is a necessary condition. These make people more sensitive to their environment and produce vicious cycles in which negative perceptions of other people lead to further instability.
The majority of people with borderline personality disorder report childhood adversities. Childhood adversities by themselves do not necessarily lead to borderline personality disorder.
Borderline personality disorder usually becomes clinically apparent during adolescence.
.....read moreTextbook of child and adolescent mental health
Chapter 4
Borderline personality disorder
Borderline personality disorder is characterized by a pervasive and persistent pattern of instability and impulsivity.
Prevalence
Prevalence of borderline personality disorder is estimated to be between 0.7 and 1.8%.
Gender and culture
Prevalence in the general population is considered to be similar for both gender. In clinical samples, females represent three quarters of all patients.
Thresholds for each criteria in the DSM may differ depending on their and their patient’s culture.
Burden of illness
The consequences of borderline personality disorder for the people around the sufferer depend on their vulnerability to the behaviour and demands of borderline personality disorder patients.
Patients with borderline personality disorder are exposed to risks due to impulsivity. Instability in emotional and inter-personal relationships leads to communication problems.
A diagnosis should not be made before the age of 18 years. Diagnosis is made earlier when symptoms are clear and persistent.
Remission is common. Remission is in most cases a reduction of the number of symptoms below the diagnostic threshold. There appear to be two clusters of symptoms: 1) stable and persistent, anger, feelings of abandonment 2) unstable or less persistent, self-harm and suicide attempts.
The risk of dead by suicide is between 4 and 10%.
The cause of borderline personality disorder is unknown.
Repeated childhood trauma is a frequent element in borderline personality disorder.
Early maternal separation is associated with both borderline personality disorder and the persistence of borderline personality disorder symptoms over time.
Inheritance of borderline personality disorder is polygenic.
Subtypes
Subtypes of borderline personality disorder may be defined by the comorbidities.
Some researchers propose two subtypes: 1) dependent, characterized by ambivalent, unstable relationships 2) impulsive, characterized by impulsive acts in multiple areas.
Presenting symptoms
Presentations are often prompted by another psychiatric problem, problematic behaviour, or relationship problems.
From a categorical to a dimensional concept of borderline personality disorder
For a dimensional diagnosis of borderline personality disorder, the following would be required: 1) significant
.....read moreOxford Textbook of Psychopathology
Chapter 26
Antisocial personality disorder and psychopathy
ASPD in DSM-5
The categorical diagnostic criteria for ASPD in DSM-5 are polythetic, only a proportion need to be met.
Child criteria for ASPD include: 1) aggressive and destructive behaviours 2) deceitfulness/theft 3) non-aggressive rule-breaking acts.
The adult criteria for ASPD include: 1) one aggression-specific criterion, irritability/aggressiveness 2) three clearly nonaggressive criteria, deceitfulness, impulsivity, irresponsibility 3) three nonspecific criteria, failure to conform to norms with respect to lawful behaviours, reckless disregard for safety of self or others, lacks remorse.
Disinhibition entails tendencies toward impulsivity, irresponsibility, and deceitfulness. Aggressive disregard entails irritability or aggressiveness and behaviours indicative of recklessness and lack of concern for self and others.
The characterisation of personality pathology according to the alternative dimensional-trait approach (not used in DSM-5) entails two steps 1) assessment of the presence of personality disturbance, as indicated by dysfunction of areas of self and social relations 2) designation of the specific nature of personality pathology, in terms of elevations on PD-relevant traits with five thematic domains.
The estimated prevalence of ASPD in the general community is 2% (for men 3% and for women 1%).
The prevalence of ASPD in clinical (forensic) settings has a 50-80% rate.
ASPD sows patterns of comorbidity, in particular with substance use disorders. They show common personality correlates, namely: impulsiveness and aggressiveness.
There might be an heritable basis to a general externalizing factor. This may be different expressions of a general factor.
Neurobiological correlates
Antisocial individuals show evidence of reduced levels of serotonin. Reduced serotonergic modulation of appetitive urges and negative emotional reactions may account in part for the lack of inhibitory control.
Autonomic hypoarousal has been interpreted as reflecting dispositional sensation-seeking tendencies.
Reduced P300 response (a positive cortical potential), has been observed in relation to various specific impulse control problems. It is an indication of an general externalizing factor.
Oxford Textbook of Psychopathology
Chapter 30
Narcissistic personality disorder and pathological narcissism
The DSM-5 NPD diagnosis exemplifies the conceptualization of pathological narcissism as excessive grandiosity.
Criteria for NPD in DSM-5
The DSM-5 criteria for NPD describe the following symptoms: 1) the person with NPD has an inflated sense of self-worth 2) is preoccupied with fantasies of unlimited influence, achievement, intelligence, attractiveness, or romance 3) believes that he or she is extraordinary or distinctive and can only be understood by, and should only associate with, other unusual or elite status people or institutions 4) requires excessive respect, appreciation and praise 5) has a sense of privilege and due 6) is willing to use and take advantage of others for personal gain 7) lacks compassion 8) is often jealous of others or believes that others are jealous of him or her 9) exhibits conceited, self-aggrandizing behaviours and attitudes.
The diagnosis reflects chronic expression of excessive or extreme grandiosity.
Prevalence
It is the least commonly diagnosed PD. Prevalence of NPD ranges from 0-5.7%.
Stability
The temporal stability of NPD is modest.
Discriminant validity of NPD criteria
The discriminant validity of NPD against other PD’s is poor.
Comorbidity
NPD exhibits the highest rates of comorbidity with antisocial and histrionic PDs. There are also comorbidities with symptom disorders. Diagnoses that most strongly predicted comorbid NPD are: bipolar I disorder, anxiety disorders, drug dependence, post-traumatic stress disorder, mood disorders and substance use disorders.
NPD research
Research on NPD is rare because of the low prevalence.
Patients with NPD exhibit deficits in emotional empathy but not cognitive empathy.
Patients with NPD have smaller gray volume in the left anterior insula and in frontoparalimic brain regions comprising the rostral and median cingulate cortex and the dorsolateral and medial parts of the prefrontal cortex.
Patients with NPD show a specific deficit for emotions representing fear and disgust. They do not have lower explicit self-esteem.
There are no empirically validated treatments for NPD.
Critiques for NPD
The lack of research on patients with NPD renders the validity and clinical utility of the diagnosis questionable.
The low prevalence of NPD reported in large-scale epidemiological studies are lower than the rates being treated in psychotherapy. It may be that there is a lack of sufficient NPD criteria.
.....read morePersonality disorders
Chapter 7
(part of) The narcissistic and histrionic personality disorders
Histrionic personality disorder and gender
Histrionic PD is a predominantly female disorder.
Histrionic personality disorder as seen through assessment instruments
People with histrionic PD have an elevation on a mania scale, ad a lower score on social introversion. These findings are characteristic of more energetic, expansive individuals who are not bothered by uneasiness or shyness in social situations.
Histrionic PD is characterized by a lower trait level of altruism, and on the facet level, elevated scores on gregariousness, feelings, warmth, and tendermindedness. This suggests and emotionally expressive, outgoing person who is also self-centred and rather superficially engaged in relationships.
Treatment issues
The course and prognosis of histrionic PD will largely depend on its severity and comorbidity. More extreme versions will be harder to treat. When concurrent features of antisocial PD and narcissistic PD are present, treatment gains will be harder to achieve.
The Oxford Handbook of Personality Disorders
Chapter 23
Dependent personality disorder
Dependent personality disorder is associated with an array of negative outcomes. It is also associated with increased adaptation in a variety of areas 1) sensitivity to subtle interpersonal cues 2) decreased delay in seeking medical help following symptom onset 3) conscientious adherence to medical and psychological treatment regimes.
Descriptive psychiatry and psychoanalysis
In classical psychoanalytic theory, dependency is inextricably linked to events that occur during the first months of life (the oral state). Frustration or over gratification during the infantile, oral phase was thought to result in oral fixation and an inability to resolve the developmental issues that characterize this period (conflicts regarding dependency and autonomy). Research regarding this has produced weak results.
DSM-IV/DSM-IV-R
The essential feature of dependent personality disorder in the DSM-IV and DSM-IV-R is ‘a pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning in early adulthood and present in a variety of contexts’.
The DSM-IV list eight specific symptoms. The patient must meet criteria for five of these symptoms to qualify for a dependent personality disorder diagnosis. 1) difficulty making everyday decisions without excessive advice and reassurance 2) needing other people to assume responsibility for most major areas in life 3) difficulty expressing disagreement because of fear of loss of support or approval 4) difficulty initiating projects or doing things on one’s own 5) going to excessive lengths to obtain nurturance and support from others 6) feeling uncomfortable and helpless when alone 7) urgently seeking another relationship as a source of care and support when a close relationship ends 8) being unrealistically preoccupied when fears of being unable to care for oneself
Empirical evidence regarding these criteria is mixed. And none of the symptoms include mention of the central cognitive feature of dependency, a perception of oneself as powerless and ineffectual.
The PDM
In the Psychodynamic diagnostic manual, dependent personality disorder is described in terms of dependent individuals’ tendency to ‘define themselves mainly in relation to others and seek security and satisfaction predominantly in interpersonal contexts’. Dependency must be evaluated with sensitivity to cultural and subcultural contexts.
The PDM is descriptive. It does
.....read moreThe Oxford Handbook of Personality Disorders
Chapter 25
Avoidant personality disorder
Avoidant personality disorder (AVPD) is characterized by a desire for affiliation coupled with a sense of personal inadequacy and intense fears of interpersonal rejection. A heightened sensitivity to criticism and expected condemnation by others are key features of AVPD.
Approximately 1.6% of individuals suffer from AVPD.
DSM-IV-TR definition and criteria
AVPD is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
At least four of any of the seven criteria to meet the diagnostic threshold for AVPD: 1) Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval or rejection. 2) is unwilling to get involved with people unless certain of being liked 3) shows restraint within intimate relationships because of the fear of being shamed or ridiculed. 4) is preoccupied with being criticized or rejected in social situations 5) is inhibited in new interpersonal situations because of feelings of inadequacy 6) views self as socially inept, personally unappealing, or inferior to others 7) is unusually reluctant to take personal risk or to engage in any new activities because they may prove embarrassing.
Avoidant personality disorder and DSM diagnostic co-occurrence
Comorbidity of AVPD is the norm.
Disorders frequently co-occurring with avoidant personality disorder
AVPD frequently co-occurs with a spectrum of anxiety and depressive disorders.
Avoidant personality disorder and social phobia
The DMS diagnosis of social phobia is characterized by a fear or avoidance of social situations that is presumably more circumscribed than AVPD. But, there is considerable overlap, it is more likely to be a continuum..
Personality traits may be an important distinction.
Other comorbide dsm conditions
Another personality disorder that overlaps or may share features with AVPD is dependent personality disorder. The key distinction is that AVPD is driven by fear of being rejected.
Avoidant personality disorder and the five-factor model
Two domains that are relevant to AVPD are (high) neuroticism and (low) extraversion. Neuroticism is composed of the facets: anxiety, angry hostility, depression, self-consciousness, impulsiveness and vulnerability.
Extraversion is composed of the facets: warmth, gregariousness, assertiveness, activity, excitement
.....read moreThe Oxford Handbook of Personality Disorders
Chapter 26
Obsessive-compulsive personality disorder
Early psychoanalytical perspectives
Freud hypothesized that orderliness, parsimony and obstinacy were either sublimations of. Or reaction formations against, anal-erotic instincts of childhood. This is without empirical support.
Early psychoanalysts provided rich clinical descriptions of what would later become known as compulsive or obsessive-compulsive personality disorder. Several of the traits were incorporated into later diagnostic criteria.
The diagnostic and statistical manual of mental disorders and revisions
DSM-IV and DSM-IV-TR specified the essential feature of obsessive-compulsive personality disorder as ‘preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. An individual must have at least four of the eight criteria in order to meet the diagnosis.
Obsessive-compulsive personality traits in moderation may be especially adaptive, particularly in situations that reward high performance.
International classification of diseases
The equivalent of obsessive-compulsive personality disorder in the ICD-10, is anankastic personality disorder. Criteria are: 1) preoccupation with details, rules, list, order, organisation or schedule 2) perfectionism that interferes with task completion 3) excessive conscientiousness and scrupulousness 4) undue preoccupation with productivity to the exclusion of pleasure an interpersonal relationships 5) rigidity and stubbornness 6) unreasonable insistence by the individual that others submit to exactly his or her way of doing things 7) feelings of excessive doubt and caution 8) excessive pedantry and adherence to social conventions.
Epidemiology
Estimates about the prevalence of obsessive-compulsive personality disorder range from 1.6-2.5%.
The prevalence in men and women is similar. The prevalence s greater in older age groups.
Comorbidity
Anxiety and mood disorders
Patients with OCPD had higher prevalences of anxiety disorder, social phobia, obsessive-complusive anxiety disorder and mood disorder.
Obsessive-compulsive disorder
Neuroticism and OCPD may be alternative expressions of the same underlying vulnerability in at least some families with OCD.
Eating disorders
OCPD has been found to be the most common personality disorder in patients with eating disorders.
Co-occurrence with other personality disorders
There is considerable diagnostic overlap between OCPD and other personality disorders. There are significant correlations with: avoidant PD, dependent PD, paranoid PD and borderline PD.
More than half the patients with OCPD had a co-occurring personality disorder.
Functional impairment
A substantial proportion of patients with OCPD show evidence of functional
.....read morePersonality Disorders: Toward the DSM-V
Chapter 3
Paranoid personality disorder
Paranoid personality disorder (PPD) is characterized by a mistrust of other people. Other features include: quarrelsomeness, hostility, emotional coldness, hypersensitivity to lights of criticism, stubbornness and rigidity held maladaptive beliefs of others’ intents.
The underlying assumption is that other are malevolent. Measures must be taken to protect oneself.
People with paranoid personality disorder tend to hold grudges, have enemies are often litigious, and can be pathologically jealous.
Paranoid personality disorder exemplifies one extreme pole of the agreeableness-antagonism dimension of the five-factor model of personality.
The pattern of antagonistic behaviour often causes difficulties in interpersonal relationships. It may provocate the kinds of attacks these individuals fear.
People with paranoid personality disorder are usually not psychotic, although they may experience transient psychotic-like symptoms under conditions of extreme stress. The beliefs in paranoid personality disorder are rarely of psychotic proportions.
Unlike PPD, paranoid schizophrenia and delusional disorder involve frank delusions, false beliefs of psychotic proportions. Such beliefs are not always evident.
People with PPD sometimes develop transient delusions when under extreme stress.
Schizotypal individuals display odd or eccentric ideas, peculiar thinking or speech, unusual perceptual experiences and other ‘schizophrenia-like’ features that are not seen in PPD.
Schizoid individuals are socially withdrawn because of a preference of being alone rather than a desire to protect themselves from imagined threats.
Outstanding issues
PPD patients are seen in a variety of clinical populations, and they can pose special problems for treatment when their mistrust affects the therapeutic relationship.
Some PPD patients can achieve good outcomes when they are given treatments appropriate to their problems.
Are the DSM-IV criteria for PPD valid descriptions of the disorder?
A long-standing debate, centres on the question of whether less severe paranoid disorders, such as PPD and delusional disorder, lie on a genetic continuum with schizophrenia, of whether it is a distinct spectrum.
The DSM-IV criteria for PPD appear to overrepresent the cognitive PPD trait mistrust/suspiciousness and to underrepresent the prototypical behavioural, affective, and interpersonal expressions of paranoid personality traits. Nearly all of the DSM-IV PPD criteria reflect the cognitive trait of mistrust. Three reflect the affective/interpersonal trait of hypersensitivity. Two reflect the affective/interpersonal trait of anatognism. Two reflect the cognitive trait of hypervigiliance. One reflects
.....read morePersonality Disorders: Toward the DSM-V
Chapter 4
Schizoid personality disorder
Schizoid personality disorder (SCPD) is distinguished from the other two personality disorders in the ‘odd/eccentric’ cluster by the prominence of social, interpersonal and affective deficits in the absence of psychotic-like cognitive/perceptual distortions.
Prevalence
Schizoid personality disorder is among the least frequently observed of the personality disorders. This may be due to the uncommon appearance of schizoid individuals in clinical settings.
Schizoid personality disorder may be first apparent in late childhood. This is a period in which cooperative play is in ascendance, and the social isolation becomes more salient.
The disorder is more common in men.
DSM-IV-TR criteria for schizoid personality disorder
The DSM-criteria for schizoid personality disorder are: a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four of the following: 1) neither desires nor enjoys close relationships 2) almost always chooses solitary activities 3) has little, if any, interest in having sexual experiences with another persons 4) takes pleasure in few, if any, activities 5) lacks close friends or confidants other than first-degree relatives 6) appears indifferent to praise or criticism from others 7) behaviour or appearance that is odd, eccentric or peculiar.
Psychometric properties
The internal consistency of measures of schizoid personality disorder is poor.
The highest co-occurrence of schizoid personality disorder is with schizotypal personality disorder. This might be due to the high overlap between the two criteria sets. Another high comorbid disorder is avoidant personality disorder. Lesser degrees of comorbidity are demonstrated with paranoid, antisocial, and borderline personality disorder.
Schizoid and avoidant personality disorder
Some studies suggest that schizoid personality disorder can be distinguished from avoidant personality disorder on the basis of intimacy needs and sensitivity to rejection. But, anxiety and clinical symptoms occur in both disorders.
Research literature has demonstrated poor discriminant validity between schizoid personality disorder and avoidant personality disorder.
Schizoid personality disorder and Asperger’s syndrome
There is significant overlap in the phenomenological criteria for schizoid personality disorder and asperger’s syndrome.
The clinical presentation of the two disorders is different. Autism becomes evident between two and three years of age when
.....read morePersonality Disorders: Toward the DSM-V.
chapter 5
Schizotypal personality disorder
The DSM-IV diagnostic criteria for schizotypal personality disorder (SPD) include attenuated versions of the defining features of schizophrenia.
Prevalence of SPD
The prevalence of schizotypal personality disorder in the general population is 3%, according to the DSM-IV.
The concept of SPD hinges on its genetic link with schizophrenia.
SPD and schizophrenia share common features such as: odd beliefs, social impairment and abnormalities in perceptual experiences and emotional expression.
SPD criteria specify an attenuated version of the psychotic symptoms necessary for a schizophrenia diagnosis.
SPD and schizophrenia share a genetic liability. Environmental factors also play a key role.
The relationship between negative expressed emotion in family members and poor outcome in patients appears to be bidirectional.
The developmental link between SPD and schizophrenia
SPD and schizophrenia share a developmental link.
SPD signs, and even the full SPD syndrome, often predate the onset of schizophrenia.
Those who meet criteria for SPD show functional deficits and physical abnormalities that parallel those observed in schizophrenia, although the magnitude of the deficits typically is less severe in SPD.
Cognitive functioning
Adults who meet the criteria of SPD show: general cognitive impairment, including deficits in verbal fluency, learning and retention, deficits in sustained attention and mixed findings in respect to executive functioning.
Motor and physical correlates of SPD
Individuals with SPD manifest abnormalities in motor functions.
Psychophysiology
There are abnormal psychophysiological responses in both schizophrenia and SPD. Abnormalities have been found in prepulse inhibition, heart rate, electrodermal activities, and other autonomic nervous system-controlled responses.
Structural brain abnormalities
SPD patients have larger ventricular volumes, reduced cortical gray matter volumes, and smaller temporal lobes.
Functional brain abnormalities
Individuals with SPD manifest functional brain abnormalities, particularly in the frontal and temporal regions.
Neurochemistry
There are elevated dopamine levels in SPD that mimic the pattern found in schizophrenia. SPD adolescents manifest elevated cortisol levels.
Cognitive Therapy of Personality Disorders
Chapter 1
Overview of cognitive-behavioural therapy of personality disorders
According to the Big Five model, human personality is composed of five factors: openness, conscientiousness, extraversion, agreeableness and neuroticism.
Each factor includes a variety of more specific personality traits.
The cognitive-behavioural therapy (CBT) framework/paradigm has a set of interrelated theoretical principles.
Among CBT psychological treatments there are 1) acceptance and commitment therapy 2) dialectic behaviour therapy 3) schema therapy 4) cognitive therapy 5) rational-emotive behaviour therapy.
CBT doesn’t treat personality disorder symptoms as an expression of an underlying illness, but as learned human responses to specific or general stimuli. The cognitive component is often prompted as a preliminary ‘cause’ of the disorder. This doesn’t mean that the causality is unidirectional. Al types of responses are strongly interrelated, forming a multidimensional interactive psychological structure.
The general ABC model of CBT is: 1) A, activating event, whether external and/or internal 2) B, beliefs 3) C, consequences: emotional, behavioural and psychophysiological.
Once generated, a consequence can become a new activating event, thus further priming metabeliefs/secondary beliefs that generate metaconsequences/secondary consequences.
Cold cognitions are descriptions of reality and the individual’s interpretations/inferences. Hot cognitions refer to how we evaluate/appraise these descriptions and inferences about reality. Both can be more surface beliefs or core beliefs.
The sequence of CT typically focuses first on automatic thoughts and later on core beliefs. At some point, CT focuses on activating events by problem-solving strategies and/or on the consequences of the beliefs by behavioural and/or coping techniques. The interactive nature of the core elements is different for each individual.
REBT focuses on altering dysfunctional consequences by changing irrational beliefs first and then, on changing cold cognitions. The process is first focuses on the surface beliefs in forms of specific irrational self-statements and later on general irrational core beliefs. After the cognitive restructuring process, REBT would focus on the other components.
Integrative multimodal CBT framework
According to the integrative and multimodal CBT framework, there are two types of core beliefs 1) Related to core cognitions, the general core beliefs coded in the human mind as general schemas 2) Hot cognitions, general irrational core beliefs coded in the mind as evaluative schemas.
These cold
.....read moreCognitive Therapy of Personality Disorders
Chapter 5
General principles and specialized techniques in cognitive therapy of personality disorders
Patients with personality disorders frequently continue to perceive themselves or their experiences in problematic ways and may acknowledge that they have ‘always’ thought this way, even though they no longer feel as depressed or anxious as the disorder subsides.
The personality disorder mode differs from the symptom disorder mode in a variety of ways: 1) the frequency and intensity of dysfunctional automatic thoughts observed during the acute disorder level off when patients return to their regular cognitive functioning 2) Although the patients may have fewer dysfunctional automatic thoughts and feel less distressed overall, their exaggerated or distorted interpretations and the associated disruptive affect continue to occur in specific situations
The most plausible explanation for the difference between the syndromes and the personality disorders is that the extreme faulty beliefs and interpretations characteristic of the symptomatic disorders are relatively plastic. The more persistent dysfunctional beliefs of the personality disorder are structuralized, built into the ‘normal’ cognitive organization and embedded in primal schemas.
The dysfunctional beliefs remain operative because they form the substrate for patients’ orientation to reality. People rely on their beliefs to interpret events, so they cannot relinquish these beliefs until they have incorporated new adaptive beliefs and strategies to take their place.
When patients return to their premorbid level of functioning, they rely on their customary strategies, keeping the underlying beliefs activated through interconnected networks.
Specific individual conceptualization that is data based and collaborative in nature is essential for understanding the patient’s maladaptive behaviour, selecting effective treatment strategies, and modifying dysfunctional attitudes.
The therapist should engage the patient early on in codeveloping a formulation to explain the nature and source of the patient’s difficulties. Much of the data will come from discussions about the patient’s current life situation, and the problems that precipitated treatment consultation. The therapist also gathers data about the patient’s general developmental history. Direct interaction with and observation of the patient in the course of consultation is also an important source of data.
In a therapeutic triad model, the therapist simultaneously integrated attention to the developmental narrative, current life problems, and the treatment relationship. Specific techniques will vary with the goals specific to the disorder and the person. The therapist can approach the work of conceptualization and intervention as a fluid movement among these spheres to assist the patient in identifying and
.....read moreHandbook of Personality Disorders
Chapter 29
Dialectical behaviour therapy
Dialectial behaviour therapy (DBT) is developed to address the skills deficits of individuals with borderline personality disorder, as well as the issues that lead therapist frequently to get stuck.
DBT is rooted in the principles of behaviour therapy including 1) a strong emphasis on ongoing data collection during treatment 2) clearly defined target behaviours 3) a collaborative therapist-patient relationship 4) the use of standard cognitive and behavioural treatment strategies.
DBT has an emphasis on dialectics. The fundamental dialectic is the need for both acceptance and change. The therapist needs to fully accept the patient as (s)he is and at the same time persistently push for and help the patient to change. The therapist also tries to develop and strengthen an attitude of acceptance toward reality on the part of the patient, as well as the motivation and ability to change what can be changed.
The fundamental treatment dialectic of acceptance and change is expressed through validation and problem solving.
DBT involves a dialectic of communication style between reciprocal, warm interpersonal style and a more irreverent style.
There is a dialectic in case management between consultation to the patient to help manage his or her environment and direct environmental intervention by the therapist.
Scope and focus: Domains of psychopathology
DBT addresses problems associated with pervasive emotion dysregulation.
DBT consists of five stages: 1) Pretreatment 2) control 3) order 4) synthesis 5) transcendence.
Each session agenda is based on the patient’s behaviour since the last session. It is the therapist’s responsibility to remain mindful of treatment goals and to ensure that patient treatment activities are directed toward creating a life worth living.
Pretreatment
The objectives of this stage are 1) To orient patients to the philosophy and structure of treatment 2) for therapist and patient to reach agreement on the goals of treatment.
If patients are currently engaging in suicidal or other self-harming behaviours, they must agree that reducing or eliminating such behaviour is the first priority. Patients must agree not to kill themselves while they are on DBT. Explicit patient agreement is necessary prior to full participation in treatment.
With patients who express reluctance to commit to DBT goals, ongoing pretreament focuses on commitment-enhancing strategies.
Stage 1: from behavioural dyscontrol to stability and behavioural control
For patients who enter treatment with
.....read moreHandboek borderline persoonlijkheidsstoornis
Hoofdstuk 5.3
Transference-focused psychotherapie
Transference-focused psychotherapie (overdrachtsgerichte psychotherapie) is een intensieve psychodynamische psychotherapie gebaseerd op objectrelationeel denken.
Het uitganspunt is dat mensen sociale wezens zijn en dat hun persoonlijkheidsstructuur zich sociaal ontwikkeld in relatie tot hun primaire objecten (meestal ouders). Hier verandering in krijgen vereist een interactioneel proces waarbij de behandelaar zijn eigen gevoelsleven inzet. Zowel de pathologie als de remedie voltrekt zich in de interactie. De therapeut probeert de analyseren hoe de cliënt de wereld, zijn belangrijke anderen ervaart.
De therapie heeft als doel dat de innerlijke wereld van de cliënt (meestal met borderline) meer geïntegreerd raakt.
In het psychoanalytische denken wordt observeerbaar gedrag beschouwd als een afspiegeling van een onderliggende structuur. Dit is een stabiele en constante configuratie van mentale functies/processen die het gedrag en de subjectieve beleving van een individu organiseren. Symptomen en lijden worden gezien als het gevolg van onbewuste innerlijke conflicten.
De kern van TFP is het volgende. Primaire affectieve krachten (driften) worden van jongs af aan niet beleefd, maar altijd in relatie tot een specifieke ander (het object). Het gaat om het verlangen naar hechting versus het streven naar autonomie. In de objectrelatietheorie worden ‘interne objectrelaties’ gezien als de basiselementen van de psychologische structuur. Een geïnternaliseerde objectrelatie bestaat uit een beeld (representatie) van een interactie tussen het zelf en een ander en de verbindende affectieve toestand.
Interne objectrelaties vormen zich vanaf de geboorte uit twee elementen: 1) de aangeboren affectieve disposities van de baby 2) de interacties met primaire verzorgers.
Als een affect regelmatig wordt ervaren in de context van een specifieke interactie, dan raken de affectieve herinneringen georganiseerd tot duurzame, affectief geladen representaties. Dit zijn interne objectrelaties.
De vroegst gevormde interne objectrelaties zijn dynamisch, ze bestaan uit twee representaties. Later ontstaan ook relaties met meer partijen.
Een normale, stevige, coherente identiteit omvat de subjectieve ervaring van een stabiel en realistisch gevoel over het zelf en anderen. Een pathologisch verlopen identiteitsformatie leidt tot een instabiel, gepolariseerd en onrealistisch gevoel over zelf en anderen. Dit leidt tot ruwe, intense en niet-gemoduleerde affecten met vooral een negatieve kleur.
In de ontwikkeling worden aanvankelijk positief en negatief geladen affectieve ervaringen actief van elkaar gescheiden gehouden. Normaal gesproken integreert dit gaandeweg. Onvoldoende koestering en onvoldoende grenzen kunnen zorgen dat gespleten werelden blijven bestaan. De neiging om
.....read moreNieuwe ontwikkelingen in de Transference-focused psychotherapie
Draijer (2015)
Transference-focused psychotherapie (TFP) is ontwikkeld voor mensen met een borderline-persoonlijkheidsorganisatie (BPO). De borderline persoonlijkheidsorganisatie stamt uit objectrelationeel denken. Hier is in de borderline-persoonlijkheidsorganisatie de identiteit gespleten (de cliënt opereert in zwart-of-wit termen), de domenante afweer is onrijp en de realiteitstoetsing meestal intact.
Mensen met de borderline persoonlijkheidsorganisatie voelen zich verscheurd door hun verlangen naar nabijheid en hun verlangen naar autonomie. Het wordt beleeft als of-of. Ook ervaren zij zichzelf als wisselend alleen goed of alleen slecht.
Het doel van TFP is de integratie van de gespleten organisatie van de binnenwereld en identiteit, zodat men ambivalenties kan verdragen en kan leven met beperkingen van zichzelf en anderen (van of-of naar en-en).
De behandeling start met contractafspraken waarin het ageren begrensd wordt, dit houd het gevoel op een afstand. Een voorwaarde voor TFP is dat de cliënt toegezegd er alles aan te zullen doen om het ageergedrag niet te vertonen, als er neiging of sprake van het gedrag is moet dit als eerste worden besproken in de eerstvolgende zitting.
Het contract dient ook als het frame van de behandeling. Deze afspraken kan aan worden gerefereerd om moralisme binnen de behandelrelatie te voorkomen en het gevoel te kunne analyseren.
De belangrijkste interventies zijn: 1) Clarificatie, opheldering vragen 2) het benoemen van de dyade in de overdracht, de zelf, objectrepresnetatie en het verbindend affect 3) confrontatie, benoemen wisselingen tussen dyades 4) interpretatie, met elkaar in verband brengen van tegengestelde dyades.
Het centrale mechanisme van verandering in TFP is de integratie van gepolariseerde affectieve toestanden en afgesplitste representaties van zelf en anderen. Deze integratie begint op gang te komen als een therapeut de negatieve overdracht zo goed mogelijk containt (meekijkt) en empathisch begrijpt en zo teruggeeft aan de cliënt. De combinatie van de negatieve overdracht me de positieve ervaring van zich goed begrepen voelen werkt integrerend.
Interpretatie is een proces. Het begint met het signaleren en benoemen van de overdrachtsconstellatie, de dyade, waarin de cliënt de behandelaar een bepaalde rol toedicht binnen een voor hem relevant kader.
TFP is alleen op werkzaamheid onderzocht bij borderlinepatiënten. In twee RCT’s was TFP beter dan de vergelijkingscondities in werkzaamheid.
TFP is een effectieve behandeling die in één jaar tot verbetering leidt.
TFP laat een structurele verandering zien in persoonlijkheidsstructuur.
Handbook of Personality Disorders
Chapter 30
Mentalization-based treatment
Mentalizing is the capacity to understand ourselves and others in terms of intentional mental states. It includes an awareness of mental states in oneself or in other people, particularly when it comes to explaining behaviour. It involves a spectrum of capacities 1) the ability to see one’s own behaviour as coherently organized by mental states 2) to differentiate oneself psychologically form others.
The capacity to mentalize emerges in the context of early attachment relationships. This is a key determinant of self-organization and affect regulation.
The role of mentalizing should be understood as a central element of child social development.
The account of mentalizing and psychopathology focuses strongly on the development of the systems for social processes. These drive many higher-order social-cognitive functions underpinning interpersonal interactions. Four of these functions are of primary importance in understanding many severe personality disorders: 1) Affect representation and related affect regulation 2) Attentional control 3) The dual arousal involved in maintaining an appropriate balance between mental function undertaken by the anterior and posterior posterior portions of the brain 4) mentalization.
These capacities emerge in the context of the primary caregiving relationships experienced by the child. They are affected by the quality of the child’s social context. The developmental achievement of these capacities is particularly vulnerable to extremes of environmental deficiency.
MBT is organized around the development of an attachment relationship with the patient. It offers a careful focus on the patient’s internal mental processes, primarily of affect, as they are experienced moment by moment. It emphasizes the therapeutic relationship following principles of marking and contingency of affect states, with the active repair of ruptures in the relationship.
The emphasis is on identifying the context in which serious breaks in mentalizing occur, with the aim of restoring mentalizing and eventually enabling he patient to maintain mentalizing. The core to this process is exploring mentalizing problems within the context of the individual attachment experiences that are activated within the patient-clinician relationship.
Basic principles and procedures of MBT are: 1) collaborative process 2) formulation of
.....read moreHandboek Schematherapie
Hoofdstuk 3
Theoretisch model: schema’s, copingstrategiën en modi
Vroeg ontstane disfunctionele schema’s
Vanaf de eerste levensjaren worden ervaringen opgeslagen in ons autobiografisch geheugen in de vorm van schema’s. Zij omvatten de zintuigelijke waarnemingen, de ervaren emoties en handelingen en de betekenis die eraan is verleend. Vroegkinderlijke ervaringen worden op niet-verbale wijze opgeslagen.
Schema’s functioneren als filters waarmee mensen de wereld om zich heen ordenen, interpreteren en voorspellen.
De meeste mensen hebben schema’s ontwikkeld die hen helpen zichzelf en het gedrag van anderen en gebeurtenissen in de wereld beter te begrijpen. Dit stelt hen in staat een positief zelfbeeld en een genuanceerd beeld van anderen te ontwikkelen en om adequaat problemen op te lossen.
Mensen met persoonlijkheidsproblematiek hebben disfunctionele schema’s ontwikkeld.
Disfunctionele schema’s ontstaan op jonge leeftijd door de wisselwerking van het temperament van het kind, de opvoedingsstijl en de ouders en significante ervaringen. Disfunctionele schema’s weerspiegelen onvervuld emotionele behoeften van het kind. Het zijn aanpassingen aan negatieve ervaringen, gebrek aan liefde en warme, inadequate ouderlijke zorg en steun.
Disfunctionele schema’s zijn in de vroege kinderjaren, gezien de omstandigheden, adaptief. Ze interfereren wel met het goed doorlopen van ontwikkelingstaken. Dit kan leiden tot voortdurende negatieve ervaringen, die ervoor zorgen dat het schema steeds meer ingesleten en rigide raakt.
Hoe meer iemand op een bepaald gebied te kort is gekomen en hoe ernstiger de traumatische gebeurtenissen zijn, des te rigider en sterken bepaalde overtuigingen zich wortelen en des te meer last de persoon er van heeft.
Schema’s zijn niet altijd even actief. Als omstandigheden meer gelijkenis vertonen met de situaties die hebben geleid tot het ontstaan van het schema, dan zal het schema ook meer op de voorgrond staan.
Iemand heeft copingstrategieën om zo min mogelijk last te hebben van het schema.
Er zijn negentien schema’s, namelijk:
Emotionele verwaarlozing, de cliënt verwacht dat de eigen basale emotionele behoeften niet of onvoldoende door anderen zullen worden beantwoord. Hij volgt zich alleen een eenzaam.
Verlating/instabiliteit, de cliënt verwacht dat iedereen hem uiteindelijk in de steek zal laten. Anderen zijn onbetrouwbaar en onvoorspelbaar in hun steun en toewijding.
Wantrouwen en/of misbruik, de cliënt heeft de overtuiging dan anderen uiteindelijk misbruik van hem zullen maken of hem bedriegen of vernederen.
Sociaal isolement/vervreemding, de cliënt voelt zich geïsoleerd en anders dan anderen.
Minderwaardigheid/schaamte, de cliënt vind zichzelf innerlijk onvolkomen en slecht.
Sociale ongewenstheid, de
.....read moreDit magazine gaat over persoonlijkheidsstoornissen. Dat is diepgewortelde psychoproblematiek. Hier kun je artikelen vinden om het onderwerp beter te begrijpen en erachter te komen wat voor soort behandelingen er zijn.
Practice questions
Personality disorders
Chapter 1
Description of personality disorders
Personality is the individual differences in usual tendencies to think, feel and behave. Abnormal personality or pathology refers to maladaptive traits that are overly rigid and/or extreme. Constellations of such pathologically amplified personality traits may constitute personality disorders.
A personality disorder is a chronic psychiatric disorder with onset in adolescence continuing into adulthood, characterized by pathological personality traits that lead to a disruption in the development and maintenance of mutual interpersonal relationships. This is to an extent that leads to prolonged subjective distress of self and/or others.
Personality disorders concern how people matured into adult personalities, and the building blocks are often referred to as traits. Associated problems don’t typically fall into circumscribed specific categories. They involve personal identity and dissatisfaction and dysfunction in interpersonal relationships. It is about difficulties related to how people typically experience and respond to themselves, others, and the world around them (ego-syntonic pathology).
The hallmark of personality disorders is disturbed relationships.
The DSM defines personality disorder as an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two or more of the following areas: cognition, affectivity, interpersonal functioning and impulse control. This is inflexible and pervasive across a broad range of personal and social situations and present for a long duration.
Personality disorder is a longstanding, pervasive and persistent pattern of experience and behaviour. This is different from cultural expectation and problematic in terms of personal suffering and/or impairment in functioning.
Most patients manifest personality pathology that is a combination or mix of the various personality disorders identified in the DSM.
Cluser A
Cluster A consists of: paranoid, schizoid and schizotypical disorders.
This is the odd or eccentric cluster.
Paranoid personality disorder
The criteria are variations of profound mistrust and suspiciousness regarding the motives of other persons. Patients are hypervigilant to hidden meanings and threats, but in a contentious hostile way.
DSM-IV criteria:
Textbook of child and adolescent mental health
Chapter 4
Borderline personality disorder
Borderline personality disorder is characterized by a pervasive and persistent pattern of instability and impulsivity.
Prevalence
Prevalence of borderline personality disorder is estimated to be between 0.7 and 1.8%.
Gender and culture
Prevalence in the general population is considered to be similar for both gender. In clinical samples, females represent three quarters of all patients.
Thresholds for each criteria in the DSM may differ depending on their and their patient’s culture.
Burden of illness
The consequences of borderline personality disorder for the people around the sufferer depend on their vulnerability to the behaviour and demands of borderline personality disorder patients.
Patients with borderline personality disorder are exposed to risks due to impulsivity. Instability in emotional and inter-personal relationships leads to communication problems.
A diagnosis should not be made before the age of 18 years. Diagnosis is made earlier when symptoms are clear and persistent.
Remission is common. Remission is in most cases a reduction of the number of symptoms below the diagnostic threshold. There appear to be two clusters of symptoms: 1) stable and persistent, anger, feelings of abandonment 2) unstable or less persistent, self-harm and suicide attempts.
The risk of dead by suicide is between 4 and 10%.
The cause of borderline personality disorder is unknown.
Repeated childhood trauma is a frequent element in borderline personality disorder.
Early maternal separation is associated with both borderline personality disorder and the persistence of borderline personality disorder symptoms over time.
Inheritance of borderline personality disorder is polygenic.
Subtypes
Subtypes of borderline personality disorder may be defined by the comorbidities.
Some researchers propose two subtypes: 1) dependent, characterized by ambivalent, unstable relationships 2) impulsive, characterized by impulsive acts in multiple areas.
Presenting symptoms
Presentations are often prompted by another psychiatric problem, problematic behaviour, or relationship problems.
From a categorical to a dimensional concept of borderline personality disorder
For a dimensional diagnosis of borderline personality disorder, the following would be required: 1) significant
.....read moreOxford Textbook of Psychopathology
Chapter 26
Antisocial personality disorder and psychopathy
ASPD in DSM-5
The categorical diagnostic criteria for ASPD in DSM-5 are polythetic, only a proportion need to be met.
Child criteria for ASPD include: 1) aggressive and destructive behaviours 2) deceitfulness/theft 3) non-aggressive rule-breaking acts.
The adult criteria for ASPD include: 1) one aggression-specific criterion, irritability/aggressiveness 2) three clearly nonaggressive criteria, deceitfulness, impulsivity, irresponsibility 3) three nonspecific criteria, failure to conform to norms with respect to lawful behaviours, reckless disregard for safety of self or others, lacks remorse.
Disinhibition entails tendencies toward impulsivity, irresponsibility, and deceitfulness. Aggressive disregard entails irritability or aggressiveness and behaviours indicative of recklessness and lack of concern for self and others.
The characterisation of personality pathology according to the alternative dimensional-trait approach (not used in DSM-5) entails two steps 1) assessment of the presence of personality disturbance, as indicated by dysfunction of areas of self and social relations 2) designation of the specific nature of personality pathology, in terms of elevations on PD-relevant traits with five thematic domains.
The estimated prevalence of ASPD in the general community is 2% (for men 3% and for women 1%).
The prevalence of ASPD in clinical (forensic) settings has a 50-80% rate.
ASPD sows patterns of comorbidity, in particular with substance use disorders. They show common personality correlates, namely: impulsiveness and aggressiveness.
There might be an heritable basis to a general externalizing factor. This may be different expressions of a general factor.
Neurobiological correlates
Antisocial individuals show evidence of reduced levels of serotonin. Reduced serotonergic modulation of appetitive urges and negative emotional reactions may account in part for the lack of inhibitory control.
Autonomic hypoarousal has been interpreted as reflecting dispositional sensation-seeking tendencies.
Reduced P300 response (a positive cortical potential), has been observed in relation to various specific impulse control problems. It is an indication of an general externalizing factor.
Oxford Textbook of Psychopathology
Chapter 30
Narcissistic personality disorder and pathological narcissism
The DSM-5 NPD diagnosis exemplifies the conceptualization of pathological narcissism as excessive grandiosity.
Criteria for NPD in DSM-5
The DSM-5 criteria for NPD describe the following symptoms: 1) the person with NPD has an inflated sense of self-worth 2) is preoccupied with fantasies of unlimited influence, achievement, intelligence, attractiveness, or romance 3) believes that he or she is extraordinary or distinctive and can only be understood by, and should only associate with, other unusual or elite status people or institutions 4) requires excessive respect, appreciation and praise 5) has a sense of privilege and due 6) is willing to use and take advantage of others for personal gain 7) lacks compassion 8) is often jealous of others or believes that others are jealous of him or her 9) exhibits conceited, self-aggrandizing behaviours and attitudes.
The diagnosis reflects chronic expression of excessive or extreme grandiosity.
Prevalence
It is the least commonly diagnosed PD. Prevalence of NPD ranges from 0-5.7%.
Stability
The temporal stability of NPD is modest.
Discriminant validity of NPD criteria
The discriminant validity of NPD against other PD’s is poor.
Comorbidity
NPD exhibits the highest rates of comorbidity with antisocial and histrionic PDs. There are also comorbidities with symptom disorders. Diagnoses that most strongly predicted comorbid NPD are: bipolar I disorder, anxiety disorders, drug dependence, post-traumatic stress disorder, mood disorders and substance use disorders.
NPD research
Research on NPD is rare because of the low prevalence.
Patients with NPD exhibit deficits in emotional empathy but not cognitive empathy.
Patients with NPD have smaller gray volume in the left anterior insula and in frontoparalimic brain regions comprising the rostral and median cingulate cortex and the dorsolateral and medial parts of the prefrontal cortex.
Patients with NPD show a specific deficit for emotions representing fear and disgust. They do not have lower explicit self-esteem.
There are no empirically validated treatments for NPD.
Critiques for NPD
The lack of research on patients with NPD renders the validity and clinical utility of the diagnosis questionable.
The low prevalence of NPD reported in large-scale epidemiological studies are lower than the rates being treated in psychotherapy. It may be that there is a lack of sufficient NPD criteria.
.....read morePersonality disorders
Chapter 7
(part of) The narcissistic and histrionic personality disorders
Histrionic personality disorder and gender
Histrionic PD is a predominantly female disorder.
Histrionic personality disorder as seen through assessment instruments
People with histrionic PD have an elevation on a mania scale, ad a lower score on social introversion. These findings are characteristic of more energetic, expansive individuals who are not bothered by uneasiness or shyness in social situations.
Histrionic PD is characterized by a lower trait level of altruism, and on the facet level, elevated scores on gregariousness, feelings, warmth, and tendermindedness. This suggests and emotionally expressive, outgoing person who is also self-centred and rather superficially engaged in relationships.
Treatment issues
The course and prognosis of histrionic PD will largely depend on its severity and comorbidity. More extreme versions will be harder to treat. When concurrent features of antisocial PD and narcissistic PD are present, treatment gains will be harder to achieve.
The Oxford Handbook of Personality Disorders
Chapter 23
Dependent personality disorder
Dependent personality disorder is associated with an array of negative outcomes. It is also associated with increased adaptation in a variety of areas 1) sensitivity to subtle interpersonal cues 2) decreased delay in seeking medical help following symptom onset 3) conscientious adherence to medical and psychological treatment regimes.
Descriptive psychiatry and psychoanalysis
In classical psychoanalytic theory, dependency is inextricably linked to events that occur during the first months of life (the oral state). Frustration or over gratification during the infantile, oral phase was thought to result in oral fixation and an inability to resolve the developmental issues that characterize this period (conflicts regarding dependency and autonomy). Research regarding this has produced weak results.
DSM-IV/DSM-IV-R
The essential feature of dependent personality disorder in the DSM-IV and DSM-IV-R is ‘a pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning in early adulthood and present in a variety of contexts’.
The DSM-IV list eight specific symptoms. The patient must meet criteria for five of these symptoms to qualify for a dependent personality disorder diagnosis. 1) difficulty making everyday decisions without excessive advice and reassurance 2) needing other people to assume responsibility for most major areas in life 3) difficulty expressing disagreement because of fear of loss of support or approval 4) difficulty initiating projects or doing things on one’s own 5) going to excessive lengths to obtain nurturance and support from others 6) feeling uncomfortable and helpless when alone 7) urgently seeking another relationship as a source of care and support when a close relationship ends 8) being unrealistically preoccupied when fears of being unable to care for oneself
Empirical evidence regarding these criteria is mixed. And none of the symptoms include mention of the central cognitive feature of dependency, a perception of oneself as powerless and ineffectual.
The PDM
In the Psychodynamic diagnostic manual, dependent personality disorder is described in terms of dependent individuals’ tendency to ‘define themselves mainly in relation to others and seek security and satisfaction predominantly in interpersonal contexts’. Dependency must be evaluated with sensitivity to cultural and subcultural contexts.
The PDM is descriptive. It does
.....read moreThe Oxford Handbook of Personality Disorders
Chapter 25
Avoidant personality disorder
Avoidant personality disorder (AVPD) is characterized by a desire for affiliation coupled with a sense of personal inadequacy and intense fears of interpersonal rejection. A heightened sensitivity to criticism and expected condemnation by others are key features of AVPD.
Approximately 1.6% of individuals suffer from AVPD.
DSM-IV-TR definition and criteria
AVPD is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
At least four of any of the seven criteria to meet the diagnostic threshold for AVPD: 1) Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval or rejection. 2) is unwilling to get involved with people unless certain of being liked 3) shows restraint within intimate relationships because of the fear of being shamed or ridiculed. 4) is preoccupied with being criticized or rejected in social situations 5) is inhibited in new interpersonal situations because of feelings of inadequacy 6) views self as socially inept, personally unappealing, or inferior to others 7) is unusually reluctant to take personal risk or to engage in any new activities because they may prove embarrassing.
Avoidant personality disorder and DSM diagnostic co-occurrence
Comorbidity of AVPD is the norm.
Disorders frequently co-occurring with avoidant personality disorder
AVPD frequently co-occurs with a spectrum of anxiety and depressive disorders.
Avoidant personality disorder and social phobia
The DMS diagnosis of social phobia is characterized by a fear or avoidance of social situations that is presumably more circumscribed than AVPD. But, there is considerable overlap, it is more likely to be a continuum..
Personality traits may be an important distinction.
Other comorbide dsm conditions
Another personality disorder that overlaps or may share features with AVPD is dependent personality disorder. The key distinction is that AVPD is driven by fear of being rejected.
Avoidant personality disorder and the five-factor model
Two domains that are relevant to AVPD are (high) neuroticism and (low) extraversion. Neuroticism is composed of the facets: anxiety, angry hostility, depression, self-consciousness, impulsiveness and vulnerability.
Extraversion is composed of the facets: warmth, gregariousness, assertiveness, activity, excitement
.....read moreThe Oxford Handbook of Personality Disorders
Chapter 26
Obsessive-compulsive personality disorder
Early psychoanalytical perspectives
Freud hypothesized that orderliness, parsimony and obstinacy were either sublimations of. Or reaction formations against, anal-erotic instincts of childhood. This is without empirical support.
Early psychoanalysts provided rich clinical descriptions of what would later become known as compulsive or obsessive-compulsive personality disorder. Several of the traits were incorporated into later diagnostic criteria.
The diagnostic and statistical manual of mental disorders and revisions
DSM-IV and DSM-IV-TR specified the essential feature of obsessive-compulsive personality disorder as ‘preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. An individual must have at least four of the eight criteria in order to meet the diagnosis.
Obsessive-compulsive personality traits in moderation may be especially adaptive, particularly in situations that reward high performance.
International classification of diseases
The equivalent of obsessive-compulsive personality disorder in the ICD-10, is anankastic personality disorder. Criteria are: 1) preoccupation with details, rules, list, order, organisation or schedule 2) perfectionism that interferes with task completion 3) excessive conscientiousness and scrupulousness 4) undue preoccupation with productivity to the exclusion of pleasure an interpersonal relationships 5) rigidity and stubbornness 6) unreasonable insistence by the individual that others submit to exactly his or her way of doing things 7) feelings of excessive doubt and caution 8) excessive pedantry and adherence to social conventions.
Epidemiology
Estimates about the prevalence of obsessive-compulsive personality disorder range from 1.6-2.5%.
The prevalence in men and women is similar. The prevalence s greater in older age groups.
Comorbidity
Anxiety and mood disorders
Patients with OCPD had higher prevalences of anxiety disorder, social phobia, obsessive-complusive anxiety disorder and mood disorder.
Obsessive-compulsive disorder
Neuroticism and OCPD may be alternative expressions of the same underlying vulnerability in at least some families with OCD.
Eating disorders
OCPD has been found to be the most common personality disorder in patients with eating disorders.
Co-occurrence with other personality disorders
There is considerable diagnostic overlap between OCPD and other personality disorders. There are significant correlations with: avoidant PD, dependent PD, paranoid PD and borderline PD.
More than half the patients with OCPD had a co-occurring personality disorder.
Functional impairment
A substantial proportion of patients with OCPD show evidence of functional
.....read morePersonality Disorders: Toward the DSM-V
Chapter 3
Paranoid personality disorder
Paranoid personality disorder (PPD) is characterized by a mistrust of other people. Other features include: quarrelsomeness, hostility, emotional coldness, hypersensitivity to lights of criticism, stubbornness and rigidity held maladaptive beliefs of others’ intents.
The underlying assumption is that other are malevolent. Measures must be taken to protect oneself.
People with paranoid personality disorder tend to hold grudges, have enemies are often litigious, and can be pathologically jealous.
Paranoid personality disorder exemplifies one extreme pole of the agreeableness-antagonism dimension of the five-factor model of personality.
The pattern of antagonistic behaviour often causes difficulties in interpersonal relationships. It may provocate the kinds of attacks these individuals fear.
People with paranoid personality disorder are usually not psychotic, although they may experience transient psychotic-like symptoms under conditions of extreme stress. The beliefs in paranoid personality disorder are rarely of psychotic proportions.
Unlike PPD, paranoid schizophrenia and delusional disorder involve frank delusions, false beliefs of psychotic proportions. Such beliefs are not always evident.
People with PPD sometimes develop transient delusions when under extreme stress.
Schizotypal individuals display odd or eccentric ideas, peculiar thinking or speech, unusual perceptual experiences and other ‘schizophrenia-like’ features that are not seen in PPD.
Schizoid individuals are socially withdrawn because of a preference of being alone rather than a desire to protect themselves from imagined threats.
Outstanding issues
PPD patients are seen in a variety of clinical populations, and they can pose special problems for treatment when their mistrust affects the therapeutic relationship.
Some PPD patients can achieve good outcomes when they are given treatments appropriate to their problems.
Are the DSM-IV criteria for PPD valid descriptions of the disorder?
A long-standing debate, centres on the question of whether less severe paranoid disorders, such as PPD and delusional disorder, lie on a genetic continuum with schizophrenia, of whether it is a distinct spectrum.
The DSM-IV criteria for PPD appear to overrepresent the cognitive PPD trait mistrust/suspiciousness and to underrepresent the prototypical behavioural, affective, and interpersonal expressions of paranoid personality traits. Nearly all of the DSM-IV PPD criteria reflect the cognitive trait of mistrust. Three reflect the affective/interpersonal trait of hypersensitivity. Two reflect the affective/interpersonal trait of anatognism. Two reflect the cognitive trait of hypervigiliance. One reflects
.....read morePersonality Disorders: Toward the DSM-V
Chapter 4
Schizoid personality disorder
Schizoid personality disorder (SCPD) is distinguished from the other two personality disorders in the ‘odd/eccentric’ cluster by the prominence of social, interpersonal and affective deficits in the absence of psychotic-like cognitive/perceptual distortions.
Prevalence
Schizoid personality disorder is among the least frequently observed of the personality disorders. This may be due to the uncommon appearance of schizoid individuals in clinical settings.
Schizoid personality disorder may be first apparent in late childhood. This is a period in which cooperative play is in ascendance, and the social isolation becomes more salient.
The disorder is more common in men.
DSM-IV-TR criteria for schizoid personality disorder
The DSM-criteria for schizoid personality disorder are: a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four of the following: 1) neither desires nor enjoys close relationships 2) almost always chooses solitary activities 3) has little, if any, interest in having sexual experiences with another persons 4) takes pleasure in few, if any, activities 5) lacks close friends or confidants other than first-degree relatives 6) appears indifferent to praise or criticism from others 7) behaviour or appearance that is odd, eccentric or peculiar.
Psychometric properties
The internal consistency of measures of schizoid personality disorder is poor.
The highest co-occurrence of schizoid personality disorder is with schizotypal personality disorder. This might be due to the high overlap between the two criteria sets. Another high comorbid disorder is avoidant personality disorder. Lesser degrees of comorbidity are demonstrated with paranoid, antisocial, and borderline personality disorder.
Schizoid and avoidant personality disorder
Some studies suggest that schizoid personality disorder can be distinguished from avoidant personality disorder on the basis of intimacy needs and sensitivity to rejection. But, anxiety and clinical symptoms occur in both disorders.
Research literature has demonstrated poor discriminant validity between schizoid personality disorder and avoidant personality disorder.
Schizoid personality disorder and Asperger’s syndrome
There is significant overlap in the phenomenological criteria for schizoid personality disorder and asperger’s syndrome.
The clinical presentation of the two disorders is different. Autism becomes evident between two and three years of age when
.....read morePersonality Disorders: Toward the DSM-V.
chapter 5
Schizotypal personality disorder
The DSM-IV diagnostic criteria for schizotypal personality disorder (SPD) include attenuated versions of the defining features of schizophrenia.
Prevalence of SPD
The prevalence of schizotypal personality disorder in the general population is 3%, according to the DSM-IV.
The concept of SPD hinges on its genetic link with schizophrenia.
SPD and schizophrenia share common features such as: odd beliefs, social impairment and abnormalities in perceptual experiences and emotional expression.
SPD criteria specify an attenuated version of the psychotic symptoms necessary for a schizophrenia diagnosis.
SPD and schizophrenia share a genetic liability. Environmental factors also play a key role.
The relationship between negative expressed emotion in family members and poor outcome in patients appears to be bidirectional.
The developmental link between SPD and schizophrenia
SPD and schizophrenia share a developmental link.
SPD signs, and even the full SPD syndrome, often predate the onset of schizophrenia.
Those who meet criteria for SPD show functional deficits and physical abnormalities that parallel those observed in schizophrenia, although the magnitude of the deficits typically is less severe in SPD.
Cognitive functioning
Adults who meet the criteria of SPD show: general cognitive impairment, including deficits in verbal fluency, learning and retention, deficits in sustained attention and mixed findings in respect to executive functioning.
Motor and physical correlates of SPD
Individuals with SPD manifest abnormalities in motor functions.
Psychophysiology
There are abnormal psychophysiological responses in both schizophrenia and SPD. Abnormalities have been found in prepulse inhibition, heart rate, electrodermal activities, and other autonomic nervous system-controlled responses.
Structural brain abnormalities
SPD patients have larger ventricular volumes, reduced cortical gray matter volumes, and smaller temporal lobes.
Functional brain abnormalities
Individuals with SPD manifest functional brain abnormalities, particularly in the frontal and temporal regions.
Neurochemistry
There are elevated dopamine levels in SPD that mimic the pattern found in schizophrenia. SPD adolescents manifest elevated cortisol levels.
Personality disorders are pervasive, persistent and pathological personality structures. In this magazine, information is given about the personality disorders, the current theories and a bit about how to treat a personality disorder.
What are the ten personality disorders?
How do personality disorders come to be and how do you treat them?
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