What is personality disorder?

Empowering you with the language and concepts

Personality

We all have one. It makes us unique. It shapes how we understand and interact

with the world

3 P’s3 P’s

Pattern of relating to self, other and the world that deviates from Pattern of relating to self, other and the world that deviates from cultural norm.cultural norm.

50-78% prisoners believed to meet criteria for one or more PD.50-78% prisoners believed to meet criteria for one or more PD. 10% of people in the community would meet criteria for PD.10% of people in the community would meet criteria for PD. A helpful way of thinking about PD relates to the 3 P’sA helpful way of thinking about PD relates to the 3 P’s

Persistent – happens frequently – happens frequently

PPervasiveervasive – across different circumstances – across different circumstances

PProblematicroblematic – and cause problems for themselves and others – and cause problems for themselves and others

Immune system metaphorMillon (2004)

Robust immune system responds constructively & appropriately to our environment.

PD = system that interacts with the environment

Personality = Psychological equivalent of

body’s immune system

Rigidity in strategies + Others reactions =

Repeated bad one-act play

PD Diagnosis

Labelling and the Disease model

Classification into PD types

Akin to diagnosing a disease that you either have or don’t have

Categories based on “pure” prototype. Assumes each personality disorder is

distinct

Diagnostic systemsDiagnostic systems

DSM IV-TRDSM IV-TRParanoidParanoidSchizoidSchizoid

SchizotypalSchizotypalAntisocialAntisocialBorderlineBorderlineHistrionicHistrionic

NarcissisticNarcissisticAvoidantAvoidant

Dependent Dependent Obsessive CompulsiveObsessive Compulsive

Not Otherwise Specified Not Otherwise Specified

ICD-10ICD-10ParanoidParanoidSchizoidSchizoidDissocialDissocial

Emotionally unstable Emotionally unstable HistrionicHistrionic

AnankasticAnankasticAnxiousAnxious

DependentDependentOther specific PDOther specific PDUnspecified PDUnspecified PD

Mixed and other PDMixed and other PD

DSM Clusters

Cluster A

Odd / Ecentric

Cluster B

Dramatic / Erratic

Cluster C

Anxious / Fearful

Character Assassination Character Assassination

Schizoid

Schizotypal

Borderline

Histrionic

Antisocial/ Psychopathy

Pros and Cons of Types

Facilitates communication by the use familiar language between professionals. It’s best we’ve got at the moment.

Enables quick signposting to services

Rarely find “pure types” in real life. People are individuals. BPD = 5 of 9 criteria = potentially only 1

symptom overlap. Lack of empathic understanding of the origins and maintenance of the

problem which is central to therapy. Stigma facilitates reactions in others which perpetuates the problem

(eg. verbal attack driven by paranoid interpretation is met by defensiveness, which further creates suspicion in the individual).

Dimensions of personality

The direction to be taken in DSM-V?

Dimensional perspective

1) Personality represented by severity of traits rather than distinct categories.

2) Or, ASPD variations = Normal variation:

Adventurer, Independent, Courageous

Pathological variation

Callous, Lacking conscience Breaks rules Impulsive

‘Normal’ continua of Antisocial

Normal variation Adventurer, lives life on the edge, pioneers, risk-takers, courageous and

tough.

Slight pathological normal variation Does things own way, flirts with legal boundaries, dislikes daily routine,

action-oriented, independent thinkers, confrontational and masterful leaders.

Cusp No forensic history but only due to being good at covering their tracks,

will deceive and exploit by minimising negatives and exaggerating positives but not physically cruel, industrialists, exploit legal technicalities and loopholes for personal gain, “smooth-talking businessman”, “dodgy used-car salesman”.

‘Normal’ continua of Paranoid

Normal variation Highly independent, value their freedom, sensitive to issues of

power, authority and domination. Cautious and reserved with others and enter relationships only after careful consideration. Touchy, but not intimidated, when given criticism

Paranoid “style” Distant from others, places premium on honesty and loyalty.

Plays cards closely to chest with acquaintances. Attuned to subtleties and nuances of communication at many levels. Skeptical.

Dimensions of personality Five Factor Model (Costa & McCrae, 1992) - five dimension (primary traits):Five Factor Model (Costa & McCrae, 1992) - five dimension (primary traits):

OOpenness to experience penness to experience vs tradition/conventionvs tradition/conventiona general appreciation for art, emotion, adventure, unusual ideas, imagination, a general appreciation for art, emotion, adventure, unusual ideas, imagination,

curiosity, curiosity, and variety of experienceand variety of experience

CConscientiousness onscientiousness vs negligencevs negligence

tendency to show self-discipline, act dutifully, and aim for achievement. tendency to show self-discipline, act dutifully, and aim for achievement. Preference for planned rather than spontaneous behaviourPreference for planned rather than spontaneous behaviour

EExtraversion xtraversion vs introversionvs introversion

characterized by positive emotionscharacterized by positive emotions engagement with the external world enthusiastic, action-oriented individuals

AAgreeableness greeableness vs antagonisticvs antagonistic tendency to be compassionate and cooperative rather than suspicious and tendency to be compassionate and cooperative rather than suspicious and

antagonistic antagonistic towards otherstowards others

NNeuroticism euroticism vs emotional stabilityvs emotional stability

emotionally reactive and vulnerable to stressemotionally reactive and vulnerable to stress

DAPP (Livesley & Jackson 2009)

Cluster label Contributing dimensions

Emotional dysregulation Affective lability AnxiousnessCognitive dysregulation Identity problemsInsecure attachment OppositionalitySubmissiveness

Dissocial Behaviour Conduct problems CallousnessNarcissism RejectionStimulus seeking

Social Avoidance Intimacy problems Low affiliationRestrictive expression

Compulsiveness Compulsivity

Pros and Cons of Dimensions

Research gives greater support to the dimensional view of personality

Engenders a more compassionate understanding of personality Diagnostic types can be translated into dimensions

No consensus about nature and number of dimensions More complex picture of personality = more difficult to comprehend

and communicate to other clinicians