Substance Abuse With Personality Disorder: A Case Study

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In addition, to prepare for this discussion read Chapter 4, Chapter 7, and Chapter 9 in your required textbook and the articles Substance Use Disorders and Borderline Personality: Common BedfellowsLinks to an external site. and Borderline Personality Links to an external site.Disorder & Substance AbuseLinks to an external site.. Lastly, view the video Debunking the Myths & Misunderstandings of Borderline Personality DisorderLinks to an external site. and play the Mouse PartyLinks to an external site. interactive game.

Read the following case studies and refer to your textbook, and the DSM-5, as needed to support your understanding.

Borderline Personality Disorder – Week 3

Janice is a 35-year-old Caucasian female who came to counseling after being released from the hospital with non-life-threatening, self-inflicted cuts on her arm after she threatened suicide when her boyfriend of 4 months broke up with her. Janice reported she was hoping to prove how much she loved her boyfriend by doing this, so he would not break up with her. You received a report from the hospital that stated client came in extremely angry and could not be calmed down. Her ex-boyfriend stated that their relationship had been very intense where she would one day praise him and talk about her love for him to the point he was uncomfortable, and the next day something would happen and she would call him horrible names. Janice has been to the hospital several times for similar situations with past relationships. She states she doesn’t want to kill herself really and often cuts to take away her emotional pain. She states her need to be in a relationship due to the emptiness she feels, she just wants something to make her feel less empty.

Substance Abuse – Week 3

Gentry is a 23-year-old Pacific Islander male, who is a recent college graduate. He is seeking treatment after being fired from his first job out of college due to too many absences and coming to work hungover. Gentry stated he started drinking socially at 18 when he entered college. At first, he would drink only on weekends at parties and would often blackout or become sick. He stated this is what his friends did, and he didn’t see a problem. During his senior year, he didn’t have as many classes and started to drink during the week and earlier in the day, since his classes ended at noon.

Once out in the college, he got a job a year ago, and he would go out after work with co-workers a few nights a week to drink. On the nights he didn’t go out with co-workers he would drink at home by himself. Slowly drinking more and more to feel a buzz. Over the past few months, Gentry has struggle to get out of bed in the morning due to having a headache, nausea, and lack of good sleep. After being warned several times about consequences for being late over the past 3 months, he continued his drinking behavior and was eventually fired because he missed too much work.

In your initial post,

  • First, choose one of the options and describe the patient’s symptoms and the available demographic and historical data.
  • Based on the scenario you chose, evaluate how the intensity, duration, and focus support the identified diagnosis.
    • List all references used at the end of your discussion according to APA 7 guidelines.
    • Discuss the available treatments for this patient.
  • Discuss the implications of a therapist who actively encourages a patient to take medication that has been shown to be effective when the patient has strong objections to the use of a pharmacological approach to treatment.
  • Develop at least three recommendations for the patient/family for ongoing functioning (social, occupational, and academic, if applicable), associated with the scenario you chose.
  • Finally, analyze the differences between both scenarios: Borderline Personality Disorder and Substance Abuse? Do the recommendations differ?

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9 Personality Disorders Ingemar Edfalk/Blend Images/SuperStock Chapter Objectives After reading this chapter, you should be able to do the following: • Describe what “personality” means. • Understand the evolution of a personality disorder. • Explain how a personality can be disordered. • Discuss the causes of personality disorders. • Explain the differences among the various DSM–5 personality disorders. • Explain how people with personality disorders can be helped. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 249 2/16/18 4:51 PM Evolution of a Personality Disorder: From Psychopath to Antisocial Personality Section 9.1 When we describe people who prefer spending a quiet night at home to attending a party as “introverted” or when we call ace fighter pilots “brave,” we are implying that their behavior is caused by their personality traits. (Why do fighter pilots take to the sky? Because they are brave.) Such trait-based explanations of behavior have an intuitive appeal: They fit our beliefs about human nature. Some people are naturally shy; others, gregarious. Some are timid; others are brave. This is the “popular” meaning of personality. For this chapter, we will use a more scientific definition of personality. According to the DSM–5, the sum of an individual’s traits constitutes his or her personality, a set of “enduring patterns of perceiving, relating to, and thinking about the environment and oneself, which are exhibited in a wide range of important social and personal contexts” (American Psychiatric Association [APA], 2013, p. 647). Experience tells us that there is at least some consistency to people’s behavior and that maladaptive personality traits can cause distress. The DSM–5 considers people with these maladaptive personality traits to have a personality disorder: an enduring pattern of inner experience and behavior that deviates markedly from the expectations of an individual’s culture. Although both the DSM–5 and the International Statistical Classification of Diseases and Related Health Problems (ICD-9-CM) include a diagnostic category for personality disorders, the idea that a personality can be disordered is steeped in controversy (Sutker, 1994; Widiger & Trull, 2007). For example, do career criminals really suffer from a personality disorder, or have they simply made a choice about how they wish to lead their lives? Experts have differing opinions on this issue. They also disagree about which personality traits are debilitating enough to constitute a disorder. Perhaps the fundamental problem with personality disorders is that they have so little in common. The personality disorders covered in the DSM–5 include excessive shyness, self-absorption, and schizophrenic-like behaviors, and there seems little logical, empirical, or theoretical justification for grouping such disparate “disorders” into a single category. In contrast to clinical disorders such as schizophrenia, personality disorders are supposed to arise from enduring character traits. Taken to extremes, practically any personality trait can impair social functioning and create problems. Shy people may lead restricted social lives; those who are extremely aggressive may get into trouble with the law. Because any personality trait, taken to extremes, can produce difficulties in living, some psychologists prefer to conceptualize personality disorders as the unlucky result of falling at the extreme of some personality trait—too shy, too hostile, too self-centered, and so on (Wakefield, 2012). 9.1 Evolution of a Personality Disorder: From Psychopath to Antisocial Personality The idea that criminal behavior is inherited was a subject loathed by social reformers, who hoped to create a more caring society. What is the point of trying to improve the lot of disadvantaged people if their destiny is genetically predetermined? In the 19th century, however, social reformers were in the minority. Most professionals followed psychiatrist Emil Kraepelin, who said that criminal behavior was largely genetic in origin. Kraepelin grouped people who lied, cheated, committed crimes, and harmed others into a diagnostic category he called © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 250 2/16/18 4:51 PM Evolution of a Personality Disorder: From Psychopath to Antisocial Personality Section 9.1 “constitutional psychopathic inferiority.” “Psychopaths” were people who behaved in an antisocial manner. The cause of their behavior was genetic (“constitutional”) and probably the result of some failure in evolutionary development (“inferiority”). Although Kraepelin admitted that individuals considered to be psychopaths in one culture—terrorists, for example— might be hailed as freedom fighters in another culture, he still believed that social causes were secondary to genetics in the etiology of antisocial behavior. Over the years, Kraepelin’s category was shortened (by dropping “constitutional” and “inferiority”) to psychopath, defined as a person who lacks empathy, does not fear punishment, and will continue to break the law even if capture and punishment are likely. The first DSM, published in 1952, abandoned the term psychopath entirely. Instead, it referred to a sociopathic personality. This change in nomenclature signified the dominance of social theories of antisocial behavior: Criminals are made, not born. Moral Insanity Revived Ross Dolan/Glenwood Springs Post Independent/AP Images Commonly, pyschopaths can be sociable, yet they often lack empathy. Serial killer Ted Bundy was often characterized as being charismatic and friendly. The term sociopath never entirely replaced psychopath. Indeed, psychopath was still a widely used diagnostic term when Hervey Cleckley published The Mask of Sanity in 1976. Cleckley’s psychopaths were antisocial people who appeared “normal,” even to professionals, but whose normality was really only a superficial “mask of sanity.” Beneath the surface, Cleckley argued, psychopaths were deeply disturbed. Because of their mask of sanity, psychopaths initially make a good impression. They can be friendly, intelligent, and show no overt signs of a mental disorder. Yet they lead highly aberrant lives. They have dismal social relationships and disordered work histories, and they are often unreliable. On an impulse, they may give up a successful career to follow some momentary whim. Their projects, both legal and illegal, often turn out badly because, despite their intelligence, they fail to plan ahead. When confronted with evidence of their misbehavior, psychopaths first try to blame others. When this fails, they may admit their misdeeds and feign regret, but their remorse and concern for their victims are not genuine, and their misbehavior is often repeated. Punishment does not deter them. In fact, psychopathic people engage in antisocial behavior even when they are almost certain to be caught and punished. It is as if they cannot see the future. When they are apprehended, psychopaths remain self-centered. Some have even been known to ask employers for references after being fired for stealing. The subject of this chapter’s case study, Eric Cooper, has many of the characteristics of Cleckley’s psychopaths. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 251 2/16/18 4:51 PM Evolution of a Personality Disorder: From Psychopath to Antisocial Personality Section 9.1 The Case of Eric Cooper: Part 1 Excerpt from the Assessment of Eric Cooper by the Court Psychologist MUNICIPAL COURT Psychological Assessment Date: December 4, 2011 Client: Eric Cooper Instruments Minnesota Multiphasic Personality Inventory–2 (MMPI-2) Thematic Apperception Test (TAT) Wechsler Adult Intelligence Scale (WAIS-IV) Psychopathy Checklist–Revised (PCL-R) Clinical interview Psychologist: Dr. Aaron Lusted Referral: Judge Warren Reason for Referral: Judge Warren requested this presentencing report on Eric Cooper, a 30-year-old man who has been previously convicted of several crimes, including robbery and assault. Behavioral Observations: Although the client was cooperative and friendly, he rarely made direct eye contact. Also, despite his general good mood, he would swear out loud and pound the table whenever he missed any questions on the intelligence test. There were no signs of delirium or alcohol intoxication, and the client was able to complete all tests with little prompting. The client reported that he had tried to rob a bank, while drunk, in order to pay his bills. He expressed concern that a guard was hurt during the attempted robbery and said he was pleased that no permanent damage was done. He asked whether there was a cure for his problem but when asked what his problem was, he said, “Bad luck, mostly.” Social History: [See Document 10.3, Social Work Report.] Intellectual Assessment: The client’s scores on the WAIS-IV intelligence test place him in the above-average range of intelligence. His scores on the verbal scales were higher, in general, than his scores on the performance scale. This is not surprising in someone with the client’s educational achievement. Personality Assessment: The validity scales of the MMPI-2 were all in the average range, indicating that the test profile could be safely interpreted. The main feature of the profile was an elevated score on the psychopathic deviate scale. The client’s responses revealed a self-centered person, whose own feelings always take precedence over those of other people, and a person who lacks empathy for the feelings and rights of others. He also has a strong tendency to act impulsively. . . . The client’s TAT responses reflected a preoccupation with violence—there were numerous references to death, blood, and corpses—but no mention about how the characters in the story might respond or be affected by the violence. It was as if the client could not imagine what might be going through the heads of his own characters. . . . The client’s responses to the PCL-R (which assesses manipulative behavior and impulsivity) were those found among people who have been labeled “psychopaths”— people who lack empathy and are likely to use violence to achieve their goals. (continued) © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 252 2/16/18 4:51 PM Evolution of a Personality Disorder: From Psychopath to Antisocial Personality Section 9.1 The Case of Eric Cooper: Part 1 (continued) Based on the test results, behavioral observations, and my clinical interview, it appears that the client is a person who has little empathy for or understanding of other people. He thinks mainly of himself, his needs, and his feelings. He is prepared to use violence to meet his needs, no matter how simplistic or complex they may be. He will use violence if someone has something he needs (money or food or alcohol), or something he wants but cannot afford (an automobile). Because he lacks empathy, the client is almost certain to have trouble in personal relationships. In addition, his self-centered attitude as well as his impulsiveness and willingness to use violence are likely to bring him into continued conflict with the law. Diagnostic Considerations: The client meets the DSM–5 criteria for antisocial personality disorder; he also meets many of the criteria for borderline personality disorder. In addition, he seems to have a pattern of substance abuse. He recently experienced stress from business problems, but his global functioning is only mildly impaired, and he is capable of a high level of psychological functioning. Alcohol use disorder Antisocial personality disorder (possible borderline personality disorder as provisional secondary diagnosis) See appendix for full case study. Cleckley’s Etiological Hypothesis: An Inability to Feel Emotions For Cleckley, the failure to learn from experience was a central clue to the cause of psychopathic behavior. To explain why psychopathic people failed to profit from experience, Cleckley hypothesized that they are unable to experience normal emotions. They pretend to feel regret, affection, and fear, but they are really like actors, who simulate emotions they are not really experiencing. Because they do not feel anxiety about future punishment, psychopaths continue to commit antisocial acts for which they have been punished in the past (Crego & Widiger, 2015; Silverstein, 2007; Zuckerman, 1999). DSM–IV Abandons Psychopathy The experimental data collected over the decades are remarkably consistent with Cleckley’s clinical observations (Hare, 1996; Hare & Neumann, 2006). People who meet his definition of a psychopath act on their immediate instincts and seem not to fear punishment. Not surprisingly, they are continuously in trouble. Despite these intriguing, and largely consistent, research findings, the DSM–IV abandoned both the term psychopath and the term sociopath, replacing them with antisocial personality disorder, which remains in the DSM–5. The DSM– IV deliberately replaced Cleckley’s psychopath—a clearly deviant person—with a diagnostic category that is so general it can accommodate practically anyone who behaves in an antisocial manner. Moreover, the new diagnostic criteria omit the hallmark of Cleckley’s concept of psychopathy—an inability to feel emotions. Why the change? The main reason is the DSM–5’s attempt to make its diagnostic criteria as objective as possible. The DSM–5 criteria for antisocial personality disorder focus on © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 253 2/16/18 4:52 PM Evolution of a Personality Disorder: From Psychopath to Antisocial Personality Section 9.1 observable behaviors (such as impulsivity) and omit those that refer to presumed etiologies (such as a failure to feel emotions). The hallmark of the DSM–5’s antisocial personality disorder is a flagrant disregard for the rights of other people. People with antisocial personality disorder are often irresponsible, impulsive, and untrustworthy. Although the objective criteria strived for in the DSM–5 are an improvement over the subjective diagnostic criteria sometimes used in the past, it is curious that such a consistent body of psychological research has had so little effect on modern diagnostic practice. Because only three of seven criteria need be met for the diagnosis of antisocial personality disorder, the DSM–5 criteria can encompass the behaviors of, among others in no particular order, con artists, thieves, career criminals, charlatans, corrupt politicians, even devious used car salespeople. Because the category is so broad, it tells us remarkably little about a person’s behavior. People with an antisocial personality disorder can have markedly different demeanors. Some can be charming; others may be surly and aggressive. In other words, despite its status as a disorder of “personality,” the antisocial personality label tells us little about a person’s temperament; it is just a shorthand way of saying that a person engages in a habitual pattern of irresponsible behavior. Often, this behavior brings the person in contact with the law (Crego & Widiger, 2015). Nevertheless, it is important to note that an antisocial personality is not the equivalent of criminality. Not all criminals have a psychological disorder and not all people who have antisocial personality disorder are criminals (Crego & Widiger, 2015). For a diagnosis of antisocial personality disorder, there must be evidence of a conduct disorder in childhood and an adult pattern of antisocial behavior that is evident by age 15. By insisting on such a lifelong pattern, the DSM–5 seems to have moved back in the direction of Kraepelin’s “constitutional psychopath,” who is either born antisocial or who develops such tendencies early in life. In practice, the initial onset of antisocial behavior is difficult to document (Ogloff, 2006). Objective information about a person’s childhood is rarely available, retrospective reports by others are often unreliable, and people suspected of being antisocial cannot be trusted to give an accurate history of their own lives. Despite these uncertainties, the idea that people who are “psychopathic” are different from birth, or at least early childhood, is sometimes used to argue that they cannot help their actions—that they are simply suffering from an illness. Prevalence and Course of Antisocial Personality Disorder Between 0.2% and 3.3% of the general population, mainly men, meet the DSM–5 criteria for antisocial personality disorder (APA, 2013; Zimmerman, Favrod, Trieu, & Pomini, 2005). Although the preponderance of men diagnosed with antisocial personality disorder may reflect a difference between the sexes, it may also be the result of stereotypical sex roles or of the clinician’s own biases (Castro, Carbonell, & Anestis, 2011). In our society, men are expected to be aggressive and to take more risks than women (see Figure 9.1). Men may be socially reinforced for behaving in ways consistent with at least some of the diagnostic criteria for antisocial personality disorder. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 254 2/16/18 4:52 PM Section 9.1 Evolution of a Personality Disorder: From Psychopath to Antisocial Personality Figure 9.1: Are some cultures more antisocial than others? In a cross-cultural study, teenagers were asked to write stories describing how imaginary characters would respond to various conflicts. About one third of the respondents from New Zealand, Australia, Northern Ireland, and the United States described violent responses, compared to less than one fifth of the subjects from Korea, Sweden, and Mexico. New Zealand 38.7% Australia 37.8% Country Northern Ireland 32.6% United States 30.2% Japan 29.0% England 28.7% Canada 27.2% 24.2% France Mexico 19.9% Sweden 19.3% Korea 18.6% 0 5 10 15 20 25 30 35 40 45 50 Percentage with violence in stories Source: Adapted from Archer and McDonald (1995), as appearing in R. J. Corner, Abnormal Psychology, 6th ed. New York: Worth Publishers, 2007, Figure 16.3, p. 473. Reprinted by permission. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 255 2/16/18 4:52 PM Section 9.1 Evolution of a Personality Disorder: From Psychopath to Antisocial Personality By the DSM–5’s definition, antisocial personality disorder usually has its origins in adolescence, but it may begin even earlier (APA, 2013; Krastins, Francis, Field, & Carr, 2014). In fact, poor impulse control and aggressiveness as a child are important predictors of antisocial personality disorder later in life (Krastins et al., 2014). A typical sequence is for an impulsive prepubescent boy to be labeled as a “conduct problem” in school. In adolescence, the same boy is labeled “delinquent,” and in early adulthood, he is diagnosed as antisocial (Krastins et al., 2014). Girls usually show fewer problems before adolescence (Javdani, Sadeh, & Verona 2011). About 10% of children have conduct disorder; of that group, 75% are male (Nock, Kazdin, Hiripi, & Kessler, 2006). Those with conduct disorder are more likely to be diagnosed with antisocial personality disorder in later life (Krastins et al., 2014; Lahey, Loeber, Burke, & Applegate, 2005). The highest prevalence of antisocial personality disorder is among men aged 25 to 44 years. In middle and old age, the incidence of antisocial personality disorder declines. It is not clear whether this means the disorder diminishes with age or whether people with antisocial personality disorder fail to live past middle age (Hare, McPherson, & Forth, 1998; Oltmanns & Balsis, 2011). We do know that many die young from suicide, homicide, accidents, and substance abuse (National Collaborating Centre for Mental Health, 2010). Causes of Antisocial Personality Disorder Many researchers do not believe that there is a gene that makes a person a criminal. The modern view is that genetics and environment both contribute to every type of behavior, including antisocial behavior. In this section, we will examine some of the ways in which heredity, biology, and experience interact to produce antisocial behavior (see Figure 9.2). Figure 9.2: Risk factors for antisocial personality disorder Dysfunctional, abusive family environment Genetic tendency toward low arousal and sensation seeking Exposure to antisocial models in real life and in the media Antisocial Personality Source: From S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 10.3, p. 437. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 256 2/16/18 4:52 PM Evolution of a Personality Disorder: From Psychopath to Antisocial Personality Section 9.1 Genetics Considerable evidence points to a genetic element in antisocial behavior, particularly when the antisocial behavior includes aggression. This evidence includes a higher concordance for antisocial traits among identical siblings than among nonidentical siblings (National Collaborating Centre for Mental Health, 2010) and the finding that adopted children grow up to resemble their antisocial biological parents more than their non-antisocial adopted parents. All of the simple explanations that have been offered to date (for instance, that antisocial behavior is the result of an extra male chromosome) have proved to be blind alleys (Harmon, Bender, Linden, & Robinson, 1998). All researchers agree that the mechanism by which antisocial behavior is inherited is likely to be complicated (National Collaborating Centre for Mental Health, 2010). One popular theory is that low levels of serotonin possibly contribute to violent antisocial behavior (National Collaborating Centre for Mental Health, 2010). A complication for this hypothesis is that some of the variables that affect serotonin levels may, by themselves, cause antisocial behavior. For example, disadvantaged people, whose diets are poor, may have low serotonin levels. Their poverty also puts them at high risk of engaging in antisocial behavior. Is it their low serotonin that causes their antisocial behavior, or is it their poverty? Perhaps it is both. There is a pressing need to clarify the ways in which genes affect antisocial behavior. Opponents view genetic research as racially motivated, an attempt to redefine social problems in biological terms. They fear that genetic research will be used to stigmatize some minority groups as “born criminals.” Stigmatizing minorities is a danger, of course, but such an outcome can be avoided by properly educating the public about the meaning of genetic findings. Banning research on the genetics of antisocial personality disorder for political reasons would make it impossible for researchers to get a complete picture about how genetics and environment interact to produce antisocial behavior. Sensation Seeking A hypothesis with a long history in psychology suggests that antisocial personality disorder is the result of low emotional arousal (Schoorl, 2015). The idea is that low arousal is an aversive state that people naturally try to escape. They do this by seeking the stimulation and excitement that comes from dangerous, often antisocial, behavior (Schoorl, 2015). Of course, stimulation seeking need not always lead to antisocial behavior. Successful businesspeople, mountain climbers, and even scientists may also crave stimulation, but their behavior is not antisocial. Clearly, sensation seeking alone is not a sufficient explanation for why some people develop antisocial personality disorder. We must also explain why such people seek stimulation in socially disapproved ways. One likely place to look is in early childhood family experiences. Family Dynamics Psychodynamic theorists attribute antisocial and most other personality disorders to an absence of trust in other people (National Collaborating Centre for Mental Health, 2010). This loss of trust, which results from a lack of love during infancy, leads to emotional detachment. Children grow up unable to empathize with others; as a result, they become self-absorbed. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 257 2/16/18 4:52 PM Evolution of a Personality Disorder: From Psychopath to Antisocial Personality Section 9.1 The evidence for this view is the frequent finding of dysfunctional backgrounds in the histories of people with antisocial personality disorder (National Collaborating Centre for Mental Health, 2010). Again, however, there are many people who grow up with abuse who do not develop antisocial personality disorder, so family dynamics, on their own, are not a sufficient etiological explanation. Modeling and Media Many lifelong habits, including antisocial ones, are first developed in childhood. For this reason, a childhood spent with criminal models is an ideal training ground for children to learn antisocial behavior (Paris, 2001). More often, however, exposure to antisocial behavior is not direct, but through the media. Children see crimes, including violent ones, on television, in the movies, and of course on the Internet; they can even “perpetrate” a pretend form of violence by playing computer games. Certainly, some evidence indicates that the number of hours spent watching media violence is a predictor of aggression, both in children and later in life (Coker et al., 2015). But it is only one of many predictors, and not a very strong one at that. The correlation between aggression among males and the time spent watching violent television programs in the United States is 0.25. In Australia it is 0.13, and in Finland, 0.22 (corIngemar Edfalk/Blend Images/SuperStock relations can range from 1.0 to –1.0; numbers such as those here are not significant Does violence in the media contribute to because they are too weak to have statistical childhood violence? Researchers have significance; Huesmann, Moise, & Podolski, conducted numerous studies on this topic, but 1997). These correlations are too small to the results have not pinpointed an exact cause. explain or predict violence on their own (Barrett, 1997). Perhaps aggressive kids are more likely to watch violent videos and play violent computer games. To make things even more complicated, there are strong counterexamples to the relationship between media violence and actual violence. Japan, for instance, is famous for its violent pornographic comics and gory cartoons, yet it has a much lower incidence of violent crime than other countries (NationMaster, 2017). The evidence boils down to this: Violence in the media is not a sufficient explanation for childhood violence. Censorship of media violence may reduce violence among some susceptible children (at the risk of violating everyone else’s right to free speech), but it is unlikely to eliminate what is really a complicated social problem that has multiple causes. Treatment of Antisocial Personality Disorder Few adults with antisocial behavior seek treatment, and even fewer are motivated to change. In general, treatments tend to be ineffective (National Collaborating Centre for Mental Health, 2010). The most common “treatment” for people with antisocial personality disorder is incarceration in a correctional facility. But incarceration is notoriously unsuccessful © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 258 2/16/18 4:52 PM Evolution of a Personality Disorder: From Psychopath to Antisocial Personality Section 9.1 at rehabilitating most individuals, and repeat offenses are common. Psychological treatment does not usually thrive in involuntary settings such as prisons, yet there have been controlled studies showing the effectiveness of behavior therapy and behavioral staff training programs in reducing antisocial behavior, especially violence, by persons in institutions (Brazil, Van Dongen, Maes, Mars, & Baskin-Sommers, 2016). Clinicians have also had some success in reducing violence using antipsychotic and antidepressant medications, but more evidence is needed (Brazil et al., 2016). Given the difficulties encountered in treating antisocial personality disorder after it is established, some psychologists have emphasized prevention instead (National Collaborating Centre for Mental Health, 2010). Prevention programs are usually aimed at children and adolescents from high-risk backgrounds (abused children, children in single-parent families, and children from marginal neighborhoods). These programs include parent training and school-based counseling programs, among others. Highlight: The Slender Man Stabbings On May 31, 2014, a horrific case shocked the relatively small city of Waukesha, Wisconsin. Two 12-year-old girls, Anissa Weier and Morgan Geyser, lured their best friend, 12-yearold Payton (Bella) Leutner, into the woods after a birthday sleepover at Geyser’s house. Weier and Geyser allegedly stabbed Leutner 19 times, purportedly to impress the fictional character Slender Man. By sacrificing Leutner, they believed that their families and they would be spared the Slender Man’s fatal wrath. After being stabbed, Leutner crawled to a road and lay on a sidewalk where a cyclist found her and called 911. She was rushed to a hospital, at which point she was close to death. Miraculously she recovered after being hospitalized for six days and later returned to school. How could two 12-year-old girls, who were raised in evidently loving households where they did not lack basic needs, stab their best friend and leave her for dead? What could have led them to do such a thing? Although the case has a spectacular aspect to it that made major news headlines, an examination of some of the released facts provides a clearer picture of what might have occurred. Geyser purportedly had mental health issues since she was a very young child, according to her mother. What is not widely known is that her father has schizophrenia, currently in remission as of this writing. Weier was bullied extensively in school and would be drawn to unusual, often bizarre websites while withdrawing in her room. Still, do these few facts (there are many others, of course) help to explain how two young girls could find themselves facing at least 60 years in prison? More relevant to the facts presented in this chapter, what if one or both also had premorbid indicators (warning signs) of a personality disorder? Neither girl can be diagnosed with a personality disorder because they are not yet 18. But does the inability to diagnose them prevent us from properly treating the girls? It seems not, as Geyser is in an inpatient psychiatric unit under court order, after being diagnosed with early-onset schizophrenia, and is doing reasonably well. Weier’s trial concluded in September 2017. A jury determined that she was mentally ill at the time of the attack, so Weier will avoid prison. Her attorney, Maura McMahon, said during closing (continued) © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 259 2/16/18 4:52 PM Evolution of a Personality Disorder: From Psychopath to Antisocial Personality Section 9.1 Highlight: The Slender Man Stabbings (continued) arguments that Weier was lonely and depressed after her parents divorced and she latched onto Geyser. Once they became friends, they became obsessed with Slender Man, developing a condition called shared delusional disorder. Although not a DSM–5 diagnosis (the term in the DSM–5 is delusional symptoms in partner of individual with delusional disorder), this means that Weier ended up believing the Slender Man delusions that Geyser kept telling her about. The defense argued that Geyser’s delusions provided content for Weier’s delusions. This decision means that Weier will be sent to a psychiatric hospital rather than prison. A plea agreement states that she has to spend at least three years at a hospital before further determination is made. Geyser’s trial was scheduled to begin in October 2017 but in late September, she reached a plea deal. The terms of the deal state that Geyser will be evaluated by doctors, and based on the doctors’ testimony a judge will determine how long she will remain in a state mental hospital. Milwaukee Journal Sentinel/GettyImages Anissa Weier (left) and Morgan Geyser (right) developed shared delusional disorder and believed that they were being threatened by a fictional bogeyman called Slender Man. This case raises many interesting questions: Why can’t we diagnose someone under age 18 with a personality disorder, even when it seems likely the signs and symptoms are present? Can we help someone who believes that fictions like Slender Man are real and who will go as far as attempting to kill another person? Although we can hypothesize that since Geyser’s father has schizophrenia, she may have inherited its diathesis, what about Weier? Is this the behavior of two misguided 12 year olds? Why didn’t anyone pick up on Geyser’s warning signs earlier, before it was too late? Or Weier’s? Would you be able to work with someone who has difficulty separating fantasy from reality, not knowing the difference between “right” and “wrong”? How important is it to stop bullying once it is detected? For the moment, these questions must remain hypotheses to a case that, sadly, has echoes in many school shootings and other tragic incidents, in which bullying and other possible premorbid indicators of a future personality disorder, or other kind of mental illness, are missed, downplayed, or ignored. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 260 2/16/18 4:53 PM Section 9.2 Diagnosing Personality Disorders 9.2 Diagnosing Personality Disorders All personality disorders begin to become apparent during adolescence or early on in adulthood, although some do not make their first appearance until adulthood (APA, 2013). Once these disorders appear, they change little over the years, and they affect behavior in numerous situations. Some personality disorders—antisocial personality disorder, for example—do not normally cause the individuals who have them personal distress. Instead, other people, especially their victims, feel the anguish. In such cases, diagnosis depends not on the self-perceptions of the individuals concerned but on the effects of their behavior on others. This is not unusual in abnormal psychology. Categories Versus Dimensions Because each of us can be described by noting where we fall on one or more personality traits, or “dimensions,” some psychologists have advocated a dimensional approach to diagnosing personality disorders. Instead of employing the “exclusional” diagnostic categories of the DSM–5—a person either meets the diagnostic criteria for a personality disorder or does not meet them—the dimensional approach to diagnosis describes people using a standard set of personality dimensions. The DSM–5 includes the dimensional model in Section III, “Emerging Measures and Models.” This section includes proposed diagnostic criteria for this new model. Perhaps this model will replace the current personality disorders model in the DSM’s next revision (see the accompanying Highlight). Highlight: Personality Disorder Trait Specified (PDTS) The APA (2013) has come up with an alternative dimensional approach to be considered in a possible DSM–5 update. A core component of this approach is the diagnosis of personality disorder trait specified (PDTS). Individuals would receive this diagnosis if one or more of their traits significantly impaired their functioning in everyday life. Psychologists and other helping professionals would identify and list the traits that were impaired, as well as rate the severity of the impairment. The five groups of traits are as follows: • • Negative affectivity: People who display this trait have and experience negative emotions frequently and intensely. They will demonstrate at least one of the following traits: emotional lability (unstable emotions), anxiousness, separation insecurity, submissiveness, hostility, perseveration (repeating certain behaviors despite repeated failures from prior attempts), depression, suspiciousness, and restricted affectivity (lack of affect). Detachment: These people often avoid social interactions, often withdrawing from them. They will demonstrate one of the following traits: withdrawal, intimacy avoidance, anhedonia (inability to feel pleasure or get pleasure from pleasurable things), depression, restricted affectivity, and suspiciousness. (continued) © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 261 2/16/18 4:53 PM Diagnosing Personality Disorders Section 9.2 Highlight: Personality Disorder Trait Specified (PDTS) (continued) • • • Antagonism: These individuals will behave in ways that will put them in confrontation with others. They will demonstrate one of the following traits: manipulativeness, deceitfulness, grandiosity, attention seeking, callousness, and hostility. Disinhibition: These individuals behave impulsively without reflecting on potential future consequences. They will demonstrate one of the following traits: irresponsibility, impulsivity, distractibility, risk taking, and lack of rigid perfectionism. Psychoticism: These individuals have unusual and bizarre experiences. They will demonstrate one of the following traits: unusual beliefs and experiences, eccentricity, and cognitive and perceptual dysregulation (odd or unusual thought processes or sensory experiences) (APA, 2013). An individual would qualify for a PDTS diagnosis if he or she has significant impairment in any of these five groups of traits, or in only one of the traits listed in any of the groups. As mentioned earlier, this approach and diagnosis are currently in review for the next revision of the DSM–5. What is your opinion about this dimensional approach? The advantage of the dimensional approach is that it avoids pigeonholing people into narrow categorical boxes, thereby allowing them to be described in richer and more complex ways. Over the years, several attempts have been made to develop dimensional systems for describing personality (Cloninger, Bayon, & Przybeck, 1997; Widiger & Trull, 2007). These have not had wide consensus because psychologists have not been able to agree on which personality dimensions to use for this purpose (Widiger, 1991). One more widely accepted model is the five-factor model. People are rated on the following dimensions, and the combination determines the reasons why we are all so different: extroversion, agreeableness, conscientiousness, neuroticism, and openness to experience (Costa & McCrae, 2005; Goldberg, 1993). Types of Personality Disorders Following the DSM–5, this chapter divides the personality disorders into three clusters. Cluster A includes the paranoid, schizoid, and schizotypal personality disorders. Individuals who fall into Cluster A appear odd or eccentric. Cluster B includes the antisocial, borderline, histrionic, and narcissistic personality disorders. Individuals in Cluster B are dramatic, emotional, and erratic. Cluster C includes the avoidant, dependent, and obsessive-compulsive personality disorders. Individuals in Cluster C are anxious and fearful. It is not uncommon for the same person to be simultaneously diagnosed with personality disorders from more than one cluster (APA, 2016; Phillips & Gunderson, 1996; Skodol, 2005). The precise number of personality disorders and the names of these disorders have varied from one version of the DSM to the next. Although the DSM–5 has settled on the 10 personality disorders listed in Table 9.1, keep in mind that these disorders represent only a sample of the total number of potential personality disorders. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 262 2/16/18 4:53 PM Section 9.2 Diagnosing Personality Disorders Table 9.1 DSM–5 personality disorders Diagnostic Term Primary Personality Characteristics Cluster A Paranoid personality Distrust and suspicion of others, poor social relations Schizotypal personality Cluster B Eccentric behavior, including cognitive distortions Antisocial personality Disregard of the rights of other people Histrionic personality Excessive emotional display and the pursuit of attention Schizoid personality Borderline personality Narcissistic personality Restricted range of emotions and unstable relationships Unstable relationships, poor self-image, impulsivity Cluster C Grandiose feelings of superiority Avoidant personality Socially sensitive, inhibited, feelings of inadequacy Obsessive-compulsive personality Preoccupation with order and control Dependent personality Submissive and needing the care of others Diagnostic Reliability Clinicians have difficulty deciding which personality disorder diagnosis is appropriate for which individual. The problem is that the same diagnostic criteria can be applied to supposedly different disorders. Clinicians have no trouble agreeing that a person has poor social relations (one of the diagnostic criteria), but they do not agree about whether a person with poor social relations should be classified as having a borderline, schizoid, or avoidant personality disorder (each of which is marked by the same criterion—poor social relations). Therefore, diagnostic reliability (the consistency of a measuring device, here referring to the DSM–5) is rather poor. Similarly, hostility (another of the diagnostic criteria) is easy to recognize, but of little discriminatory value because it is a feature of more than half the personality disorders. Also, given the overlapping diagnostic criteria, it is not surprising that, as mentioned earlier, there is high comorbidity among personality disorders (APA, 2013). In fact, choosing between two or more personality disorders may be so difficult that clinicians may find it easier to simply give people both diagnoses. Diagnostic Validity The predictive value of the personality and impulse-control disorders is somewhat uncertain. Here we would examine validity, that is, does the DSM–5 measure what it claims to measure? In addition, does the DSM–5 have eternal validity, meaning do the diagnostic criteria generalize to many individuals? Knowing that someone has a personality disorder tells us little about © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 263 2/16/18 4:53 PM Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders Section 9.3 how different personalities develop. Predicting how a person will behave in any situation requires that we understand not only the person’s personality but also the social situation in which the behavior takes place (Sherman et al., 2015). Diagnostic Biases Clinicians must be on the alert for potential biases in themselves when making any diagnosis, but personality disorders lend themselves to diagnostic biases. For example, dependence, submissiveness, and allowing one’s life to be directed by a spouse are all signs of a dependent personality disorder. However, they are also traits encouraged in females by many societies. If women adopt the dependent social role expected by their social group, are we really justified in calling their behavior a personality disorder? And gender biases are not the only ones that clinicians must avoid. Unless clinicians are careful, their evaluation of other people may also be biased by their own beliefs about or perceptions of social class, ethnicity, age, and education. As discussed in the following sections on specific personality disorders, each of these variables can bias clinical judgments about who is suffering from a personality disorder. 9.3 Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders Cluster A personality disorders are marked by eccentricity, not to the point of losing touch with reality, but enough for the individual to be perceived by others as odd. The disorders included in Cluster A all share at least a superficial similarity with schizophrenia. Indeed, Cluster A personality disorders have sometimes been construed as milder versions or precursors of schizophrenia (Via et al., 2016). There is considerable overlap among the Cluster A personality disorders, making it difficult for clinicians to differentiate among them (APA, 2013; Via et al., 2016). Paranoid Personality Disorder People with paranoid personality disorder lack trust in others and constantly fear that their friends may be disloyal or unfaithful. Consequently, people with paranoid personality disorder avoid revealing their thoughts and feelings. Often, others perceive them as being hypersensitive. Those with this disorder may interpret even innocuous events (omission of their name from a roster, for example) as a sign that others are plotting against them. Any offers of assistance are taken as criticisms that the person is unable to cope on his or her own. Because they react to these perceived insults with anger, people with paranoid personality disorder are perceived by others as hostile. At one time, paranoid personality disorder was viewed as a milder form of schizophrenia, but there are important differences between the two conditions. In contrast to people with © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 264 2/16/18 4:53 PM Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders Section 9.3 schizophrenia, those with paranoid personality disorder do not have delusions, hallucinations, or other forms of thought disorder (APA, 2013). Instead, they are characterized mainly by their suspicion of other people. Today, most clinicians believe that paranoid personality disorder is at best only a distant member of schizophrenia spectrum and other psychotic disorders (Triebwasser, Chemerinski, Roussos, & Siever, 2013). Sometimes, several people with paranoid personality disorder band together into groups with others who share their paranoid beliefs. Of course, seemingly “paranoid” people may have real enemies, so this diagnosis should not be applied lightly to political or economic refugees or to people whose backgrounds may have actually included conspiracies and prejudice. Some critics have argued that paranoid personality disorder should have been removed from the DSM– 5, as there is not enough empirical data to support its inclusion (Triebwasser et al., 2013). Etiology Paranoid personality disorder first becomes apparent in childhood and seems to occur more often in males than females (APA, 2013). It affects between 0.5% and 4.4% of the general population (APA, 2013; O’Connor, 2008; Triebwasser et al., 2013). Because both traumatic brain injury and substance abuse may produce paranoid symptoms, care should be taken to exclude both possibilities when making the diagnosis (Gauba, Thomas, Balhara, & Deshpande, 2016). Treatment Few people with paranoid personality disorder seek psychological treatment; they are too suspicious of therapists. Those who do find their way into treatment may receive psychodynamic psychotherapy, cognitive-behavioral therapy, and medication. Unfortunately, none of these approaches to treatment have met with much success (Triebwasser et al., 2013). Schizoid Personality Disorder Schizoid personality disorder consists mainly of negative rather than positive symptoms. As was discussed in Chapter 8, positive and negative do not refer to “good” and “bad” aspects. Rather, positive symptoms refer to something added to an individual’s behaviors or personality (like a delusion), whereas negative symptoms refer to an absence of something or some kind of behavior that typically is present (for example, proper hygiene or speech). That is, the defining feature of schizoid personality disorder is not a delusion, obsession, or thought disorder—it is the lack of social relationships (Triebwasser, Chemerinski, Roussos, & Siever, 2012). People with schizoid personality disorder prefer solitary pursuits and spend much of their time alone (see the accompanying Highlight). They have flat affect (a limited range of emotions) and are indifferent toward the opinions of others. Because of their social isolation, people with schizoid personality disorder are socially inept and appear self-absorbed, cold, and aloof (Triebwasser et al., 2012). © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 265 2/16/18 4:53 PM Section 9.3 Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders Highlight: Veronica’s Sunday Veronica is a 32-year-old woman who works during the week as a security guard at a bank. This excerpt from a letter written by Veronica’s sister, with whom she lives, to their mother, is a description of a typical Sunday in the life of this woman with a schizoid personality disorder: Dear Mom, I hope you are well, and over your cold. I am doing OK, but I’m worried about Veronica. I have been keeping a close eye on her as you suggested, but she seems to be getting even more withdrawn. Let me tell you about Sunday. Veronica got up at 8:30 and switched on the television. She watched for an hour while still in bed. She then had some juice and coffee while watching a news show on television. At around 10:30, she fed Kat [the cat]. She sat and watched the cat eat for a while and then spent 45 minutes washing and ironing her clothes. She organized her drawers and then had a shower and got dressed. By this time, it was noon. Her next activity was to sit on a chair directly in front of a window and read the newspaper that we get delivered. After about an hour of this, Veronica once again turned on the television. She watched a talk show, and then she went outside for a walk. When she returned home, she ate a tiny dinner and watched television until late, when she fell asleep. She did not utter a word to me, or anyone else, all day. . .. To keep schizophrenia and schizoid personality disorder separate, the DSM–5 rules out schizoid personality disorder in people with schizophrenia (or any other psychotic disorder). It is also important that diagnosticians consider a person’s social situation. For example, the diagnosis of schizoid personality disorder is inappropriate for people who have recently migrated from one culture to another. Although immigrants may show the signs of a schizoid personality disorder (immigrants often take a while to settle into their new surroundings), it would be unwise to make a diagnosis until they have had the opportunity to adjust to their new environment. Finally, the diagnosis should be reserved for people in distress, not for people who prefer and adjust well to living as “loners.” Etiology Although the term simple schizophrenia was once used to describe people with schizoid personality disorder, it, like paranoid personality disorder, is probably only a distant (at best) member of the spectrum of schizophrenia-related disorders Mrk movie/Marka/SuperStock Some people have diagnosed Batman with schizoid personality disorder due to his solitary tendencies and aloof persona. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 266 2/16/18 4:53 PM Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders Section 9.3 (Fulton & Winokur, 1993; Laulik, Chou, Browne, & Allam, 2013; Maier, Lichtermann, Minges, & Heun, 1994). Schizoid personality disorder is no more common among the relatives of people with schizophrenia than it is among the relatives of people without schizophrenia. Like paranoid personality disorder, it is more likely to be found among the relatives of depressed people than of schizophrenic people. Psychodynamic (and most behavioral) theorists blame rejecting and abusive parents for causing their offspring to shun other people (Laulik et al., 2013; Sperry, 2003). The trouble with this hypothesis is that precisely the same etiology is applied to paranoid personality disorder. What psychodynamic theorists do not explain is why some rejected children withdraw and develop a schizoid personality disorder, whereas others react with anger and become paranoid. Based on the restricted range of affect often displayed by people with schizoid personality disorder, cognitive theorists have hypothesized that their symptoms are the result of some deficit in processing emotional information (Smith, 2006; Triebwasser et al., 2012). Treatment People with schizoid personality disorder rarely seek treatment; they are too disengaged from others to care and too threatened by close relationships to get involved in psychotherapy (Mittal, Kalus, Bernstein, & Siever, 2007; Triebwasser et al., 2012). Those who do find their way into treatment usually suffer from some associated condition, such as substance abuse or depression. For those who receive treatment, psychoanalytic therapy focuses on working through the trauma produced by early rejection, whereas cognitive-behavioral therapy attempts to teach people the social skills they need to interact with others. There have been case reports of successful psychological treatment of schizoid personality disorder in young people (Gooding, 2016; Herlihy, 1993), but, for most people, psychotherapy has produced only limited success (Belcher et al., 1995) and medications have not proved much better (Gooding, 2016; Koenigsberg et al., 2002). Schizotypal Personality Disorder Like people with schizoid personality disorder, those with schizotypal personality disorder are loners who are unable to form relationships with other people or are uninterested in doing so. They prefer solitary activities to those involving others, and, like people with schizoid personality disorder, they are often perceived as cold and unemotional. There are also similarities between schizotypal personality disorder and paranoid personality disorder. Both disorders are marked by suspicion of the motives of others and by ideas of reference, the belief that unrelated comments and events pertain to those with the disorder. Clearly, the schizotypal personality disorder shares symptoms with both the schizoid and the paranoid personality disorders, but it differs in an important respect: Schizotypal personality disorder is hypothesized to be related to, and like, schizophrenia (Koenigsberg et al., 2005; Thames & Lilienfeld, 2015). People with schizotypal personality disorder have peculiar thoughts, rambling speech, odd appearance, and eccentric behaviors. Put simply, schizotypal personality disorder seems to be a mild form of schizophrenia that occurs in approximately 0.6% to 3.9% of the population (APA, 2013; Bollini & Walker, 2007; Rosell et al., 2014; Thames & Lilienfeld, 2015). © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 267 2/16/18 4:53 PM Section 9.3 Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders Etiology Because of the similarity between schizotypal disorder and the schizophrenia spectrum of disorders, researchers have tried to apply the diathesis-stress etiological model of schizophrenia to schizotypal personality disorder. Certainly, the diathesis appears to be similar. Schizotypal personality disorder is most commonly found in families with schizophrenic relatives (Thames & Lilienfeld, 2015), and people with schizotypal personality disorder exhibit attentional deficits similar to those seen in people with schizophrenia (Bollini & Walker, 2007; Thames & Lilienfeld, 2015). The similarities between the two disorders do not end there. Both schizophrenia and schizotypal personality disorder have also been linked to higher than average levels of dopamine as well as to enlarged brain ventricles (Bollini & Walker, 2007; Fervaha & Remington, 2013). Treatment As it is with schizophrenia, psychotherapy is of limited value in schizotypal personality disorder (Ewing, Falk, & Otto, 1996; Ryan, Macdonald, & Walker, 2013). The most successful treatment approaches mirror those used in schizophrenia—skills training (McKay & Neziroglu, 1996; Ryan et al., 2013) and antipsychotic medication (Bollini & Walker, 2007; Ryan et al., 2013). See Table 9.2 for a comparison of Cluster A personality disorders and schizophrenia. Table 9.2 Comparison of Cluster A personality disorders and schizophrenia on selected characteristics Disorder Schizophrenia Characteristics Negative Symptoms (e.g., blunt affect) Yes Cluster A Personality Disorders Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder Yes Yes Paranoid Ideas Family Members With Schizophrenia Positive Symptoms (e.g., thought disorder) Yes Yes Yes Yes Yes Yes Yes © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 268 2/16/18 4:53 PM Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders Section 9.4 9.4 Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders People with Cluster B personality disorders tend to be self-absorbed. They find it difficult to empathize with others because they spend so much time and energy on themselves. In addition, they exaggerate the importance of everything that happens to them, usually in a theatrical and overly dramatic way. Because of their excessive self-concern and melodramatics, people with Cluster B personality disorders find it difficult to establish and maintain interpersonal relationships (APA, 2013). Antisocial personality disorder has already been discussed, so this section focuses on the remaining three Cluster B disorders: borderline, histrionic, and narcissistic personality disorders. Borderline Personality Disorder Clinicians and researchers who work from different paradigms have used the term borderline in several different ways: (a) to refer to people whose behavior fell at some hypothetical border between “neurotic” mood disorders and psychotic ones, (b) as a general term for the symptoms caused by mild brain damage, and (c) to describe people whose poor social relations are marked by manipulative suicide attempts (Gunderson, Zanarini, & Kisiel, 1995; Ogden & Prokott, 2013; Tyrer, 1994). In an attempt to give systematic meaning to the term borderline, the DSM–5 has chosen to emphasize instability and impulsivity. According to the DSM–5, people with borderline personality disorder are insecure because they have a morbid fear of abandonment. They want to form close relationships, and, initially at least, they succeed. But their need for attention and reassurance eventually becomes too overwhelming and their relationships break down. This is a recurring cycle—other people begin as perfect friends and evolve into enemies; there is no in-between. This tendency to categorize people as entirely good or entirely bad is known in psychoanalytic circles as “splitting.” When relationships deteriorate, people with borderline personality disorder may threaten to harm themselves just to keep the connection going. If this does not work (and it rarely does), they may actually carry out their threats by mutilating or even killing themselves (Ogden & Prokott, 2016; Sherry & Whilde, 2008). In addition to self-harm, people with borderline personality disorder may engage in various forms of imprudent behavior—reckless driving, unsafe sex, gambling, and substance abuse (Schub & Kornusky, 2016; Sherry & Whilde, 2008). Indeed, their moods tend to swing widely depending on the state of their interpersonal relationships. When these are going well, they may be elated, friendly, and good company. When their relationships are going badly, they become depressed, sullen, and aggressive. Etiology There is considerable overlap between the symptoms of antisocial personality disorder and those of borderline personality disorder. There are some differences as well. Although people with both diagnoses are impulsive, reckless, unable to form stable relationships, and often hostile, borderline personality is also associated with a morbid fear of abandonment. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 269 2/16/18 4:53 PM Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders Section 9.4 Borderline personality disorder occurs in anywhere from 1.6% to 5.9% of the general population (APA, 2013; Sherry & Whilde, 2008), with about 75% being female. As we have seen, sex differences in the incidence of a disorder can have many explanations. In the case of borderline personality disorder, social factors, especially sex role expectations, seem to play an important part (Becker, 1997; Hoertel et al., 2014). Through the process of socialization, similar etiological factors wind up producing somewhat different disorders. For instance, it is possible that the underlying causes of antisocial and borderline personality disorders are similar but that women are socialized to be more frightened of being alone and to turn their aggression inward in the form of suicidal gestures rather than outward toward others (Hoertel, Peyre, Wall, Limosin, & Blanco, 2014; Paris, 1997). Of course, social roles change from one society to another, so it is important to keep in mind that practically all of the research and clinical reports concerning borderline personality disorder come from developed countries such as the United States. Traditional societies, such as those found in developing countries, have different sex roles. For example, in some societies, women are almost guaranteed supportive relationships through a network of mutual family and community obligations. Perhaps this is the reason such societies have a low incidence of borderline personality disorder (Paris, 1996; Paris & Lis, 2012). Borderline personality disorder has been attributed to parental loss or abuse in childhood (Ogden & Prokott, 2016; Sansone, Levitt, & Sansone, 2005) or to posttraumatic stress later in life (Ogden & Prokott, 2016; Zlotnick, 1997). In both cases, psychological trauma is thought to produce a fear of further loss and a subsequent fear of abandonment (Ogden & Prokott, 2016; Sherry & Whilde, 2008). Although this seems a plausible theory, it is hardly specific to borderline personality disorder. Parental loss and abuse are found in the backgrounds of many psychological disorders. A similar lack of specificity may be found in the various biological explanations offered for borderline personality disorder—genetics, low levels of serotonin (Norra et al., 2003; Ogden & Prokott, 2016), thyroid dysfunction (Klonoff & Landrine, 1997; Sinai et al., 2015), and brain structures either being unusually small or being overactive or underactive (Donegan et al., 2003; Visintin, Voci, Pagotto, & Hewstone, 2016); all occur in other disorders as well. Treatment There have been many attempts to develop treatments for borderline personality disorder, but none has proved especially successful. Psychoanalytic psychotherapy concentrates on analyzing the transference relationship that develops between patient and therapist. That is, in psychoanalysis, it is essential to establish a patient-analyst relationship in which the patient responds to the analyst as though the analyst is or was an important figure (for example, father, mother) in the patient’s life. The goal of treatment is to use the transference relationship as a model to show people the way in which they undermine their interpersonal relationships (Gabbard et al., 1994; Horwitz, 1996; Stoffers et al., 2013). A strong patienttherapist transference may also help people with borderline personality disorder to learn to trust others. As you can imagine, however, building a transference relationship and analyzing a client’s interpersonal functioning is difficult with people whose relationships are characteristically turbulent. Following their usual pattern, patients with borderline personality disorder begin by idealizing the therapist as a potential savior and later, through splitting, turn this completely around so that the therapist becomes a money-seeking charlatan. In such cases, © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 270 2/16/18 4:53 PM Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders Section 9.4 analyzing the transference relationship takes some time, with many regressions along the way (Bender & Oldham, 2005; Stoffers et al., 2013). Although cognitive-behavioral therapy may assist people with borderline personality disorder to lead more effective lives (Stoffers et al., 2013; Waldo & Harman, 1998), people with this disorder may find it difficult to complete a course of therapy. They may drop out of treatment at the first sign (real or imagined) that the therapist is neglecting them. To help such clients follow through with treatment, clinicians may first try to increase a client’s emotional stability. For example, emotional awareness training, in which people with borderline personality disorder are given practice in recognizing their emotions (as well as those being experienced by others) and then taught ways to control their emotions, may help clients to cope with the stress of cognitive and behavioral interventions (Oldham, 2006; Stoffers et al., 2013). Therapists, too, must make certain adjustments. For example, they must learn to deal with the manipulative behavior of clients who are hypersensitive to criticism and are always imagining that they are being rejected. Cognitive-behavioral therapists may employ a multimodal treatment strategy known as dialectical behavior therapy. This approach combines group and individual therapy, supportive counseling, and a behavioral contract (usually an agreement not to harm oneself) with skill training aimed at improving and maintaining relationships (Linehan & Dexter-Mazza, 2008; Stoffers et al., 2013). Support may also be given to friends and family members who need to learn what to expect and how to deal with a person who has a borderline personality disorder (Gale, 2016). In addition to psychological treatment, the entire spectrum of psychoactive drugs has been used to treat borderline personality disorder, usually in conjunction with some form of psychological therapy (Ogden & Prokott, 2016; Soloff, 2005). The most effective drugs are antidepressants (especially the SSRIs), which seem to reduce the impulsivity, depression, and rage that destroy relationships (Binks et al., 2006; Ogden & Prokott, 2013). Histrionic Personality Disorder Histrionic personality disorder is a direct descendant of the 19th-century concept of hysteria. People with this disorder do not have conversion symptoms, though. They are mainly motivated by the need to be the center of attention (Bates, 2016; Skodol, 2005). To gain the notice they crave, people with this disorder may act seductively, dress in eccentric clothes, or act in a loud and boisterous fashion. People with a histrionic personality disorder actively seek compliments and are easily upset by criticism. Because of their melodramatic displays, histrionic people are viewed as shallow and phony. RubberBall/SuperStock People with histrionic personality disorder desire to be the center of attention. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 271 2/16/18 4:54 PM Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders Section 9.4 Etiology Histrionic personality disorder appears to have a prevalence of 1.84% to 3% in the general population (APA, 2013; Bates, 2016; O’Connor, 2008) and affects men and women equally (Bates, 2016; O’Connor, 2008). Treatment Although people with histrionic personality disorder may seek treatment, they make difficult clients. They tend to use the therapeutic environment as another opportunity to “be on center stage” and present exaggerated versions of their problems (Bates, 2016; Gutheil, 2005). Group treatment is generally not possible for people with histrionic personality disorder because of their need to monopolize the therapist’s attention. Nor are histrionic people good candidates for insight-oriented therapy (self-awareness and understanding of the influence of the past on their present behavior); they find it impossible to accept any but their own interpretations of their behavior. Perhaps the best therapeutic approach is to concentrate on helping people with this disorder to separate important problems from trivial ones, and to teach them how to pay attention to others. There are no specific drug treatments for histrionic personality disorder, although drugs may be used to treat any comorbid disorders (such as major depressive disorder; Bates, 2016; Grossman, 2004). Narcissistic Personality Disorder According to Greek mythology, Narcissus was a boy of legendary beauty who fell in love with his own reflection in the waters of a pond. He stared at his reflection until he wasted away to a flower. From this story, Freud derived the word narcissistic, meaning a person who is consumed with self-love. Freud’s use of the term has evolved into the DSM–5 diagnosis of narcissistic personality disorder. People with this disorder are characterized by their strong sense of superiority. They consider themselves to be important and demand special treatment. People with this disorder are often rude because they view rules and common courtesy as meant for others (Kealy, Goodman, Rasmussen, Weiderman, & Ogrodniczuk, 2017; Miller, Campbell, & Pilkonis, 2007). Like people with histrionic personality disorder, narcissistic people crave attention. They dream of achieving positions that will gain them the power and attention they seek. More often, however, narcissistic people exaggerate their own successes and envy the achievements of others. Beneath the surface, narcissistic people are so plagued by self-doubt that, even when they have reached a goal, they remain unsatisfied because success never brings them the level of adulation they desire. Etiology In psychodynamic terms, narcissism starts in childhood. We are all narcissistic as children because the world seems to revolve around us. When we are hungry, someone feeds us; when we are cold, someone always caters to our needs. One of the most important tasks facing children during the process of socialization is learning that there are other people in the world, with their own feelings and needs. Learning to empathize with others is a skill that develops © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 272 2/16/18 4:54 PM Cluster C: Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders Section 9.5 through childhood and the teenage years, so we must be wary of applying the DSM–5 criteria to young people (APA, 2013). However, by early adulthood, a narcissistic personality disorder should become clear. Once such a disorder develops, it tends to be ongoing (Bates & Neff, 2017; Ronningstam, 1998). Narcissistic personality disorder affects about 0% to 6.2% of the general population (APA, 2013), mainly males. Treatment Both psychodynamic and cognitive-behavioral approaches to the treatment of narcissistic personality disorder focus attention on helping people to become more realistic in their goals and to find satisfaction and fulfillment in the normal events of daily life (Beck, Freeman, & Davis, 2004; Kealy et al., 2017). Training in recognizing and empathizing with the emotions of others is an important adjunct goal of treatment. As in many other personality disorders, drugs may be used to treat some symptoms or for comorbid disorders (Bateman, Gunderson, & Mulder, 2015; Joseph, 1997). 9.5 Cluster C: Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders The disorders in Cluster C share the characteristics of fearfulness and worry (Alpert et al., 1997; Laulik et al., 2013). In contrast to the anxiety disorders, however, Cluster C personality disorders tend to have an earlier onset, no clear cause, and a stable lifelong course (O’Donohue, Fowler, & Lilienfeld, 2007). Cluster C disorders include avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder. Research support for the various etiological hypotheses is very limited. At the same time, treatments for these disorders appear to be modestly to moderately helpful—considerably better than for other personality disorders. Avoidant Personality Disorder People with avoidant personality disorder are shy and socially uncomfortable. Unlike people with schizoid personality disorder, people with avoidant personality disorder would prefer to be sociable, but they avoid social contact because they fear embarrassment and criticism. In practice, it is difficult to separate avoidant personality disorder from social phobia (Prerost, 2016; Ralevski et al., 2005). When social anxiety is long-standing, the diagnoses are probably interchangeable. Because shyness and social reticence are developmentally appropriate for young children (and because some cultural groups encourage social timidity for one or both sexes), a client’s age and culture should be taken into account when making this diagnosis (APA, 2013). Avoidant personality disorder occurs in around 2.4% of the general population, and it affects men and women in equal numbers (APA, 2013; O’Connor, 2008; Prerost, 2016). It is often found in conjunction with the diagnosis of unipolar depression (APA, 2013; Prerost, 2016). Cognitive-behavioral treatments aimed at reducing social anxiety can also help people with avoidant personality disorder to lead fuller lives (Beck, 2016; Emmelkamp et al., 2006). © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 273 2/16/18 4:54 PM Cluster C: Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders Section 9.5 Etiology Avoidant personality disorder is similar to social anxiety disorder in a number of ways, and may be comorbid with it (see, for example, Eikenaes et al., 2013). Both disorders present with a fear of humiliation and low self-confidence. However, there appears to be a key difference between the two disorders: People with social anxiety disorder mainly fear social circumstances, whereas people with avoidant personality disorder fear close social relationships (Lampe & Sunderland, 2013). Others believe that the two disorders are very similar and therefore should be combined (Eikenaes et al., 2013). Treatment One of the main issues with treating individuals with avoidant personality disorder is keeping them in treatment. This should not be a surprise, as many of the patients begin to avoid the sessions. This is not necessarily resistance but is based on the patient’s not trusting the clinician, and fearing being rejected by the clinician. An important aspect of treatment is therefore for the clinician to gain the patient’s trust (Colli et al., 2014; Leichsenring & Salzer, 2014). Typically, clinicians will treat avoidant personality disorder the same way they treat social anxiety disorder, and the success rate is usually moderate to good (Kantor, 2010; Porcerelli et al., 2007). As you might expect, psychodynamic therapists try to help the patients recognize and resolve their unconscious conflicts (Leichsenring & Salzer, 2014). Cognitive therapists, among other aspects, will work with patients to help them change their upsetting, irrational beliefs and thoughts, carry on in the face of painful emotions, and improve their self-image (Beck et al., 2004; Rees & Pritchard, 2013). Behavioral therapists will provide social skills training as well as exposure therapy, gradually requiring patients to increase their day-to-day interpersonal interactions (Herbert, 2007). Group therapy can be especially successful, as it provides the patient a chance to practice interpersonal interactions in a safe environment (Herbert et al., 2005). Dependent Personality Disorder People with dependent personality disorder have a strong need to be taken care of by someone else, preferably someone important (Bornstein, 2005; Disney, 2013; Skodol, 2005). To fulfill this need, they tend to be submissive to the demands of their chosen caretaker, acting, at times, as if they were helpless to look after themselves. Like people with histrionic personality disorder, those with dependent personality disorder have a strong need for approval. However, dependent people are timid, whereas histrionic people actively seek attention. Like people with borderline personality disorders, dependent people worry about being abandoned. Instead of reacting with rage, however, dependent people become submissive. Finally, both avoidant and dependent personality disorders are characterized by feelings of inadequacy, but avoidant people tend to withdraw, whereas dependent people seek to develop relationships with people who can care for them. Dependent personality disorder affects anywhere from 0.6% to 2.5% of the general population (APA, 2013; Grant et al., 2004). The DSM–5 asserts that the disorder affects both sexes with only a small bias toward females (APA, 2013). This sex difference probably reflects the cultural stereotype of the dependent woman. Because young children are expected to be dependent and because some cultural groups foster dependent behavior among females, © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 274 2/16/18 4:54 PM Cluster C: Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders Section 9.5 caution should be taken in applying this diagnosis to children or to members of some cultural groups (APA, 2013). Etiology Although the precise causes of dependent personality disorder are not known, it is thought to begin with a fearful temperament (a genetic disposition) that evokes overprotectiveness from parents (Disney, 2013; Sperry, 2003). Illness in childhood, abandonment, and traumatic loss can produce a similar overprotectiveness. Children may resent this attitude but may learn to submit rather than challenge their parents. Treatment Few people seek treatment for dependent personality disorder. However, some may find their way into therapy for an associated anxiety or depressive disorder (Disney, 2013; Skodol, Gallaher, & Oldham, 1996). In psychodynamic treatment, the therapist uses the transference relationship first to form a bond with the client and then to teach the person how to separate. The idea is that, through the transference experience, the person will learn more effective modes of relating to others (Disney, 2013; Sperry, 2003). Cognitive therapists try to help their dependent clients to recognize the faulty cognitions that produce their lack of self-confidence (Disney, 2013; Freeman, 2002). Behavioral therapists use assertiveness training to enhance self-esteem by providing dependent clients with a nonsubmissive mode of relating to others. Relaxation training may also be helpful in reducing anxiety. Although people with this disorder usually go along with their therapist’s treatment suggestions (they are submissive people, after all), they are still difficult to treat because of their need for constant reassurance. Long-term treatment is probably not a good idea with dependent people because it may make them overly dependent on their therapist. Support and self-help groups could be useful places for clients to practice new skills learned in therapy (provided, of course, that clients participate in the group and do not simply let others do all the talking). Drugs may be prescribed for the anxiety and depression often experienced by people with dependent personality disorder (Disney, 2013; Fava et al., 2002), but care should be taken because clients may use drug overdoses as a way of manipulating other people. Obsessive-Compulsive Personality Disorder It is rather easy, based on the name among other aspects, to confuse obsessive-compulsive disorder (OCD) with obsessive-compulsive personality disorder. OCD behaviors fall along a continuum from relatively mild to severe (Stein & Hollander, 1997; Vorstenbosch et al., 2012). Obsessive-compulsive personality disorder (OCPD) behaviors fall at the mild end of the continuum. People who have this disorder do not display true obsessions or even severe compulsions. Instead, they are characterized by a perfectionistic attitude toward daily life (APA, 2013). People with this disorder try to maintain a rigid control over their routines and, when possible, the behavior of other people. They accomplish the latter by insisting on a tight adherence to rules and schedules. They feel that their approach to all matters is the only correct one, and they tend to deny that other people might have reasonable alternative views. Not surprisingly, they are viewed by others as moralistic, rigid, and stubborn. The © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 275 2/16/18 4:54 PM Cluster C: Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders Section 9.5 disorder seems to be more common among white, educated, married males and has a prevalence in the community of about 2.1% to 7.9% (APA, 2013; Bartz, Kaplan, & Hollander, 2007). Etiology ABC Photo Archives/GettyImages Felix Ungar (left) of The Odd Couple is a notorious neat freak, always mopping, cleaning, and picking up dust bunnies. He is always immaculately dressed. Does he have OCPD? As for many of the personality disorders, research on the etiology of OCPD is limited. A number of theories link OCPD with OCD even though there may in fact be little similarity between the two conditions. As you might expect, Freudian concepts are heavily represented. Freudian theorists suggest that people with OCPD are anal retentive. This is due to very strict toilet training by the individual’s parents during the anal stage. Therefore, they become anal retentive and fixated in the anal stage. They develop a lot of anger, which is repressed; in order to control this anger and stay in control, they withhold their feces. The end result is that they become extremely orderly and restrained (Millon, 2011). Cognitive theorists, as you might guess, believe that illogical and irrational thinking maintains OCPD (Beck et al., 2004; Weishaar & Beck, 2006). Treatment People with OCPD do not usually believe there is anything wrong with them. Because of this they are not likely to seek treatment unless they are also suffering from a comorbid condition. This is often an anxiety disorder or unipolar depression. They may seek treatment if a close friend or family member insists on it (Bartz et al., 2007). Part of the treatment process, therefore, might involve the clinician’s trying to establish rapport and trying to convince the patient to stay in treatment (Colli et al., 2014). In therapy, Freudians would try to help patients recognize and accept their insecurities and personal limitations. Cognitive therapists would again focus on helping patients to change their irrational, all-or-nothing thinking, as well as their perfectionism, procrastination, and chronic worrying. The response rate to both modalities is usually quite good (Svartberg & McCullough, 2010; Weishaar & Beck, 2006). © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 276 2/16/18 4:54 PM Chapter Summary Chapter Summary Evolution of a Personality Disorder • Personality disorders constitute distinct diagnostic categories; a person either meets the criteria for a personality disorder or does not meet them. • Alternatively, people may be described by where they fall on a variety of personality dimensions. The dimensional approach provides richer descriptions and avoids pigeonholing people into narrow categories. • Unfortunately, there are many possible personality dimensions, and no one knows which ones are appropriate for describing people. Diagnosing Personality Disorders • Clinicians often disagree about personality disorder diagnoses because of overlapping criteria. • Borderline, schizoid, and avoidant personality disorders are all marked by poor social relations. • To make diagnosis easier, clinicians often simply give people more than one personality-disorder diagnosis. • In some cases, personality-disorder diagnostic criteria reflect cultural and gender stereotypes. Antisocial Personality Disorder • The hallmark of antisocial personality disorder is a flagrant disregard for the rights of other people. • The disorder is found mainly in males, it affects between 0.2% and 3.3% of the population, and its incidence decreases with age. • Like much human behavior, antisocial personality disorder begins in childhood, especially among children from abusive or discordant families. • Few people with antisocial personality disorder are motivated to seek treatment. Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders • Cluster A personality disorders are marked by eccentricity, not to the point of losing touch with reality, but sufficient for the individual to be perceived by others as odd. • Psychological treatments for Cluster A disorders mirror those used in schizophrenia—social skill training and antipsychotic medication. Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders • People with Cluster B personality disorders are self-absorbed. They find it difficult to empathize with others, and they exaggerate the importance of everything that happens to them in a theatrical and overly dramatic way. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 277 2/16/18 4:54 PM Chapter Summary • Because of their excessive self-concern and melodramatics, people with Cluster B disorders find it difficult to establish and maintain interpersonal relationships. • These disorders are difficult to treat but may sometimes respond to therapy, particularly a mixture of psychodynamic and cognitive-behavioral treatment. • Drugs are also used in treatment but mainly for associated conditions or specific symptoms. Cluster C: Avoidant, Obsessive-Compulsive, and Dependent Personality Disorders • The disorders in Cluster C share many characteristics with the anxiety disorders, such as fearfulness and worry, and they tend to co-occur with depression. • Cluster C personality disorders tend to have no clear cause and a stable lifelong course. Critical Thinking Questions 1. Personality disorders are chronic and difficult to treat. What makes these disorders so difficult to treat? 2. Antisocial personality disorder appears to be associated with criminal tendencies or behaviors. Discuss the possible connection between the two. 3. Narcissistic personality disorder was under consideration for removal from the DSM–5 as a diagnostic category. Discuss some possible reasons for this consideration. 4. Individuals with a Cluster B personality disorder often do not come into treatment voluntarily. Let’s assume you had someone with antisocial personality disorder in treatment who hated being there. How would you go about treating him or her? 5. Imagine that your coworker has a narcissistic personality disorder. What types of issues do you think you might encounter in working with him or her? Key Terms antisocial personality disorder A Cluster B disorder; the key characteristic is a flagrant disregard for the rights of other people. People with antisocial personality disorder are often irresponsible, impulsive, and untrustworthy. avoidant personality disorder A Cluster C disorder; people with avoidant personality disorder are shy and socially uncomfortable. They would prefer to be sociable, but they avoid social contact because they fear embarrassment and criticism. borderline personality disorder A Cluster B disorder; people with borderline personality disorder are insecure because they have a morbid fear of abandonment. They tend to be self-injurious and have short-term, intense interpersonal relationships. dependent personality disorder A Cluster C disorder; people with this disorder have a strong need to be taken care of by someone else, preferably someone important. They tend to be submissive to the demands of their chosen caretaker, acting, at times, as if they were helpless to look after themselves. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 278 2/16/18 4:54 PM Chapter Summary dialectical behavior therapy A treatment approach for borderline personality disorder that combines group and individual therapy, supportive counseling, and behavioral contracting with skill training aimed at improving and maintaining relationships. dimensional approach This system for diagnosing personality disorders describes people using a standard set of personality dimensions. histrionic personality disorder A Cluster B disorder; these individuals are motivated mainly by the need to be the center of attention. People with this disorder may act seductively, dress in eccentric clothes, or act in a loud and boisterous fashion. narcissistic personality disorder A Cluster B disorder; these individuals have a strong sense of superiority. Those with the disorder consider themselves to be important and demand special treatment, and they are often rude because they view rules and common courtesy as meant for others. obsessive-compulsive personality disorder A Cluster C disorder; people who have this disorder are characterized by a perfectionistic attitude toward daily life. They try to maintain a rigid control over their routines and, when possible, the behavior of other people. paranoid personality disorder A Cluster A disorder; individuals with the disorder avoid revealing their thoughts and feelings and may interpret even innocuous events as a sign that others are plotting against them. personality The sum of an individual’s traits. personality disorder trait specified (PDTS) A personality disorder currently under consideration for inclusion in a future DSM–5 revision. Individuals would receive this diagnosis if one or more of their traits significantly impaired their functioning in everyday life. psychopath A person who lacks empathy, does not fear punishment, and will continue to break the law even if capture and punishment are likely. schizoid personality disorder A Cluster A disorder; people with this disorder have negative rather than positive symptoms. The defining feature of schizoid personality disorder is not a delusion, obsession, or thought disorder—it is the lack of social relationships. schizotypal personality disorder A Cluster A disorder; those with this disorder are considered “loners” who are unable to form relationships with other people or are uninterested in doing so. They are often perceived as cold and unemotional. shared delusional disorder Not a DSM–5 diagnosis (the DSM–5 term is delusional symptoms in partner of individual with delusional disorder); refers to a condition in which an individual’s delusions provide content for another person, thus fostering that person’s delusions. transference relationship In psychoanalysis, establishing a patient-analyst relationship in which the patient responds to the analyst as though the analyst is or was an important figure (for example, father, mother) in the patient’s life. personality disorder An enduring pattern of inner experience and behavior that deviates markedly from the expectations of an individual’s culture. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 279 2/16/18 4:54 PM © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_09_c09_249-280.indd 280 2/16/18 4:54 PM 7 Sleep-Wake and Eating Disorders fpwing/iStock/Thinkstock Chapter Objectives After reading this chapter, you should be able to do the following: • Describe the stages of the normal sleep cycle. • Know and describe the main differences between the major sleep-wake disorders. • Understand the main ways to treat sleep disorders. • Know and describe the main feeding disorders. • Know and describe the major differences between anorexia nervosa, bulimia nervosa, and binge-eating disorder. • Describe some of the methods used to treat eating disorders. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_07_c07_181-212.indd 181 2/16/18 4:43 PM Section 7.2 Dyssomnias 7.1 An Introduction to Sleep-Wake Disorders: The Normal Sleep Cycle We sleep close to 3,000 hours per year, which means that we spend about one third of our lives asleep. However, according to the National Sleep Foundation (2017), about 40% of people in the United States don’t get enough sleep, and lack of proper sleep can lead to health problems (Depner, Stothard, & Wright, 2014; Liu, 2016; Schochat, Cohen-Zion, & Tzischinsky, 2013). The normal human sleep cycle consists of four different stages of sleep, one of which involves rapid eye movement (REM) and three of which do not (non-REM, or NREM, sleep). The cycle begins with NREM Stage 1, which begins shortly after you fall asleep. In this stage, which lasts from 1 to 10 minutes, you are lightly asleep. However, you can quickly and somewhat easily return to being fully awake. Although you are asleep, you may wake up from this stage feeling like you didn’t sleep at all. The next stage is NREM Stage 2. This stage lasts about 20 minutes and is characterized by a slowing heart rate and a decrease in body temperature. You spend about 45% of your sleep time in NREM Stage 2 sleep. Your body reduces its activity to prepare you to go into a deep sleep, and it becomes harder to wake you up. Typically, NREM Stages 1 and 2 are referred to as light sleep. NREM Stage 3 comes next. This stage is the combination of what was previously separated into Stage 3 and 4 sleep and typically starts 35 to 45 minutes after falling asleep. Your brain waves slow down and become larger. In this stage, you will sleep through most potential sleep disturbances (noises and movements) without showing any reaction. If by some chance you actually wake up during NREM Stage 3 sleep, there is a good chance that you will feel disoriented for the first few minutes. Sometimes this stage is referred to as “slow-wave sleep” or “delta sleep.” The final stage of a normal sleep cycle is called REM Stage 4. The first REM sleep stage lasts around 10 minutes and usually happens after having been asleep at least 90 minutes. Your eyes move rapidly in all directions during REM sleep, almost as though you are watching a movie. Typically, REM stages get longer and longer as the night goes by. Dreams (and nightmares) usually happen during the last REM stage, which can last an hour and is the deepest. This stage is also known as “paradoxical sleep.” One reason for this: Even though your brain is quite active during the stage, most of your muscles are paralyzed (Chieh, 2015). The two main types of sleep disorders are the dyssomnias (irregularities or abnormalities in the amount, quality, or timing of sleep) and the parasomnias (sleep disturbances that result from unusual or abnormal events that occur when one is asleep, typically during the night). Psychological factors can play an important role in these disorders. Parasomnias can occur during both REM and NREM sleep. Somnambulism (sleepwalking) and enuresis (bedwetting) occur during the REM stage. We will describe the major sleep-wake disorders in the next two sections. 7.2 Dyssomnias Dyssomnias are disorders that affect the initiation or maintenance of sleep, which includes nighttime wakefulness, or excessive sleepiness. They include insomnia disorder, hypersomnolence disorder, narcolepsy, breathing-related sleep disorders, and circadian rhythm sleep-wake-disorders. © 2018 Bridgepoint Education, Inc. All rights reserved. Not for resale or redistribution. get83787_07_c07_181-212.indd 182 2/16/18 4:43 PM Dyssomnias Section 7.2 Insomnia Disorder Insomnia involves a disturbance in the amount, quality, or timing of sleep that occurs at least three nights per week for at least 3 months (American Psychiatric Association [APA], 2013). The most common sleep-wake disorder is insomnia, called insomnia disorder in the DSM–5. Insomnia disorder is characterized by difficulty falling asleep, maintaining sleep, or not feeling rested after normal amounts of sleep, occurring at least three nights per week for at least three months (American PsyOcusFocus/iStock/Thinkstock chiatric Association [APA], 2013). Difficulty Insomnia affects nearly 50% of the U.S. maintaining sleep is defined in the DSM–5 as having frequent awakenings or problems population every year. returning to sleep after awakening. Overall, about one third of all adults report some symptoms of insomnia, and about 6% to 10% meet the diagnostic criteria for insomnia disorder (APA, 2013; Morin & Jarrin, 2013). The National Sleep Foundation estimates that almost 50% of the U.S. population experiences some symptoms of insomnia during a given year (Morin & Jarrin, 2013). Typically these individuals go through the day quite sleepy and may have difficulty performing tasks, especially those that require memory and recall. This can also be dangerous as individuals may get sleepy while driving. Insomnia might be a result of the individual being under too much stress and being unable to cope, or perhaps being depressed or anxious. Insomnia can occur only on some nights but not others, or it can have a more chronic pattern, lasting weeks to many months, or even lasting a lifetime after onset. Hypersomnolence Disorder (Hypersomnia) Hypersomnolence disorder is characterized by excessive sleepiness even though the individual may have slept at least seven hours (this qualifies as a lot of sleep for many people these days). If a p...
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Substance Abuse with Personality Disorder

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Substance Abuse with Personality Disorder
The patient, Janice, is a 35-year-old Caucasian female admitted to the hospital
multiple times for self-inflicted cuts. Janice cuts herself to cope with the emotional pain she
experiences from her past relationships. Janice reports that she does not want to kill herself,
but cuts are a way for her to take away her emotional pain temporarily. In addition, Janice has
a history of being abusive in her relationships. This information provides context to her selfinflicted cutting behavior.
The symptoms of borderline personality disorder (BPD) include a pervasive pattern of
instability in personal relationships, intense and often overwhelming emotions, and impulsive
behaviors stemming from a heightened sensitivity to rejection and criticism and fear of
abandonment. These symptoms can cause significant distress and interfere with the patient’s
ability to function normally (Sansone & Sansone, 2011). Janice meets the criteria for BPD. In
addition, Janice’s history indicates that she is also at risk for further episodes of violence
towards herself. Therefore, Janice must receive treatment for her BPD to improve her overall
well-being.
According to Bhalavat (2019), BPD had been historically misunderstood and
misdiagnosed as schizophrenia until the 1980s, when experts understood the differences
between the two. However, despite current understanding, it is still difficult for physicians to
diagnose the disorder accurately. This difficulty primarily arises from the similarities of its
symptoms with other disorders and the common phenomenon that most people with BPD
also have a substance abuse disorder. Another aspect of BPD is its historical dismissal by
society, which has affected mental health treatment and research for years. The disorder
affects about 1.6 to 5.9 percent of the US population, with 10 and 20 percent of mental health
outpatients and inpatients having it, respectively. Additionally, the disorder affects more

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women than men, with studies showing that BPD is more common in high-income countries
than in low-income countries.
Janice’s symptoms’ intensity, duration, and focus support the BPD diagnosis. She has
been to the hospital several times, suggesting that she probably started presenting these
symptoms in her adult life. Bhalavat (2019) states that BPD becomes apparent in adulthood
in most cases. Moreover, the focus of her harmful behavior revolves around her relationships,...


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