Personality CHAPTER 18: PERSONALITY DISORDERS John Oldham, M.D. Past APA president, member Personality Disorders Work Group 1. “from the beginning of the development process for DSM-5, the personality disorders were identified as a place where we needed to move beyond the categorical diagnostic system of discrete disorders in DSM-IV toward a more dimensional system” 2. “personality types, traits, and disorders are on a continuous spectrum, much like blood pressure and hypertension. 3. “too much of a useful, adaptive trait may become a problem” 2 Personality Disorders (PD) • The PD Work Group proposed sweeping changes: – New conceptualization of PD – Fewer types of PD’s – Trait rating scales • Changes were not approved • DSM-5 retains DSM-IV-TR disorders – General criteria for a PD – Organization – But…updated text Three Major Clusters • Odd/Eccentric Cluster – Paranoid Personality Disorder – Schizoid Personality Disorder – Schizotypal Personality Disorder • Emotional/Erratic Cluster – – – – Antisocial Personality Disorder Borderline Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder • Anxious/Fearful Cluster – Avoidant Personality Disorder – Dependent Personality Disorder – Obsessive-Compulsive Personality Disorder • Diagnostic tip: First try to locate the appropriate cluster, then narrow to the specific disorder within that cluster. Everyone has personality • Everyone has STUFF. • That’s why we start with the personalitystuff, and we’ll add in other disorders as we go. Kluckhorn and Murray’s 1950 model of personality • Universal (We are all alike in some ways) • Group (Everyone in my group is alike in some ways--but different from non-group) • Individual (We are each unique in some ways) Personality as a set of skills • Each style represents a skill • to be able to take on a particular persona, assume a particular role, mask, or face. • It’s important to have several of these from which to choose. • Don’t need all of them • Genetically, we are more comfortable taking on a subset of styles Problems related to personality • Failing to switch to a more role-appropriate style • In a situation that calls for an extroverted role, you need to be able to do that Problems related to personality • Problem 1: Lack of available styles • (lack of personality skill sets) • Problem 2: Inflexibility • unwillingness or inability to move out of a specific style Personality Differentiation • Categorical Model • pregnant Dimensional Model • Descriptive • from DSM III on Interpretive - tall/short - hypertension - Big 5 - assumes causes Big 5 Personality Dimensions • Openness to Experience • Conscientiousness • Extraversion • Agreeableness • Neuroticism The Golden Mean of Aristotle • Falls equidistant between the extremes • Preferred alternative to panic • not fearlessness, but prudence Normalizing the MMPI Scale Scale name Underlying Dimension Negative Positive Hs Hypochondriasis conservation dependent, irritable, complaining, bodily preoccupations conscientious, careful, considerate, sincere D Depression evaluation critical, anxious, depressed, pessimistic deliberate, objective, contemplative, realistic Hy Hysteria expression denial, psychosomatic reactions, suggestible, overreactive empathetic, responsive, sensitive, optimistic assertion hostile, manipulative, impulsive, antisocial energetic, enterprising, venturesome, social role-flexibility self-recrimination, sex-role deviancy, identity confusion, unconventional colorful, dilettante, interesting investigative, curious, questioning, discriminatory Pd Mf Psychopathic Deviance Masculinity-Femininity Pa Paranoia inquiring grandiose, hypersensitive, suspicious, distrustful Pt Psychasthenia organization rigid, compulsive, obsessive, ritualistic methodical, systematic, convergent thinker, organized Sc Schizophrenia imagination bizarre, irrational, confused, idiosyncratic spontaneous, creative, imaginative, divergent thinker enthusiastic, eager, wholehearted, exuberant independent, self-reliant, Ma hypoMania zest hyper, ineffectual, disorganized, agitated Si Social Introversion autonomy reclusive, asocial, alienated free lance Ivey’s Developmental Personality Styles Nancy McWilliams’ Developmental Dimensions of Personality Sperry’s Developmental Levels of Personality Personality Style and Disorder Clusters • Cluster A (overlap with psychotic disorders) • Vigilant style & Paranoid personality disorder • Solitary style & Schizoid personality disorder • Idiosyncratic style & Schizotypal personality disorder • • Cluster B (overlap with depression and impulse-control disorders) • Adventurous style & Antisocial personality disorder • Mercurial style & Borderline personality disorder • Dramatic style & Histrionic personality disorder • Self-Confident style & Narcissistic personality disorder • • Cluster C (overlap with anxiety disorders) • Sensitive style & Avoidant personality disorder • Devoted style & Dependent personality disorder • Conscientious style & Obsessive-compulsive personality disorder • (Leisurely style & Passive Aggressive personality disorder) • • Others • Aggressive style & Sadistic personality disorder • Self-Sacrificing style & Self-Defeating personality disorder • Serious style & Depressive personality disorder • National online NPSP Sample DSM-5 criteria for Personality Disorders • Diagnosis of a personality disorder must satisfy the following general criteria in addition to the specific criteria listed under the specific personality disorder under consideration. • • A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas: • cognition (perception and interpretation of self, others and events) • affectivity (the range, intensity, lability, and appropriateness of emotional response) • interpersonal functioning • impulse control • • B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. • • C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. • D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood. • • E. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder. • • F. The enduring pattern is not attributable to the physiological effects of a substance (a drug of abuse, a medication) or another medical condition (e.g., head trauma). PRE890 Top Personality Styles 2011 2009 2007 2005 Conscientious Conscientious Conscientious Conscientious Dramatic Dramatic Dramatic Dramatic Serious Serious Vigilant Devoted Sensitive Sensitive Leisurely Solitary Serious Self Sacrificing Self Sacrificing Devoted Vigilant Self Sacrificing Self Sacrificing Leisurely B F X X X C X X X D X X X E X X X X A X J K X L X M N X O X P X 2 3 7 X X G X X X H X X X X X X I 4 X X X X X X X X X X X X X X X X X X X s 5 X X X X Vigil an t Solit ary Serio u Sens itive Self S acrif ic i 6 ng Self C onfid ent urial Leisu rely Merc ious ncra t ic atic ted Idios y 1 Dram RANK Devo Cons cient Aggr essiv e Adve nturo us PSP for PRE 890 2013 8 X X X X TK A 1 2 3 nturo urial 4 5 t ary us Vigil an Solit Serio Sensi tive 6 ent icing Self S acrif Merc rely c ious us yncr ati L e i su Idios atic ted cient Dram Devo Cons Aggr essiv e Adve Self C onfid 7 Tom B C D E F G H I J K L M N <== Total TK 2013 TK 2007 Personality Self Portrait Exercise • • • • • • • • • • • • • • • • • 1. List things about the personality style that you would consider STRENGTHS. For example, my highest score is on the Conscientious style, and some things about that style that come in handy include things like: Being capable of immense, single-minded effort. Whenever they commit to a task, they do the job completely and thoroughly. When a problem arises, they work tirelessly until it is solved. 2. List things about the personality style that, if unchecked, might get you into trouble. Again, going with the Conscientious style, things that might apply to me would include: Many Conscientious people find it difficult to relax and experience pleasure. They expect the same thoroughness and devotion from others, which may not always be appropriate. Sometimes lack skills required for top managerial positions such as making quick decisions, setting priorities, and delegating responsibility. 3. Finally, list things you might not do easily because of your style, but things you would do well to consider doing more of BECAUSE OF your style. For the Conscientious style, those might include: Concentrate on relaxing and enhancing your leisure time. When you have difficulty making a decision, always keep in mind that it often makes no difference which decision you make, as long as you do something. To manage your time more efficiently at work, aim for results that are good enough and not necessarily perfect. Personality Self Portrait Exercise • • • • • • • • • • • 1. 2. 3. How does this style relate to others? How does this style go about achieving their goals? How does this style cope with stress? 4. 5. What does this style look like at work? How should I best interact with this style at work? 6. 7. What does this style look like in a close relationship? How should I best interact with this style in a close relationship? 8. As a therapist, how might I LIKE to respond to this personality disorder? • 9. How might I most therapeutically respond to this personality disorder? • • 10. What cultural / gender / age considerations might be relevant to this style? • At issue is not whether we attend to normal or abnormal, or that we focus on strengths or weaknesses, but that we tell the human story from a hopeful and instrumental perspective: even our inevitable failings can be accepted – integrated – managed – lived. We (counselors and counseling psychologists) present a perspective that allows – even demands – soul. • The debate should not be about where the line is between normal and abnormal, not about the field’s focus on strengths vs. pathology, but on our commitment to embracing, in a hopeful and positive way, the whole of the human experience.