Personality Disorders Continued

Carolyn R. Fallahi, Ph. D.

Obsessive-Compulsive Personality Disorder

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  Similarities to Negativistic p.d. ( the old passive-aggressive p.d. lavel)
  
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  Common themes include ambivalent & conflicted personality dynamics that underlie presentation.
  
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  Ambivalence is defined as a lack of certainty over the source of reinforcement in one’s life.
  
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  Ambivalent individuals = conflicted over whether they should follow what others want them to do or follow their own needs and wishes.
  
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  “Anxious – fearful” cluster with anxiety & tension prominent symptoms.
  
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  OCPD: extreme rigidity, preoccupation with details & perfectionism.
  
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  Interpersonal relationships lacking – seen as cold, distant, & authoritarian. They have an excessive need to control others.
  
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  The issue with subordinate relationships.
  
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  Little motivation to become more flexible.
  
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  OCPD: avoids unwelcome thoughts or impulses & frequently distracts them by becoming unduly critical and judgmental of others.
  
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  Rigid, perfectionist, & restricted emotional expressivity.
  
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  Millon: intense ambivalence as the central feature.
  

Prevalence

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  5-20% psychiatric patients
  
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  Comorbidity: paranoid, histrionic, borderline, narcissistic, and avoidant p.d.
  
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  Issues with OCD Axis I.
  

Historically

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  Psychoanalytic theory: intense conflict during the anal stage of psychosexual development = “anal character”.
  
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  Kraft-Ebing: “compulsion” = constricted thought processes in individuals with severe depression. Then began to use the term to indicate hidden emotions, incessant questioning, doubtfulness, & other characteristics.
  
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  Anakastic (Schneider, 1923) = conceal feelings of insecurity, compensates by adopting an overly correct or scrupulous demeanor, & uses control in most relationships.
  
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  Kretschmer = “sensitive” personality type.
  
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  Kahn (1931) ambivalent tendencies = “ambitendency”.
  
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  Reich (1949) extreme attention to order, circumstantiality, rumination, indecision, self-doubt.
  
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Contemporary Theories

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  Psychoanalytic: struggles over autonomy
  
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  Erikson (1950): gain autonomy over one’s self & environment.
  
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  Rado (1959) mother’s demandingness & intrusiveness into child’s bowel patterns = defiance and anger.
  
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  Mallinger (1984) parental rejection, authoritarian attitudes, & lack of respect for privacy.
  
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  Salzman (1980) & Storr (1980) pervasive threat to security.
  

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  Behaviorial: very little in the literature.
  
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  Issues with the term OCPD.
  
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  Turkat & Maistro (1985): learns maladaptive emotional reactions in home & emphasizes hard work & minimizes close interpersonal relationships.
  

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  Cognitive Theory: Beck & Freeman (1990): OCPD clear distortions in thinking = produce rigidity & perfectionism.
  
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  Cognitive disortions
  
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  Musts and shoulds
  

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  Interpersonal Theory: Leary (1959) OCPD style defined by actions that maintain conventionality and security.
  
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  Structural Analysis of Social Behavior (Benjamin, 1974): intense fears of making a mistake / being viewed as imperfect.
  
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  Endler & Edwards (1988)
  
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  Pincus & Wiggins (1990)
  

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  Biological perspective: limited attention
  
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  Issues with anxiety.
  
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  Clonginger’s (1987) neurobiological theory – novelty seeking, reward dependence, harm avoidance.
  
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  Millon & Davis (1996) limbic system.
  

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  Integrative Model: Millon (1996)
  

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  Issues with Negativistic P.D.: stubbornness, passive resistance to fulfilling routine demands, procrastination, and inefficiency. Also sullen & irritable.
  

Borderline Personality Disorder

Essential Symptoms:

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  Impulsivity
  
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  Affective Instability
  
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  Cognitive Symptoms
  

Reliability & Validity Concerns

Prevalence

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  1-2% general population
  
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  ¾ women. Why? Stone (1993)
  

Comorbidity

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  Axis I mood disorders. Is it a form of depression?
  
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  Gunderston & Phillips (1991)
  
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  Trauma research: Kolk (1987)
  
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  The “borderline child”
  
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  Remits by early middle age.
  
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  15 years = 75%
  
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  1/10 commits suicide.
  
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  Highest risk: substance abuse + borderline
  
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  Stone (1993) less likely to marry or have children
  

Historically

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  Problems with the term “borderline”
  
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  Adolf Stern (1938)
  
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  “hysteria” or “pseudo-neurotic schizophrenia”
  
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  unstable personality disorder or emotionally unstable personality
  

Contemporary Theories

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  Biological: relatives have impulse spectrum disorders and/or affective disorders.
  
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  No specific pattern of inheritance has been found.
  
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  Torgersen (1984) twin studies – no MZ-DZ differences, but numbers small.
  
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  Torgersen (1996) BPD large heritable component.
  
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  No adoption studies.
  
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  No identifiable biological markers yet to be found. Similar markers to depression, e.g. abnormal REM latency; serotonergic activity.
  
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  Soft neurological signs, e.g. limbic activity issues.
  
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  Siever & Davis (1991)
  
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  Most likely = multiple receptors & multiple subsystems associated with each NT.
  
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  Linehan (1993) “emotional vulnerability”.
  

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  Psychological Factors: psychoanalytic emphasis on early experience.
  
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  Large number of negative events in childhood.
  
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  Borderlines also report a high frequency of childhood sexual abuse, e.g. 50-70%.
  
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  Incest abuse with penetration.
  
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  Physical abuse, frequency, duration, & severity.
  
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  Gender issues.
  
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  Herman et al (1989)
  
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  Zanarini et al (1989)
  
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  Van der Kolk et al (1991) & self-mutilation
  
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  Separation & loss b/f 16 (51%)
  
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  Parental psychopathology
  
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  Parental bonding issues; Gunderson et al (1980)
  
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  Adler (1985)
  
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  Linehan (1993)
  

Narcissistic Personality Disorder

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  Normal narcissism versus pathological narcissism
  
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  Definition: “a pervasive pattern of grandiosity, need for admiration, & lack of empathy”
  
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  Associated features: vulnerable self-esteem, sensitivity, intense reactions of humiliation, emptiness or disdain to criticism or defeat, vocational problems, feelings of shame, social withdrawal.
  
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  Antisocial or borderline characteristics
  
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  High achievement, promiscuity, excessive rage, suicidal behavior.
  

NPD Clinical Features

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  The Arrogant Narcissist
  
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  The Shy Narcissist
  
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  NPD with Antisocial / Borderline Features
  
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  Comorbid Axis I = depression or dysthymia
  
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  Suicide
  
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  Affect intolerance and vulnerability
  
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  Discriminating behaviors: Ronningstam & Gunderston (1990) boastful & pretentious behavior; self-centered & self-referential behavior; reactions to the envy of others.
  
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  Morey (1998): inflated self-esteem & marked affective reactions to assaults of self-esteem; marked need for interpersonal control; hostility; lack of overtly self-destructive behaviors.
  

Prevalence

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  2-22%. Gender differences?
  
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  Late teens & early 20s; middle age very critical.
  

Sociocultural Factors

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  Lash (1979)
  

Comorbidity

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  Dramatic cluster, e.g. histrionic, borderline, paranoid, avoidant, passive-aggressive, antisocial.
  
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  Bipolar patients, substance abuse, major depression, anorexia nervosa.
  

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  Antisocial p.d.
  
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  Borderline p.d.
  
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  Histrionic p.d.
  
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  Obsessive-Compulsive p.d.
  
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  Paranoid p.d.
  
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  Schizoid p.d.
  
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  Mania & hypomania