Normal Personality and Personality Disorders

• The Big Five model is a comprehensive, empirical, data-driven research finding.
• It contains and subsumes most known personality traits and is assumed to represent the basic structure behind all personality traits.
• The general proposal is that an individual’s personality can be described in terms of relative placement in each of these five major factors.

The 5 Personality Factors (OCEAN or CANOE)

• Openness (Intellect): (Inventive/Curious vs. Consistent/Cautious). Appreciation for art, emotion, adventure, unusual ideas, curiosity, and variety of experience.
• Conscientiousness: (Efficient/Organized vs. Easygoing/Careless). A tendency to show self-discipline, act dutifully, and aim for achievement; planned rather than spontaneous behavior.
• Extraversion: (Outgoing/Energetic vs. Solitary/Reserved). Energy, positive emotions, surgency, and the tendency to seek stimulation in the company of others.
• Agreeableness: (Friendly/Compassionate vs. Cold/Unkind). A tendency to be compassionate and cooperative rather than suspicious and antagonistic towards others.
• Neuroticism: (Sensitive/Nervous vs. Secure/Confident). A tendency to experience unpleasant emotions easily, such as anger, anxiety, depression, or vulnerability.

Sample of 'Openness' Items

• I have a rich vocabulary.
• I have a vivid imagination.
• I have excellent ideas.
• I am quick to understand things.
• I use difficult words.
• I spend time reflecting on things.
• I am full of ideas.
• I am not interested in abstractions. (Reversed)
• I do not have a good imagination. (Reversed)
• I have difficulty understanding abstract ideas. (Reversed)

There are two main methods of assessment:

• Objective tests:
  • Cattell’s 16-PF
  • Eysenck Personality Questionnaire (EPQ)
  • Minnesota Multiphasic Personality Inventory (MMPI)
  • Standardized Assessment of Personality-Abbreviated Scale (SAPAS)
• Projective Personality tests:
  • Rorschach Inkblot Test (10 cards, 5 black ink, 2 black and red, 3 multicolor)
  • Thematic Apperception Test (TAT)
  • Picture Arrangement Test
  • Sentence Completion Test

Paranoid Personality Disorder (PPD)

• Individuals with PPD display pervasive distrust and suspicion, including the belief, without reason, that others are exploiting, harming, or out to deceive him or her. There is a lack of trust and a belief of others' betrayal. They may perceive hidden meaning in remarks or events that others perceive as benign, and have recurrent suspicions without justification about the fidelity of a spouse or sexual partner.
• PPD is more common among males. The prevalence varies from 0.5% in the general population to 30% among in-patients.

Schizoid Personality Disorder (SPD)

An individual with SPD is markedly detached from others and has little desire for relationships; there is a restricted range of expression of emotions in interpersonal settings. To diagnose SPD, a person must have four or more of the following:

• Neither desires nor enjoys close relationships.
• Almost always chooses solitary activities.
• No interest in sexual experiences with others.
• Takes pleasure in few, if any, activities.
• Lacks close friends or confidants other than first-degree relatives.
• Appears indifferent to the praise or criticism of others.
• Shows emotional coldness, detachment, or flat affectivity.

Schizotypal Personality Disorder

Schizotypal Personality Disorder individuals are socially anxious, have perceptual and cognitive disturbances, show oddities of speech, magical thinking, inappropriate affective responses, and behave eccentrically. It appears to be related to schizophrenia.

Antisocial Personality Disorder (APD)

This is characterized by a long-standing pattern of disregard for other people’s rights and the rules of society. This pattern of behavior has occurred since age 15 years (but only diagnosed at 18 years and above), and includes the following features:

• Repeated violation of the law
• Pervasive lying and deception
• Impulsivity or failure to plan ahead in many areas such as spending, substance abuse, reckless driving, and sexual behavior
• Physical aggressiveness
• Reckless disregard for the safety of self or others
• Consistent irresponsibility in work and family environments
• Lack of remorse, indifferent to the wrong treatment of others

APD is estimated to be of 0.6–2% prevalence in the general population; as high as 50–70% among prison inmates and three times more common among males than females.

Borderline Personality Disorder (BPD)

• A pervasive pattern of instability of interpersonal relationships, affects, and self-image as well as marked impulsivity that begins by early adulthood and appears in a variety of contexts.
• Individuals with BPD are very sensitive to abandonment and make frantic efforts to avoid real or perceived abandonment. Efforts to avoid abandonment may include inappropriate rage, unfair accusations, and impulsive behaviors such as self-mutilation or suicidal behaviors, which often elicit a guilty or fearful protective response from others.
• BPD is also characterized by identity disturbance such as an unstable self-image or sense of self.
• Many individuals with BPD are impulsive in many self-damaging areas such as spending money irresponsibly, gambling, engaging in unsafe sexual behavior, abusing drugs or alcohol, driving recklessly, binge eating, self-mutilation, and recurrent suicidal behaviors, gestures, or threats are common.
• Affective instability is a common feature consisting of intense episodic dysphoria, irritability, or anxiety that usually lasts for a few hours. The usual dysphoric mood of these individuals is often punctuated by anger, panic, or despair.
• BPD is three times more common among females than males.
• Prevalence varies from 0.7% to 2.0% among the general population; and could be as high as 20% in inpatients.

Narcissistic Personality Disorder (DSM-IV)

• Grandiose self-importance.
• Fantasizes unlimited power or success.
• Arrogant and haughty.
• Believes himself special.
• Exploits others.
• Lacks empathy.
• Has a sense of entitlement and favors.

Avoidant Personality Disorder

• Feels socially inferior.
• Preoccupied with rejection.
• Avoids involvement and risk.
• Restraint in intimate relationships because of fear of rejection.

Dependent Personality Disorder

• Allows others to take responsibility.
• Unduly compliant.
• Needs excessive help to make decisions.

Obsessive – Compulsive (Anankastic) Personality Disorder

• Preoccupied with details and rules.
• Inhibited by perfectionism.
• Scrupulous, rigid, and stubborn.
• Expects others to submit to his/her ways.
• Miserly and hoards money.

Assessment

• Psychological testing may support or direct the clinical diagnosis.
• MMPI: is the best known psychological test for personality disorders.
• Standardized Assessment of Personality-Abbreviated Scale: 8-item questionnaire. A score of 3 or more positive.
• Personality Assessment Inventory
• Personality Diagnostic Questionnaire
• The Structured Clinical Interview for DSM-IV-TR for Axis II Disorders (SCID-II) can also be used to aid diagnosis.
• Shedler-Westen Assessment Procedure–200 (SWAP-200) or SWAP II: This is a 200-item instrument for assessing personality disorders. It is designed for use by skilled clinical observers based on either longitudinal knowledge of the patient over the course of treatment or a systematic clinical interview of the patient.
• SWAP-200-A is a version adapted from SWAP-200 for the assessment of adolescents. Both measures have shown initial evidence of reliability and validity.

Treatment:

• Psychological
• Social
• Pharmacological

Psychotherapy:

• Psychotherapy is at the core of care for PDs.
• Aims to improve perception and responses to social and environmental stressors.

Types of Psychotherapies:

• Supportive:
  • Uses direct means to ameliorate symptoms and maintain, restore, or improve self-esteem, adaptive skills, and psychological functioning.
  • Therapist listens actively, provides advice and information, and encourages problem-focused coping.
• Psychoeducation
• Psychodynamic Psychotherapy:
  • Examines the ways patients perceive events, based on the assumptions that perception is shaped by early life experiences, unconscious urges, conflict introjects, and structures believed to underlie personality disorders.
• Cognitive – Behavioural Therapy (CBT):
  • A goal-directed, problem-solving therapy that focuses on teaching specific cognitive and behavioral skills to improve current functioning.
  • The therapeutic aim is to define the patient’s presenting problems, set goals, and modify dysfunctional thinking and associated behaviors that prevent adaptive functioning.
  • The clinician’s role is to teach the patient to identify and modify dysfunctional thoughts and beliefs.
  • CBT was originally devised for the treatment of depression but has expanded to other Axis I disorders and to personality (Axis II) disorders.
• Dialectical Behavioural Therapy (DBT):
  • A form of cognitive therapy developed by Marshal Lineham.
  • Originally used in the treatment of repeatedly parasuicidal female patients with borderline personality disorder.
  • Leads to a marked reduction in the frequency of self-harm episodes.
  • Emphasis of this manual-based therapy is on the development of coping skills to improve affective stability and impulse control and on reducing self-harmful behavior.
• Interpersonal Therapy (IT):
  • Based on the fact that patient’s difficulties result from a limited range of interpersonal relationships, including such issues as role definition.
  • Posits that people may develop characteristic maladaptive styles of relating that are self-reinforcing, which can be altered by interactions with others that can force patients to engage in new patterns of behavior in controlled settings.
  • The treatment can be delivered individually but is most effective when carried out in couple, family, or group.
• Group Therapy:
  • Allows interpersonal psychopathology to display itself among peer patients whose behaviors are used by the therapist to identify and correct maladaptive ideas, communication, and behavior.
  • Sessions are held once weekly over a course that may range from several months to years.
• Therapeutic Community:
  • A therapeutic community is defined as an intensive form of treatment in which the environmental setting becomes the core therapy through which behavior can be challenged and modified (essentially through group pressure).

Drug Treatment

• Medications are not curative for PDs, but are used as adjunct for the patient to productively engage in psychotherapy.
• The focus is on treatment of symptom clusters such as cognitive-perceptual symptoms, affective dysregulation, and impulsive-behavioral dyscontrol.

• Antipsychotic drugs:
  • They are the most widely used in the treatment of personality disorders, especially those that can produce transient psychotic periods (e.g., BPD) or in those with features of chronic idiosyncratic ideation of nearly psychotic proportions (e.g., Schizotypal PD).
  • However, there is considerable confusion about their values.
  • Low doses of haloperidol and thiothexene are effective in reducing typical borderline and schizotypal symptoms.
• Antidepressants:
  • TCAs and SSRIs have been used in the treatment of PDs, most especially the borderline type.
  • SSRIs reduce impulsiveness.
• Mood Stabilizers:
  • Lithium, Carbamazepine, and sodium valproate have all been used to treat PDs, particularly the borderline type.
  • Mood stabilizers have some demonstrable efficacy in suppressing impulsive and particularly aggressive behavior in patients with PDs.