Personality Psychopathology & Impulse-Control Disorders 

This assignment covers:

1. Personality psychopathology chapter 14
2. Disorders of childhood and adolescence Chapter 15
3. About 30 pages of the study guide, from page 58 Tut letter 501

Personality psychopathology

Dysfunctional and maladaptive personality patterns that are long term and present in nearly all situations

A personality disorder is characterized by:

• impairment of self and interpersonal functioning
• pathological personality traits that are long-standing and relatively inflexible
• Personality patterns involve behavior, thoughts, emotions and interpersonal functioning
• Criteria for diagnosis:
  1. The patterns are longstanding.
  2. These patterns are extreme and deviate from cultural expectations
  3. They are inflexible and pervasive across situations
  4. They are evident from adolescence or early adulthood and stable over time
  5. They are associated with distress and impairment.

People with a personality disorder often function well enough to be independent and successful, and may not see themselves as having a problem.

They often do not seek help. So the incidence of personality disorders is uncertain. There may be a lifetime prevalence of 9 to 13%. About 5-15% of people who receive professional help have personality disorders.

Diagnostic and Classification methods

1. Categorical diagnostic model: 10 personality disorder categories representing 10 clinical syndromes
2. Alternative model: both dimensional and categorical assessment

Categories

The 10 personality disorders are grouped into 3 clusters:

1. Odd/eccentric behaviors:
   1. Paranoid (mistrust & suspicion)
   2. schizoid (isolated, cold, indifferent to others)
   3. Schizotypal (peculiar thoughts & behaviors, poor interpersonal relationships)
2. Dramatic, emotional & erratic behaviors
   1. Antisocial (not conforming to social codes, lack of anxiety & guilt, irresponsible behaviors)
   2. Borderline (intense fluctuations in mood, self image & interpersonal relationships)
   3. Histrionic (sef-dramatisation, exaggerated emotional expression, seductive/provocative/attentions seeing behaviors)
   4. Narcissistic (exaggerated sense of self importance, exploitative behavior, lack of empathy)
3. anxious/fearful behaviors
   1. Avoidant (Social inhibition, fear of rejection and humiliation)
   2. Dependent (excessive dependence on others, inability to assume responsibilities, submissive)
   3. Obsessive-compulsive (perfectionist, controlling interpersonal behavior, devotion to details, rigidity)

Antisocial personality disorder is different from impulse control disorder, being part of a criminal subculture or civil disobedience

May be on a continuum with social anxiety disorder, or it may be distinct disorder that includes social anxiety.

May be caused by an interaction between childhood environment and innate temperament.

Hypersensitivity to rejection may trigger a positive feedback loop.

Clients with avoidant personal disorder may be reluctant to confide about themselves during therapy, so building rapport and a therapeutic alliance is essential.

Research shows that CBT can be effective in treatment.

Research shows that dependency is associated with overprotective or authoritarian parenting.

Cognitive theorists address core assumptions:

• The person may believe they are inherently inadequate and unable to cope.
• They then believe they need someone to take care of them.

OCPD is different to OCD (obsessive compulsive disorder). People with OCD have unwanted intrusive thoughts and or urges that are distressing, whereas OCPD is a personality issue, which is seen by the person who has the disorder as preferable and correct.

Impulse control Disorders

Looking at antisocial personality disorder with the multipath model

I am not going to go into this in depth. The textbook gives some interesting reading on the biological, social, psychological and sociocultural causes for antisocial personality disorder, and how they may interact. Moving on….

Issues with diagnosis

The problem with the categorical diagnostic method, which is being used above is that it is:

1. unreliable – the disorders overlap, so different clinicians will give different diagnoses
2. high comorbidities may mask the personality disorder eg Post traumatic stress disorder PTSD may mask Borderline personality disorder BPD.
3. The reality is a continuum. We can all recognize at least some of the traits in each category in ourselves. The categories are all or none.

For these reasons, a dimensional model is very useful.

It allows for a continuum, and looks at:

• personality functioning:
  • identity
  • self direction
  • empathy
  • intimacy, etc
• and specific traits:
  • social withdrawal
  • affect
  • antagonism
  • psychoticism

This alternative model removes 4 of the personality disorder categories: paranoid, schizoid, histrionic & dependent, and uses both the categories and the diagnostic model according to clinician preference.

Disorders of childhood and adolescence

Very different measures of what is normal and healthy and what is psychopathological to those in adulthood.

The prefrontal cortex is associated with attention, self control and being able to take perspective. It is only fully mature in early adulthood, so children think and behave quite differently to adults, and think and behave quite differently as they grow up.

However childhood mental disorders have a similar prevalence to in adults – about 50% in the US.

The most common of these is anxiety.

Internalizing disorders

These are disorders with emotional symptoms that are directed inwards

• heightened reactions to trauma, stressors and negative events
• difficulty tolerating distress
• difficulty regulating emotions
• the most common internalizing disorders are anxiety and depression
• These are risk factors for suicide and substance abuse.
• When young people show abrupt changes in behavior, self-destructive and/or sexualized behavior, there may be a need for assessment to rule out sexual abuse.

Anxiety, traumas, stressor-related disorders

Anxiety, trauma and stressor related disorders are usually from a combination of biological predisposition and environmental issues.

The most common anxiety disorders are phobias (starting early – mid childhood) and social phobia (starting early to mid-adolescence).

• extreme worry
• discomfort
• fear of unfamiliar and anxiety provoking situations
• can lead to adult anxiety disorders
• children who are inhibited and fearful are at greater risk.
• Parental styles that increase risk:
  • overprotective and controlling parents
  • low parental warmth
  • perceived parental rejection
• Separation anxiety disorder: fear of leaving home, being separated from caregiver or being along
• Selective mutism: Failure to speak in some situations

Attachment disorders

When children and babies grow up in stressful unpredictable home environments, they may battle to form attachments and social relationships.

• Reactive attachment disorder: inhibited, and not seeking or responding to comfort, attention or nurturing. Watchful and avoidant. Rarely show positive emotions and may demonstrate:
  • irritability
  • sadness
  • fear
• Disinhibited social engagement disorder: Socialize effortlessly but indiscriminately, attaching themselves to strangers and acquaintances, and moving away from caregivers.
• these children often have a history or harsh punishment and inconsistent parenting as well as emotional neglect and limited attachment opportunities.
• When children start to get predictable and nurturing care, Reactive attachment disorder often disappears. Disinihibited social engagement disorder is more persistent.

Post Traumatic Stress Disorder PTSD

• Youth with PTSD experience recurrent distressing memories
• triggered by threats of or direct experience with death, serious injury or sexual violation
• Memories may entail:
  • nightmares
  • intense physiological and or psychological reactions to thoughts and cues associated with the event
  • episodes of playacting the event
  • dissociative reaction in which the child relives the trauma or seems unaware of the present situation.
• Children may seem socially withdrawn , show few positive emotions or lose interest in activities they used to enjoy.
• angry aggressive behavior, tantrums
• difficulty sleeping or concentrating
• exaggerated startle response & vigilance

Non-suicidal self injury NSSI

• intentionally inflicted superficial wounds
• Often preceded by intense negative thoughts & emotions and thought about self-harm
• At least 5 times over a year
• Cutting etc can provide relief from painful feelings and a temporary feeling of calm and wellbeing
• Also serves as a form of self-punishment
• Associated with increased risk of attempted suicide
• negative cognitive style and negative self-talk are associated with both NSSI and with attempted suicide.
• Usually begins in early adolescence
• both genders
• Dialectic behavior therapy has been helpful
• May self-resolve over time

Mood disorders

• depressive disorders most prevalent in girls and older teenagers.
• Often caused by environmental factors in childhood
• Genetic and biological factors in adolescence
• Environmental triggers may include:
  • childhood abuse (physical , mental & sexual)
  • parental mental & physical illness
  • loss of an attachment figure
• Strong association between depression and suicidal ideation & attempts, so treatment is a priority.
• Evidence-based treatment includes:
  • CBT (individual & group)
  • Family-focused therapy
  • building resilience through positive psychology programs
  • Selective serotonin reuptake inhibitors SSRIs are risky because they are associated with an increased risk of suicide.

Externalizing disorders

Disruptive behavior disorders – these disorders have symptoms that are distressing to others

A persistent pattern of behavior that is atypical for the child’s developmental level and cases significant distress to the child and others, or negatively affects ability to function.

Boys with CD are more aggressive, girls are more inclined to substance abuse, truancy and lying. About half of youth with CD also have inattention and hyperactivity. About 2 – 9% of youth meet the criteria for CD.

Some youth with CD have limited prosocial emotions – minimal guilt, empathy. Manipulative, superficial affect and charm, cruelty and aggression. High risk of continuing criminal behavior and being diagnosed with antisocial personality disorder in adulthood.

Etiology of externalizing disorders eg: CD

• Often being early in childhood.
• Out of the four factors (social, psychological, sociocultural an d biological), biology seems to play the most important role in CD.
• In both CD and APD, there seem to be brain abnormalities associated with deficits in social information processing, as well as reduced activity in the amygdala (less fear than the norm)
• This results in a decreased ability to learn from rewards and punishments
• Genotype low activity MAOA (allele associated with fear-regulating circuitry in the amygdala.
• People with this genotype then get subjected to childhood maltreatment. Elevated stress hormones – cortisol – associated with impulsive aggression, and low cortisol with callous unemotionally and predatory aggression

Psychological, social and sociocultural dimensions

1. Sociocultural: large family size, crowding, male gender, poverty
2. Psychological: poor processing of social information, limited fear response
   • Oppositional temperament
   • Frequent parent-child conflict which the child wins
3. Social: early maternal rejection, childhood maltreatment, harsh & inconsistent discipline, parental marital discord

Treatment of externalizing disorders

Interventions need to address the family and social context.

Cognitive behavioral parental education can teach parents:

• To regulate their own emotions
• increase positive interactions with their children
• establish appropriate rules
• consistently implement consequences for inappropriate behavior

Psychosocial interventions can teach youngsters:

• assertiveness
• anger management techniques
• skills in empathy, communication, social relationships and problem solving
• Adult mentors can demonstrate empathy, warmth and acceptance.

Neurodevelopmental Disorders

Impaired developments of the brain and central nervous system.

Include:

• Tics & Tourettes disorder
• Attention-deficit/hyperactivity Disorder
• Autism Spectrum Disorders
• Intellectual & learning disorders

• Highly hereditable disorder – possible overlapping genetically with bipolar & schizophrenia
• neuroimaging show that the frontal cortex, cerebellum and parietal lobes may be underdeveloped in children with ADHD
• There may be functional abnormalities in the frontal lobes associated with inhibition of responses and attention.
• Neurotransmitters such as dopamine and GABA my be underactive and therefore reduce signal to and from the frontal lobes
• Other biological factors that have been implicated include:
  • prematurity, perinatal oxygen deprivation, low birth weight, exposure to pollution, viral infections, meningitis & encephalitis and maternal smoking and drug and alcohol use.
• Also associated with family stress, marital discord, poverty, foster care, parental mental disorders
• May be associated with acting out due to depression, low self esteem and rebelliousness
• Treatment is though Ritalin, but behavioral and psychosocial treatments have been shown to be effective too.

• Characterized by:
  1. Deficits in social communication and interaction:
     • lack of reciprocity and acknowledgement of others,
     • atypical non verbal communication
       • no eye contact
       • no meaningful gestures and facial expressions
       • treating people as if they were objects
       • poor social boundaries
     • Difficulties in developing and maintaining relationships lack of interest in others, lack of social play, not recognizing other people’s identity and emotions
  2. Repetitive behavior or restricted interests or activities involving:
     • repetitive movement, speech or use of objects eg spinning, flapping, or stacking or spinning objects, repetitive echoing or what is said (echolalia) and one-sided conversations
     • Intense focus on rituals or routines and strong resistance to change
     • Intense fixations or restricted interests
     • atypical sensory reactivity – either underreactive or overreactive

These symptoms can be very impairing.

Almost half of all people diagnosed with ASD are high functioning.

But about a third have significant cognitive impairment.

Some children only start showing symptoms when they are a year or older, and these children, who have regressive autism are often more severely affected.

Etiology of ASD

Intense early intervention has sometimes reversed or eliminated the progression of the disorder.

This makes early diagnosis very important.

Autistic traits do seem to be somewhat hereditable, and there are many neurological findings such as

• unusual brain metabolism
• high levels of serotonin
• elevated response in the amygdala to human faces
• patchy areas of disrupted neuronal development in the frontal and temporal cortex
• possibly associated with neonatal exposure to toxins such as pesticides and heavy metals.

In general, children benefit from early and intensive interventions. For severe ID & ASD, this may begin in infancy

For ADHD, LD, mild ID or mild SD, this support may be through the school setting

Parental involvement is an integral part of intervention. Many people need ongoing support through adulthood.