Chapter 10 Personality And Personality Disorder

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Can you spot the difference? These two individuals are both are holding a toy bear above their heads in their right hands. One picture is taken outside in daylight and the other is taken indoors at night. One individual is young and female, the other is old and male. Can you make a guess at possible personality differences? The female looks more extraverted and fun loving, the male looks more conservative and grumpier. Visual appearance gives potentially useful information about the individual, but further information is required before conclusions can be reached. Does either or both have a personality disorder? Bad question. A diagnosis of personality disorder cannot be made on limited information. The female is a former porn actress who made a successful transition into the Italian parliament. The male is the current author (who wanted to be a porn star). They are probably both “different” or “eccentric”, but probably neither has a diagnosable personality disorder.
Personality Disorder
A personality disorder is a way of thinking, feeling and behaving that deviates from the expectations of the culture, causes distress or problems functioning, and lasts over time (DSM-5).
Personality disorder can only be properly understood after reviewing the definition of personality.

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There are many definitions - a good example - personality is those features which determine that individual’s unique response to the environment (human and nonhuman).
(If you know someone well you will know if they will ‘like’ certain things or events – they might like cricket, they may ‘dislike’ other things like hot weather or cats – if, you know how they respond to situations – you have knowledge of their personality.)
Expanded descriptions of personality add that it is “lifelong and persistent” (although personality changes somewhat over time, through the natural maturation process, and can be changed through sustained psychotherapy).
Personality features (i.e., warmth, perfectionism, impulsivity) obey the normal distribution curve, with most of the population in the middle of the graph and a few at the extremes.

Illustration. This person, who has long fingernails, appears to have different values, at least in some regards, to many readers.

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Alert, Alert: Dimensional versus Categorical Approach

Over recent years there had been a revolution in the way personality disorder has been conceptualized.

Until recently, personality disorders were conceptualized as 10 separate ‘types’ (this is called the “categorial” approach)

1. Cluster A – “unusual and eccentric”

• Paranoid personality disorder

• Schizoid

• Schizotypal “

2. Cluster B – seem “emotional, dramatic, erratic”

• Antisocial personality disorder

• Borderline “

• Histrionic “

• Narcissistic “

3. Cluster C – “anxiety and fear”

• Avoidant personality disorder

• Dependent “

• Obsessive-compulsive

This “categorical” approach is being replaced by a “dimensional” approach.

It was expected that the latest version of the DSM [DSM-5 (2013)] would provide a new ‘dimensional system’ for the diagnosis/classification of personality disorder. This did not happen.

Dimensional personality disorder systems

Just as we can rate our friends on degree of self-confidence or interest in fashion, everyone can be rated on defined dimensions such as “empathy” and “intimacy”. Some authorities claim personality disorder can be better defined using a list of dimensions (rather than categorical boxes).

Dimensional models have been used in the past to describe personality. For example, the famous Eysenck Personality Inventory measured two separate dimensions: extraversion-introversion (which measures reserved, versus outgoing attitude) and neuroticism (which measures tendency to distress). Also, the five-factor model (FFM) of personality (McCrae & John, 1992) which is widely accepted. It employs the personality dimensions of 1) openness, 2) conscientiousness, 3) extraversion, 4) agreeableness, and 5) neuroticism, known by the acronym OCEAN (Skodol, 2018).

The DSM-5 information on personality disorder is confusing. It provides 2 separate systems – one categorical and one dimensional. It is expected the DSM will eventually move to an exclusively dimensional system.

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I find this system very difficult to understand – presumably my advanced years.
General Criteria for Personality Disorder A. Impairment in personality functioning – that is ‘self’ and ‘interpersonal’ self-functioning ‘involves identity and self-direction” interpersonal functioning “involves empathy and intimacy”
B. “One or more pathological personality traits”. Negative Affectivity Detachment Antagonism Disinhibition Psychoticism
C. Impairment in personality functioning and pathological trait/s are inflexible and pervasive “across personal and social situations”.
D. Impairment in personality functioning and pathological trait/s “are stable across time” and track back to “adolescence or early adulthood”
E. Impairment in personality functioning and pathological trait/s “are not better explained by another mental disorder”
F. Impairment in personality functioning and pathological trait/s “not the effects of substance abuse”
G. Impairment in personality functioning and pathological trait/s “not a developmental stage”
Level of Personality Functioning Scale 3 levels are described Mild impairment Moderate impairment Severe impairment

Prevalence of Personality Disorder
Personality disorders are highly prevalent and carry serious consequence. A recent estimate of general population states 17% have a personality disorder (Tyrer, 2018).
15% of psychiatric outpatients, and 10% of psychiatric inpatients are believed to have personality disorder as the primary diagnosis. Also, 30% of psychiatric inpatients are believed to have a personality disorder in addition to the primary disorder for which they have been admitted (Tyrer, 2018).
Clinical students commonly encounter people with personality disorder. People with personality disorders are frequent attendees at hospital Emergency Departments,

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because of social crises, injuries from fights, alcohol or drug intoxication, or with selfinjuries. People with personality disorders are often encountered in general medical wards following over-doses and because of they have difficulty managing any other chronic disorder they suffer.

Clinical interview with the patient (and those who know the patient) is the best method of obtaining diagnostic material. A detailed life history provides extensive information about previous and likely future responses to the environment, which is central to personality assessment.
The clinical interview itself, is a test situation, which provides practical examples of the patient’s manner of self-presentation and response. The skilled interviewer will also make observations regarding her/his own response to the patient, which is likely to be similar to the responses of others.
People with “neurotic disorders” (old fashioned term, an example is anxiety disorder) have “autoplastic defences” meaning they react to stress by attempting to change their own internal psychological process and perceive their disorder as “egodystonic”, meaning they find their symptoms unacceptable and in need of change.
People with personality disorders, by contrast, have “alloplastic defences” meaning they react to stress by attempting to change the external environment/world (rather than themselves), and perceive their symptoms to be “ego-syntonic”, meaning they find these aspects of themselves to be acceptable, and not in need of change.
However, the world does not change to suit people with personality disorder (or anyone else) they (people with personality disorder) experience distress - their maladaptive responses lead to failed relationships (with lovers, family and employers), multiple losses, disappointments and consequent distress.
Niesten et al (2016) reported the reduced ability to co-operate with others caused people with borderline personality disorder (BPD) to experience enduring lowered economic functioning.
People with personality disorder are inflexible. They have a limited repertoire, or number of ways, of responding to the world. Faced with opposition the normal/average individual has a range of responses: to think of a new approach, work harder and try again when better prepared, to use humour, to be more assertive, to reassess whether the goal is worth further effort or not, etc. The individual with a personality disorder has a limited number of ways of responding (for example, responses may be limited to seduction or aggression). These are applied in all situations, and because of inflexibility, they are applied repeatedly, even when they have already proved unsuccessful. In these circumstances loss and disappointment, and direct and indirect distress are inevitable.

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Possible examples

US man charged for shooting mower

A 56-year-old man from the Mi dwestern US state of Wisconsin has been arrested after shooting his lawn mower in his garden because it would not start.

Keith W

was charged

by police in Milwaukee with

disorderly conduct and possession

of a sawn-off shotgun.

He could face a fine of up to $H,000 and a maximum prison sentence of six-and-a-half years if convicted.

Police officers said Mr W had told them: "It's
my lawn mower and my yard, so I can shoot it if I want."

Witnesses told police Mr W appeared to have been drinking
BBC: 26. July, 2008

Illustration. This man may not have a personality disorder. It does appear that he has low impulse control. On the other hand, his impulse control may simply have been temporarily lowered by alcohol intoxication.

Illustration. This is an entry from a notebook maintained by an 18 year old female. She states she is feeling “depressed”. She is referring to feelings of distress, rather than the experience of major depressive disorder – although the two are frequently confused by patients, their parents and some doctors. She makes mention that when she cuts herself, she feels “good”. Self cutting is very common in some people with personality disorder – it serves as a means of releasing tension/distress. She uses a code IWIWD (I wish I was dead). She makes this statement without apparent conviction – some people personality disorder frequently engage in suicidal behaviour (this is in addition to the cutting, most of which has little to do with suicide, and as mentioned, is a means of releasing tension/distress).

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Illustration. A further abstract from the notebook mentioned above. The patient was waiting at a bus stop with some people she knew when (she cannot remember why) she began to have negative thoughts. “Then I cut myself in front of everyone.” Naturally people tried to stop her – this made her angry and threw things around and kicked things. Dramatic, care eliciting, manipulative behaviour and unreasonable anger are common features in personality disorder.

Illustration. The arm of a man with a history of ‘cutting’ himself when he was stressed.

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Illustration. The arms, hands and abdomen of a man with a history of cutting. He kept the large lesion on his left arm permanently open. The edges and even the base of the lesion were scarred and indurated. He burnt the dorsum of his right hand and there was muscle tissue loss from the extensors of his right forearm. There were less obvious (in these photographs) scars on the upper chest. In the past he had swallowed razor blades, which had perforated his bowel, leading to abdominal surgery. He repeatedly removed the stiches and recut his abdominal scar leading to a large incisional hernia. (The bulge in the middle of his abdomen is abdominal organs pushing out against the skin, the muscle wall of his abdomen having been damaged through the repeated self cutting.)

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RSPCA chief at centre of donations meltdown

IBl.1e1s1.,.a...l1gldles, ~.~~~;;~;;~;~~;~~~;;;~} _,,- _

•Y unreserved apology to the Board; I am a ver moral an
a erso an • ee mere 1ble
1 shaae that thi •
has happened.·
~~e·~n! f':m to Mi chael."
__,,, - RSPCA~-J

l o s t m i l l i o n s Illustration. The leading story of a regional newspaper told that a state branch of the
Royal Society for the Protection and Care of Animals had lost millions of dollars in donations due, in part, to the “repeated lying” of the CEO. In his response the CEO wrote, “…I am a very moral and ethical person and feel incredible shame that this happened…I admit freely the lies I told…” This person’s behaviour has NOT been “moral and ethical” – there are clear problems with self and interpersonal functioning.

There is a move toward the Dimensional (AMPD) diagnoses – however, for many reasons - the current student needs to know something of the categorical criteria. All genetic and imaging studies of personality disorder (for example) use the categorical diagnoses.

Cluster A – Individuals appear odd or eccentric
Paranoid Pervasive distrust and suspiciousness, such that the motives of others are interpreted as malevolent. There must be at least 4 of the following:
• Suspects, without sufficient basis, that others are exploiting, harming, or deceiving
• Preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
• Reluctance to confide in others • Reads hidden demeaning or threatening meanings into benign remarks • Persistently bears grudges (unforgiving of insults or slights) • Perceives attacks on his/her character or reputation - not perceived by others • Recurrent unjustified suspicions regarding fidelity of spouse or partners

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Schizoid Pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings. There must be at least four of the following:
• Indifference to praise or criticism • Preference for solitary activities and fantasy • Lack of interest in sexual interactions • Lack of desire or pleasure in close relationships • Emotional coldness, detachment, or flattened affectivity • No close friends or confidants other than family members • Pleasure experienced in few, if any, activities
Schizotypal Pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behaviour. There must be at least 5 of the following:
• Ideas of reference (not delusions) • Odd beliefs and magical thinking (superstitiousness, beliefs in clairvoyance,
telepathy, etc) • Unusual perceptual disturbance (illusions, sensing the presence of nearby
people etc) • Paranoid ideation and suspiciousness • Odd, eccentric, peculiar behaviour • Lack of close friends, except family members • Odd thinking and speech without incoherence (vague, metaphorical etc) • Inappropriate or constricted affect • Social anxiety that does not diminish with familiarity and that is associated
with paranoid fears.

Cluster B – Individuals appear erratic or impulsive
Antisocial Pervasive pattern of disregard for and violation of the rights of others occurring since the age of 15 years. The individual must be at least 18 years of age and there must be evidence of conduct disorder before 15 years of age. There must be at least 3 of the following:
• Failure to conform to social norms (resulting in frequent arrests) • Deceitfulness, including lying and conning others for personal profit/pleasure • Recklessness, with disregard for the safety of self or others • Irresponsibility, failure to honour financial obligations or sustain work • Lack of remorse, indifference or rationalization of having hurt, mistreated or
stolen from others
Borderline Pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity. There must be at least 5 of the following:

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Chapter 10 Personality And Personality Disorder