Personality disorders are characterized by

person has longstanding, maladaptive thought and behavior patterns that are troublesome to others, harmful, or illegal.

Key Fact –  impairs a person’s social functioning & there will be chronic interpersonal difficulties

Problems with one’s identity or sense of self

Axis II & Comorbidity (dual diagnoses, substance abuse, eating disorders and major depression. very hard to treat)

10 personality disorders separated into 3 groups

Long term problem, not functioning well but they are functioning

Axis 2 people are working but not well

Criterion A: The pattern must be manifested in at least two of the following areas:

Cognition, Affectivity, Interpersonal functioning & Impulse control

Criterion B: The enduring pattern must be inflexible and pervasive across a broad range of personal and social situations

Criterion C: This pattern leads to clinically significant distress or impairment of functioning

Criterion D: The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early childhood

Criterion E: The pattern is not better accounted for as a manifestation or consequence of another mental disorder

risk factors: , family history (tends to run in families) childhood abuse and neglect. unstable or chaotic family life during childhood. (divorce etc) childhood conduct disorder diagnoses

less likely to have happy marriages, less likely to be successful parents, less likely to be an affective team player, 

More likely to have a poor response to treatment

more likely to be introuble with the law

more likely to be generally miserable

axis 2 disorders show up in how you perceive and understand others. emotional response to life, how you interact with people socially, how you control your impulsive behavior

Diagnostic criteria are not as sharply defined as for other Axis I categories

-not mutually exclusive. They can be fuzzy

Diagnostic categories are not mutually exclusive

Personality characteristics 

are dimensional in nature

the oddballs of the world

distrustful, suspicious. Every family has one. lives alone, doesn't talk much.

they all go through life alone

DSM-IV-TR personality disorders are grouped into three clusters.

Cluster A includes: paranoid, schizoid, and schizotypal

Some can also have a mix.

Overview and Clinical Features

Pervasive and unjustified mistrust and suspicion

Excessive jealousy

The Causes

Biological and psychological contributions are unclear

Early learning that the world is a dangerous place

Anecdotal: victims of crime such as sexual assault

Functional paranoia (adaptive) should not be mistaken as PPD

This is not a functional paranoia that we get because of things we have been through

Treatment Options 

Few seek professional help on their own

Treatment focuses on development of trust

-learning to enjoy life and relax

Cognitive therapy to counter negativistic thinking

Lack good outcome studies

Paranoid – Unwarranted suspiciousness and mistrust, overly sensitive, often envious. Avoid close relationships. NO hallucinations. bear grudges. Don't recognize their own mistakes.

Schizoid – Shy, withdrawn behavior, poor capacity for forming social relationships. Aloof, standoffish, distant from others, show little to no emotion. They don't want to be around people just cuz. Unaffected by praise or criticism. little interest in intimate relationships. Lives by themselves. Cold, dull, humorless, weak social skills. no delussions (hallucinations and delusions are the hallmark of schizophrenia). 

 Schizotypal – Odd thinking, often suspicious and hostile

People with these disorders tend to be ODD

Distrustful and suspicious

Socially detached

us and socially detached.

Magical thinking real close to delusions.

etc. The person at the market likes me etc.

extrememly discomforted in close relationships, odd thinking patters, anxious around others

seek isolation, more severe than paranoid and schizoid. Emotions can be inappropriate to the situation

communication can be very loose. Can't stay on topic. 

tend to drift through life in a very unproductive way. 

Cluster B includes: Histrionic, narcissistic, antisocial

these people are emotional and erratic. They tend to take up a lot of time in your life

People with these disorders tend to be DRAMATIC

Emotional & Erratic

Antisocial– Used to be called sociopaths or psychopaths, violate other people’s rights without guilt or remorse, can commit many violent crimes

-once called sociopath and psychopath

Very dangerous diagnoses. They lack a conscience.They do not understand the word empathy. they are empty. 

The anti-social starts to trust therapist is the prison system and then later kills the therapist. 

mostly males and are seen in prison. 

Very charming and intelligent. Use people. only go to private practice is they are court mandated.

No regard for others rights etc

Must display patterns of misbehavior before age 15 (truancy, running away, cruelty to animals etc)

80% of people in prison meet this criteria

Usually have had a very hard time not wetting the bed  until puberty, problem with starting fires, and hurting animals. run strong in their personality. (wetter bedder setters)

Narcissistic – Unrealistically self-important, expects special treatment, can’t take criticism

Men run narcissistic and women run borderline

-they do not understand the WE mode of the world. It's all about him

- He thinks he has a superior attitude, intelligence, he's special, and because you're his gf etc that makes you special

-cannot handle one ounce of criticism. 

They hold major grudges

usually pick dependent women as a relationship partner.

wants full control. they will pick out nail polish etc. She usually doesn't have a liscence and he tells her what to wear. 

Very jealous people

if you don't answer the phone they wonder why. 

They dont understand how to nurture the relationship. 

arrogant, need much admiration

very choosy about their friends and  associates

very charming at first. 

preoccupied with receiving attention from others

little evidence that any treatment in affective

Histrionic – Excessively dramatic; seeking attention and tending to overreact, egocentric

-need to be the center of attention

-their approval and praise from others is very important

-they exaggerate their relationships and life

-Tend to dress to bring forth attention

vain, self centered, demanding, cannot delay gratification.It's all about them

Borderline – Emotionally unstable, impulsive, unpredictable, irritable

Women tend to Be borderline

very charming when they want to be.

Biggest fear is abandonment and having to be alone.

she will go to extremes not to be alone

This is the female who always has a relationship.

doesnt udnerstand how to self soothe

very impulsive in her behaviors

will call someone 10x etc

They can't get themselves out of anxiety. (light bfs clothes on fire)

Very charming

in session they will tell you they feel empty

low sense of self no good identity of who they are

Borderline looks for someone to complete them

she will pick up his personality and his likes. On top of that she is very sexual because that's how they get attention. Will key a car etc

extrememly jealous of your job, ex wife, kids, etc. 

Things can get scary in 3 to six months

She flips really fast.Shell think you are the best and then in 3 seconds she hates you. Mates never know who they are coming home to.

With borderline you confront them (one more guy will help your self esteem, hows that? etc) They get really upset.Then apologize.

Borderlines would cut as teenagers

they are very very needy.

 validate the child’s feelings by the parents (stress) leads to a 

 vicious cycle.

The emotional dysregulation may be inadvertently 

   reinforced by parents if it becomes one of the only times the 

   child receives parental attention.

Emotional dysregulation in child (diathesis) and a failure to 

Emotional dysregulation in the child>>Great Demands on the Family>>invalidation by parents through punishing or ignoring demands>>> emotional outbursts by child to which parents attend

they lack insight

Individuals 18 and over may be diagnosed with antisocial personality disorder if the following criteria are met:

At least three behavioral problems occurring after age 15

At least three instances of deviant behavior before age 15

The antisocial behavior is not a symptom of another mental disorder

Must be very careful not to misdiagnos because it can carry a huge stigma.

The following characteristics are typical of psychopaths as described by Cleckley:

Inadequate conscience development

Lack of empathy

Irresponsible and impulsive behavior

Ability to impress and exploit others

includes avoidant, dependent obsessive compulsive

the anxious fearful ones

cluster C does better in treatment than the others

These people really do want to get better

they have someone in their life who wants them to get into therapy

Fearful or anxious

Includes dependent, avoidant, obsessive-compulsive.

Although this group of disorders certainly resembles mood and anxiety disorders, the few studies that exist do not suggest a link.

Treatment of this cluster is more successful than A, B.

Cluster C includes

Avoidant – Excessively sensitive to potential rejection, desires acceptance but is socially withdrawn

usually has a narcissist in their life

uncomfortable in social situations

overwhelmed by feelings of inadequecy

timid, afraid of speaking out and appearing foolish

see themselves as unappealing unattractive and will not take a risk. Very lonely people.

they want a relationship

the female that wants to be taken care of

wants everyone to make all the decisions for her

very afraid. persistent need to be taken care of

fears seperation from her parents or loved one

constantly needs assistance making any decision even the smallest.

 Doesn't think about herself too much, many have eating disorders

Dependent – excessively lacking in self-confidence, allows others to make all decisions

Axis 2- she is doing okay compared to axis 1

they are rigid personalities

they have a lot of rules

perfectionists

Obsessive-compulsive – usually preoccupied with rules, schedules, and details

They dont finish things. They like control. concerned about doing everything right. they set very high standards for themselves. Seldom are they happy with their own performance. Very hard on themselves.

Strict moral code of ethics, can be very stubborn. Have a hard time asking for help.

very hard to loosen up for them

Is our emphasis on impulse gratification, instant solutions, and pain-free benefits leading more people to develop the self-centered lifestyles that we see in more extreme forms in personality 

disorders?

could be . many people do not self soothe.

borderlines raise borderlines and it keeps going

impulse gratification and not being able to sit with the anxiety.

Its very hard to just deal with the anxiety. recite positive things. Personality disorders can't deal with life easily

Personality disorders are generally very difficult to treat

Treatment of the Cluster C disorders seems most promising

Treatment of Cluster A & B disorders is most difficult

A new form of behavior therapy (dialectical behavior therapy) shows promise for treating borderline personality disorder, which is in Cluster B

Ch. 10

Addictive behavior

behavior based n the pathological need for substance or activity, may involve the abuse of substances suchs as 'nicotine alcohol concaine

results in: potentially hazardous behavior

continued use despite a persistent social, psychologival, occupation or health problem

tolerance ( you need more and more to produce the same effect)

Withdrawel- physical symptoms that accompany abstinence from a drug

Alcoholic –

Alcoholic –

a person with a serious drinking problem whose drinking impairs his or her health, personal relationships, and occupational functioning

Alcoholism –

a dependence on alcohol that seriously interferes with life adjustment

alcohol withdrawel is potentially more letha than opiate withdrawal

people with strong will could still become alcoholics

brain damage shows up before damage to the liver

alcoholics suffer from at least one mental disorder

Alcohol has complex and often contradictory effects on the brain

At lower levels, alcohol stimulates certain brain cells and activates the brain’s “pleasure areas”

At higher levels, alcohol depresses brain functioning

abuse refers to an indicidual wo contiues to use druges even thought they know it is having and adverse affect on their health and well being 

dependence occurs when a person has built up a tolerance

native americans 19%

hispanics 10%

white- 9%

african american- 9%

asian american- 4.3%

(percentage who exhibit substance abuse)

can be genetic or passed down

Potential alcohol abusers tend to

Be emotionally immature

Expect a great deal of the world

Require an inordinate amount of praise and appreciation

React to failure with marked feelings of hurt and inferiority

Have low frustration tolerance

Feel inadequate and unsure of their abilities to fulfill expected male or female roles

Medications to block the desire to drink:

Antabuse- makes you violently ill if you drink with it. uses classical conditioning

Naltrexone- new med that takes away the cravings

Medications to lower the side effects of acute withdrawal:

Valium- helps addict overcome the pain

Group therapy- must be careful. They may all start using

Environmental intervention- always the patient to change their environment

Behavior therapy

Alcoholics Anonymous has reportedly met with considerable success

the 12 steps are used for every disorder now

the alcoholic can only stay in a bar and drink soda for 15 minutes until they cave

Narcotics

Sedatives

Stimulants

Anti-anxiety drugs

Hallucinogens

Narcotics include:

Opium

Morphine

Heroin- it is on the rise now. for the people who can afford it. very tough withdrawals

withdrawals are always the opposite of the drug.

The body's way of balancing out. Heroin addicts complain of not sleeping and exhaustion. 

These drugs were originally praised for their medical uses, but they are dangerously addictive

smoked inhaled injected

and injection bring on a rush a spasm of warmth and ecstasy. The brief spasm is followed by several housr of a pleasant feeling called a high. 

overdose closes down the respiratory section of the brain

we don't want them to go to sleep. 

accidental ods are very common esp with heroin. addict gets clean, then they use again at the level they used to before they got clean and the body can't handle it

Alleviation of physical pain

Relaxation and pleasant reverie

Alleviation of anxiety and tension

Euphoric spasm

Physiological craving for the drug

Withdrawal symptoms

Gradual deterioration of well-being

almost every drug is a gradual deterioration of the well being. The teeth get really bad

Treatment for narcotics addiction is initially similar to that for alcohol addiction

Methadone and buprenorphine are often used in conjunction with a rehabilitation program

slower withdrawal that takes away the cravings of the drug. it gradually gets you off the drug then they work on getting you off of methadone

Cocaine and amphetamines

Increase feelings of alertness and confidence

Decrease feelings of fatigue

Stimulate sex drive

Increase endurance

Over the long-term, however, amphetamines

Are psychologically and physically addictive

May result in brain damage and psychopathology

the largest seen in oc is meth

Barbiturates were once widely used to induce sleep

They are dangerous drugs commonly associated with

Physiological and psychological dependence

Lethal overdoses

can lead to death if mixed with alcohol

senior citizens can become addicted to them because they use them to sleep

Those who become dependent on barbiturates tend to be middle-aged people who rely on them as sleeping aids making withdrawal difficult.

Marijuana may be classified as a mild hallucinogen

The effects of marijuana vary but may include

Euphoria

Hilarity

Hyper-talkativeness

Anxiety

Depression

Hallucination

no longer the gateway to addiction. Nicotine is

long term lung disease

positive effects : cancer patients going through chemo. It increases the appetite and it soothes them.

long term it can cause you to become very anxious

Hallucinogens cause an individual to see or hear things in different and unusual ways

This category includes

LSD 

Mescaline

Psilocybin

PCP

Ecstasy

odorless colorless tasteless. The drug of the 70's. Can produce flashbacks (reoccurance of the sensory and emotional changes long after the drug has left the system).

very popular amphetamine int he us

produces feelings of increased arousal attention hypersexual and uninhibited

available in the form of crystals also known as ice and crystal meth which are smoked

if you don't get clean it will eventually catch up with you

Chapter 11

Sociocultural influences on sexual practices and standards

Incest is taboo across all cultures

Some aspects of sexuality are universal; others are quite variable

Homosexuality and American psychiatry

Homosexuality as sickness

Homosexuality as a normal sexual variant

Experts recognize two categories

sexual dysfunctions-problems iwth sexual responses

paraphilias- repeated and intense sexual urges and fantasies in response to socially

The paraphilias are a group of persistent sexual behavior patterns in which unusual objects, rituals, or situations are required to fulfill sexual satisfaction.

Increased sexual urges & Inappropriate sexual behavior 

Nearly all people with paraphilias are male

-testosterone?, men are more stimulated through visual (women emotional). Visual stimulation goes overboard

People with paraphilias often have more than one paraphilia

Other than sex offenders, most people with paraphilias do not seek treatment

Fetishism-reoccurent sexual urges

and fantasies, involving some innate object (baloons, shoes) pretty common

Transvestic fetishism-satisfaction being by dressing as a member of the opposite sex. (joanne)

sexual satisfaction and arousal

Voyeurism- secretly observing unsuspecting people as they undress or have sex

Exhibitionism- innapropriate exposure of genitals in innapropriate circumstances and without consent

Sadism- sexual gratification by inflicting pain or humiliation on the partner

Masochism-sexual gratification from experiencing pain

GID/O characterized by two components:

Strong and persistent identification with members of the opposite sex 

gender dysphoria– persistent discomfort about one’s biological sex or the sense that the gender role of that sex is inappropriate

Clinical Overview – Trapped in the Body of the Wrong Sex

Assume the identity of the desired sex

Goal is not sexual

Causes are Unclear

Gender identity develops between 18 months and 3 years of age

know dif b/t GID and fetishism

Transsexuals are adults with gender identity disorder who desire to change their sex

Psychotherapy is usually not effective in helping adolescents or adults resolve their gender dysphoria

Realign psychological gender with biological sex

Few large scale studies

Hormone therapy & Sex reassignment surgery

75% report satisfaction with new identity after surgery

Female-to-male conversions adjust better

transexuals are GID ***

Depending on the definition used, prevalence figures for child sexual abuse range from less than 5% to more than 30%- rising

Short-term consequences may involve fears, post-traumatic stress disorder, and sexual inappropriateness

A number of studies have found associations between reports of childhood abuse and adult psychopathology and drug abuse

easy to forgive perpetraitor , hardest to forgive mom (freud)

Pedophilia is diagnosed when an adult has recurrent, intense sexual urges or fantasies about sexual activity with a prepubescent child

- you look at the age of the child to define pedophilia

Culturally prohibited sexual relations between family members are known as incest or sexual attraction to one’s own children

not unheard of in females btu not as prevalent as in males

a child doesn't have defense mechanisms yet

-it attacks the basic psyche and very damaging

Psychophysiological Assessment of Pedophilia:

Deviant patterns of sexual arousal- they are not aroused by what is normal

cannot interact with an adult in an intimate relationship

Desired sexual arousal to adult content

Social skills Deficits

Have Difficulties Forming Appropriate Adult Relationships

Difficult to work with 

classical and opOrgasmic reconditioning – Masturbation + appropriate stimuli

Family/marital therapy – Address interpersonal problems

Coping and relapse prevention – Self-control and risk management

Efficacy of Psychosocial Interventions

About 70% to 100% of cases show improvement

Poorest outcomes – rapists/multiple paraphilias

erant conditioning:

dont seek treatment unless they are court ordered

The term rape describes sexual activity that occurs under actual or threatened forcible coercion of one person by another

Depending on the definition used, prevalence figures run from 5% to 13%

Is rape motivated by sex or aggression? Sex AND Agression --BOTH**

Rape Trauma Syndrome- mirrors and mimics PTSD **

Most often it is someone close to the victim

very rarely a stranger

Recidivism rates for sex offenders is very controversial.

Sex offenders with deviant sexual preferences (e.g., those most attracted to children) have high rates of recidivism

Megan’s Law- must check in with police and register. can find list online

Less recidivism as the rapist gets older and hormones decress

Therapies for sex offenders have at least one of the following four goals:

To modify patterns of sexual arousal

To modify cognitions and social skills to allow more appropriate sexual interactions with adult partners

To change habits and behavior that increase the chance of re-offending

To reduce sexual drive for the inappropriate

The term sexual dysfunction refers to impairment either in

The desire for sexual gratification

The ability to achieve it

Desire phase- when we start thinking about it. thought process, fantasies

Excitement phase- physiological changes begin, foreplay

Orgasm- release of dopamine

the peak

Resolution- sense of wellbeing and relaxation

Males are more troubled by this than females

Effects half the male population on at least a temporary basis

May be based on

Anxiety about sexual performance

Physiological dysfunction

- stress brings it about/ anxiety

- so do medications

every male will experience this

-heart medications lower it

incredibly common

- usually isnt a physiological dysfunction

it can come back once the pressure is off the male

involuntary spasm of the muscles at the entrance to the vagina that prevents penetration and sexual intercourse

-seen in abuse

-painful coitus

abuse as a child

Chapter 12

 Schizophrenia

The hallmark of schizophrenia is psychosis– a significant loss of contact with reality

Schizophrenia

Affects people from all walks of life, but more frequent in the lower SES - might have  alot to do with malnutrition in younger children or in the womb

-prenatal cause, brain disease

-environmental may trigger it

-nature problem brought on by nurture

Is about as prevalent as epilepsy

Usually begins in late adolescence or early adulthood

Approx 1 of every 100 ppl in the world suffer from it

hits males earliers and is harder on males than females (lower active) more debilitating disease

split mind (bleuler)

Positive symptoms of schizophrenia reflect an excess or distortion in a normal repertoire of behavior and experience such as:

Delusions- false beliefs about the world and themselves.delusions of persecution are the most common

-delusions of reference- attaching personal meaning to actions of others (movie star is in love with them. )

- delusions of grandeur- great inventors, saviors, endowed with powerful talent

-delusions on control- their thoughts and feelings are being controlled by someone else usually the govt

95% of schizo's 

Hallucinations - sensorary experience that occurs in the absense of any external stimulus

(know the difference). 

-Auditory hallucinations are the most common

-hallmark to schizophrenia

- seem to come from inside their head

-visual is second common- visions of jesus etc. 

-more rare are tactile and olfactory, gustatory

-smelling stuff

-gustatory- sense of taste is off

Something to do with dopamine levels. when some people get off meth the voices go away and some still hear voices

90% of ppl in psych hospital are schizo's

After the first psychotic break they become very fearful

Disorganized speech- word salad

Disorganized behavior- you cant connect one thing to another. Nothing they do connects (i like fries, tomorrow is saturday etc). 

have issues with ADLS - adult living scales (bathing clean clothes) low functioning

adding abnormal things to the persons character. 

Negative symptoms reflect an absence or deficit of behaviors that are normally present"

taking away something from the person

Flat or blunted emotional expressiveness

Alogia: poverty of speech

Avolition: apathy and no energy

anadonia: inability to experience pleasure

Social Withdrawal: isolation

These symptoms are more difficult to treat

Prodromal Phase- the person is starting to act odd usually in highschool. Starting to deteriorate. comes on very slowly then stress hits. 

Active Phase- a stressful even happens and they have a psychotic break. no control. start hearing and seeing things. Usually a psychotic break puts one in the hospital

Residual Phase-low self esteem, fearful ness, crying ,depression, knowing they are different

Subtypes of schizophrenia include:

**Paranoid type- most common, organized system of delusions and auditory hallucinations that guide their lives. Wide range of ideas and plots about the world. Someone hurting them

Disorganized type-usually confused. they can't get any thought process out coherently. Extremely withdrawn. Odd mannerisms. 

Catatonic type- the kind you see in the hospital because they have a psychomotor problem and become statue like. They can fall over and hurt themselves. Rigid andbizarre posturing

Undifferentiated type-they are a catch all...all over the place

Residual type- negative symptoms have become.

Medication helps the positive symptoms (50lb weight gain) Makes the negative symptoms worse and they become flatter and more isolative. 

Other psychotic disorders include (look like schizophrenia)

Schizoaffective disorder- a mood disorder along with schizophrenia**

Schizophreniform disorder- has a time limit. One month up to 6 month. Confused and thenthey have a good chance of being normal again. Noticible change, behavior becomes unusual. women after labor they can even have a psychotic break

Delusional disorder- looks like schizo except their delusions are not bizarre. They are very concerned that their partner and the world is cheating on them. 

Erotomanic, grandiose, jealous, persecutory  & somatic-

Brief psychotic disorder- lasts only a month. An onset of psychosis lasting less than a month brought on by stress and then disappears. They may never have another episode again

Shared psychotic disorder- When one person believes they have the psychosis of the other.

Folie à deux 

Genetic factors are clearly implicated in schizophrenia – “familial”

Twin Studies

As the following slide shows, having a relative with the disorder significantly raises a person’s risk of developing schizophrenia

Monozygotic twins (of schizophrenics) are much more likely to develop schizophrenia than are dizygotic twins

Schiophrenics have more dopamine recepter sites

Evidence FOR the Dopamine Theory

High doses of amphetamines cause schizophrenic-like symptoms. 

Drugs that block dopamine reduce symptoms & have side effects similar to Parkinson's disease. 

The best drugs to treat schizophrenia resemble dopamine and completely block dopamine

receptors.

when we block the receptor sites the positive symptoms go away

Antipsychotic drugs work by blocking dopamine receptors

There are two types of antipsychotics:

Conventional antipsychotics (Neuroleptics)

Novel antipsychotics- 2nd gen drugs. 50lb weight gain but not as bad with tardive

Patients taking novel antipsychotics

Have fewer extrapyramidal (motor abnormality) side effects

Tend to do better overall

Psychosocial approaches include:

Case management

Social-skills training- in self help groups

Cognitive-behavioral therapy-in higher level treatment groups. They know the thoughts and voices aren't real. You can try to turn it around a little bit. Eye contact. 

Family therapy- always trying to educate the family. sometimes dependent abuse happens.

Self Help Groups- working ADLS and taking care of themselves

we don't let them sit in board and care all day. Put them in group according to their functioning

absense of speech seen in schizophrenics

negative symptom

form of aphasia

sometimes cause by injury to left hemispher of the brain

common in schizophrenics

lack of drive to do anything meaningful or social

sometimes they sit still for long periods of time

negative symptom

from medications: inability to sit still or move

caused by taking antipsychotic drugs (dopamine drugs)

parkinson like disorders