Lecture 3 : Personality Disorder and Schizophrenia

Personality Disorder

What is personality?

• Cognition, behaviour and emotionality

• Trait vs state

• (rather) consistent way to deal with the world around you

• Influenced by Nature

• Automatic responses to reward/danger

• Harm avoidance, Reward dependence, novelty seeking,

• persistence

• Influenced by Nurture

• Attachment

• Life experiences

• Culture also influenced personality

• For example, people in the Malaysian society have a great power distance
(accept that others are more powerful) compared to the UK

• People in the UK have higher individualism compared to Malaysia

• People in the UK have higher masculinity than Malaysian

What is Personality Disorder

• Mainly problems with interacting with others (it’s a social problem) (Tyrer, 2015)

• Categorical (DSM-5) or Dimensional (Big 5?)

• Dimensional approach suggest they may better be considered as being at the

extreme of the distribution of personality characteristics rather than categorically
different from the norm

• Here is a hypothetical profile, suggested by the five-factor model of personality

(Costa and McRae 1995), for antisocial personality disorder which received
empirical support in a cohort of adolescents studied by Lynam et al. (2005):

• Low Neuroticism: lack of appropriate concern for potential problems in

health or social adjustment; emotional blandness

• Low Extraversion: social isolation, interpersonal detachment and lack of

support networks; flattened affect; lack of joy and zest for life; reluctance
to assert self or assume leadership roles, even when qualifi ed; social
inhibition and shyness.

• Low Openness: difficulty adapting to social or personal change; low

tolerance or understanding of different points of view or lifestyles;
emotional blandness and inability to understand and verbalize own
feelings; alexithymia; constricted range of interests; insensitivity to art
and beauty; excessive conformity to authority.
 • Low Agreeableness: cynicism and paranoid thinking; inability to trust even
friends or family; quarrelsomeness; ready to pick fi ghts; exploitive and
manipulative; lying; rude and inconsiderate manner alienates friends,
limits social support; lack of respect for social conventions can lead to
trouble with the law; infl ated and grandiose sense of self; arrogance

• Low Conscientiousness: underachievement: not fulfilling intellectual or

artistic potential; poor academic performance relative to ability; disregard
of rules and responsibilities can lead to trouble with the law; unable to
discipline self (such as stick to diet or exercise plan) even when required
for medical reasons; personal and occupational aimlessness.

• Dimensional approach better at predicting outcome than the DSM categorical

approach.

• Ullrich et al. (2001), for example, found that scores on personality tests
were better able to predict subsequent offending behaviour than
categorical diagnoses of antisocial personality disorder

How to measure Personality?

- Psychiatric examination
- Developmental Interview
- Questionnaires
- Big five inventory (John,1999)
o 44 items, 5 scales (Big 5)
- Minessota Multiphasic Personality Inventory
o 10 scales:
 Hyperchondriasis (lives in fear of having a serious illness, despite medical tests
never finding anything wrong)
 Depression, Hysteria, Psychopathic Deviate, Masculinity/feminity
 Paranoia (intense anxious or fearful feelings and thoughts often related to
persecution, threat, or conspiracy.)
 Psychasthenia (inability to resist specific action/thought regardless of their
maladaptive function)
 Schizophrenia, Social Introversion
 Hypomania (a mild form of mania, marked by elation and hyperactivity)
- Rorschach Inkblot test
o 10 ink blots
o Very difficult to interpret
o Reliability is a problem (whether the interpretation tells you anything about your
personality)
- Enneagram test
- Incomplete sentences: Much more reliable that Inkblot – Often used in Children
- Story telling (pictures): Shows someone’s tendencies

Personality Disorder according to DSM-5

- DSM 5: “A personality disorder is an enduring pattern of inner experience and

behavior that deviates markedly from the expectations of the individual’s culture, is
pervasive and inflexible, has an onset in adolescence or early adulthood, is
stable over time, and leads to distress or impairment.”
- Divided into 4 clusters
o Cluster A: odd or eccentric
 Paranoid
  Schizoid
 Schizotypical
o Cluster B: dramatic, emotional, erratic
 Antisocial
 Borderline
 Histrionic
 Narcissistic
o Cluster C: Anxious, fearful
 Avoidant
 Dependent
 Obsessive-Compulsive
o Other personality disorders
 Personality Change Due to Another Medical Condition (Labile, Disinhibited.
Aggressive, Apathetic. Paranoid. Other, Combined. Unspecified type)
 Other Specified/Unspecified Personality Disorder
- Antisocial and narcissistic disorders are generally thought to be more prevalent in men,
and histrionic and borderline disorders more prevalent among women (APA 2000).
o Antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and
schizotypal has a lot of overlapping features
- An Alternative model to DSM-5
o Describe Impairments in personality functioning
 Self
 Identity: Experience self as unique, clear boundaries self/others,
stable self-esteem & self-appraisal, regulate experience and
emotions
 Self-direction: Pursuit of clear short-term & life goals. Good internal
standards of behavior, able to self-reflect
 Interpersonal
 Empathy: Comprehend & appreciate others'
experiences/motivations; tolerate other perspectives; understand
effects own behavior on others
 Intimacy: Deep and long connection with others(attachment);
desire and capacity for closeness; mutuality of regard in
interpersonal behavior.

o Pathological personality traits

 5 Trait domains:
 Negative Affectivity, Detachment, Antagonism, Disinhibition, and
Psychoticism.
 25 subdomains ‘trait facets’.
 Person is described based on these trait facets
 Each personality disorder consists of a unique combination of maladaptive
personality traits (facets) OR trait specified
o New hybrid model and ‘old’ model are related (Andersen, 2014)
 Hybrid model might be better than the binary old model
 Dimensional approach might better predict outcome/behaviour

Personality Disorders Cause/Origin

1. Genetic predisposition (Nature)

a. Distel et al. (2008a), for example, studied a total of 3644 twins aged between
18 and 86 years across the Netherlands, Belgium, and Australia. They estimated
 42 per cent of the variation in borderline personality features was attributable to
genetic factors, with similar levels of heritability across all three countries.
b. Tadic´ et al. (2008) suggests the possibility that the condition may involve
interactions between genes controlling both dopaminergic and noradrenergic
systems.
2. Environment (attachment style etc)
3. Beck: self, others, (beliefs about) future
4. Sociocultural factors (Bennett, 2013)
a. Neglect, divorced parents, childhood trauma, sexual abuse, incest, violence
i. Bandelow et al. (2005) found that people with borderline personality
disorder reported much higher levels of traumatic childhood experiences
such as sexual abuse, violence, separation from parents, childhood illness
and other factors than a matched, ‘normal’ comparison group.
b. Attachment and bonding with parents
i. One significant outcome may be poor attachment and bonding with
parents – both of which may contribute to the development of borderline
personality disorder (Nickell et al. 2002)
ii. measure of parental bonding predict the long-term outcome of the
condition
c. Splitting: dichotomising in all good/all bad (borderline)(everything is either good
or bad, no middle)
i. From a psychoanalytic viewpoint, object relations theorists (e.g. Kernberg
1985) suggest that as a result of negative childhood experiences, the
individual develops a weak ego and needs constant reassuring. They
frequently engage in a defence mechanism known as splitting,
dichotomizing objects into ‘all good’ or ‘all bad’ objects, and fail to
integrate the positive and negative aspects of self or other people into a
whole
d. Maladaptive schemata self and social relationships.
i. Cognitive theorists (e.g. Young and Lindemann 1992) argue that negative
childhood experiences translate into maladaptive schemata about self-
identity and relationships with others. These include beliefs that ‘I am
bad’, leading to self-punishment; ‘No one will ever love me’, leading to
avoidance of closeness; and ‘I cannot cope on my own’, leading to over-
dependence

Cause for Antisocial personality disorder

1. Brain
a. Psychopaths had significantly less activity within their limbic systems and
greater activation of the frontal lobes while processing negative emotional words
than the other groups, suggesting that the psychopaths and nonpsychopaths
used quite different brain systems to process emotional information
b. psychopaths displayed no significant activity in this circuit, no conditioned ‘pain’
response and reported no anxiety.
2. Genetic
a. Even when separated at birth, still link between aggression in child and parent
b. Crowe (1974) reported that adopted-away children of women prisoners with
antisocial personality disorder had higher rates of antisocial personality than
control adoptees without this family history.
3. Environment
 a. most important childhood predictors were similar to those of Henry et al.: a
convicted parent, large family size, low intelligence or school attainment, a
young mother and disrupted family.
b. Family factors may also contribute to the lack of emotion associated with
psychopathy. It has been suggested that the sustained experience of negative
emotional events during childhood results in the individual learning to ‘switch off’
their emotions in response both to negative events that occur to them and to
their behaviours that affect others.
c. Peers -Henry et al. (2001) found that having violent peers was predictive of later
violent and nonviolent delinquency.
d. Physical punishment - Eamon and Mulder (2005) found that impoverished
neighbourhood and school environments, exposure to deviant peer pressure,
and parenting practices involving physical punishment and excessive monitoring
of behaviour (perhaps as a consequence rather than cause of their antisocial
behaviour) were related to antisocial behaviour among Latino adolescents in the
USA.

Personality Disorders Treatment

1. Depends on specific personality disorder

a. Treatment studies of cluster A disorders are relatively rare – perhaps because
people who could be assigned these diagnoses rarely seek treatment, and when
they do, this may be related to associated problems such as depression. With
this in mind, Parnas et al. (2005) noted that antipsychotic medication may be of
some benefit, but that adequate controlled trials of any psychotherapy or
alternative medical treatments were lacking.
2. Rather stable, difficult to ‘treat’ (influences all part of the self rather than specific
parts)
3. Psychotherapy / psychoanalysis (takes years)
a. Psychotherapy is more likely to be effective for less severe personality disorders
b. Individuals with good social support, chronic depression, who are psychologically
minded and with low impulsivity, are most likely to benefit from ‘talking
therapies’.
4. Cognitive therapy
a. Pro-social attitudes and behaviour
i. Therapy involves teaching four sets of skills: interpersonal effectiveness,
core mindfulness, emotion regulation and distress tolerance, which draw
strongly on mindfulness, distraction and acceptance skills.
ii. lower levels of parasuicidal and impulsive behaviours, sustained for six
months after the completion of treatment of DBT
b. Change negative behaviour (such as aggression, manipulation)
i. One of the most important therapeutic aims is to minimize risk of self-
harm. This involves identifying the antecedents to episodes of self-harm,
the thoughts and feelings that accompany them, and their consequences
c. Take responsibility for own actions (Bennett, 2013)
d. CBT best for cluster C (anxious and fearful)
5. System therapy (evolve a system around the patient’s environment)
a. Multi systemic
i. People who have high levels of impulsivity are most likely to benefit from
a ‘limit-setting’ ● group or a therapist who is supportive of their attempts
to struggle with uncontrollable impulses.
b. Family based (getting family involved in the patient’s treatment) – might help to
treat the disorder
 i. taught about the nature of the problems their relative was experiencing
and patients were encouraged to share their experiences of the treatment
programme
ii. participants in the cognitive behavioural intervention experienced greater
improvements on measures of impulsivity, negative affect and global
functioning
iii. They were no better on measures of the frequency of self-harm or suicide
attempts, which are generally considered key outcomes of any
intervention
iv. However, they did make fewer visits to hospital emergency departments.
6. High comorbidity with depression, bipolar and anxiety
7. There’s a lot of Self-harm (see later lecture self harm and suicide)
8. Focus on current, or most prominent problems
a. If suicidal, focus on Suicide prevention
b. Self-harm (locate triggers, alternative behaviours)
9. Focus on comorbidity rather than the disorder itself
10. Medication (unclear what would work for who)
a. Most studies have been relatively small, and evidence of any effectiveness is
‘weak’ (Paris 2008).

Schizophrenia

- Schizophrenia is one of the most stigmatised conditions and the most discriminated
against:
- 58% of people said that stigma and discrimination was as bad as or worse than
the illness itself.
- Schizophrenia affects the way you think:
- It affects about 1 in every 100 people.
- It usually starts during early adulthood.
- It does not mean that you have a split personality or that you are likely to be
violent.
- Many factors seem to affect who develops schizophrenia.
- Positive Symptoms Vs Negative Symptoms
- Positive Symptoms (Presence of symptoms that are not normal)
- Experiencing things that are not real (hallucinations)
- An experience involving the apparent perception of something not
present.
- Relies on consensual verification
- Determining between the internal and the external
- Persecutor: belief one will be harmed, harassed, etc. by an
individual,organization, or group
- Referential: belief certain gestures, comments, environmental cues
etc. are directed at oneself
- Grandiose: belief that he/she has exceptional abilities, wealth, or
fame
- Erotomanic: (false) belief that another person is in love with him or
her
- Nihilistic: belief that a major catastrophe will occur
- Somatic: preoccupations regarding health and organ function
- Bizarre vs nonbizarre
- Bizzare – Believing that you’ve been abducted by alien
 - Nonbizzare – thinking that someone is following you/police is
after you/
- Having unusual beliefs (delusions)
- An idiosyncratic belief or impression maintained despite being
contradicted by reality or rational argument, typically as a symptom
of mental disorder.
- Hallucinations and delusions are much more common than was previously
thought (van Os, 2009).
- You don’t have to have schizophrenia to experience them!
- What’s important is whether they cause you distress
- Negative Symptoms (Absence of Normal Symptoms)
- Lack of motivation
- Withdrawn
- Longer lasting
- Diminished emotional
- expression
- Avolition(inactive)

Diagnosis according to DSM

• Schizophrenia spectrum and other psychotic disorders

• Delusions

• Hallucinations (mostly auditory)

• Disorganized thinking (speech) (lots of mumbling and their sentence have no

coherent/sense)

• Disorganized/abnormal motor behaviour (i.a. catatonia)

• abnormality of movement and behaviour arising from a disturbed mental

state (typically schizophrenia). It may involve repetitive or purposeless
overactivity, or catalepsy, resistance to passive movement, and
negativism

• Waxy flexibility is a psychomotor symptom of catatonia as associated

with schizophrenia, bipolar disorder, or other mental disorders which leads
to a decreased response to stimuli and a tendency to remain in an
immobile posture.

• List of Disorder in the Spectrum

• Delusional disorder

• Brief psychotic disorder

• Schizophreniform disorder

• Schizophrenia

• Schizoaffective disorder

• Substance/medication induces psychotic disorder

• Psychotic disorder due to another medical condition

 • Catatonia

• Often Associated With Another Mental Disorder (Catatonia Specifier)

• Due to another medical condition

• Unspecified

• Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

• Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

• Requirements for Diagnosis of Schizophrenia

• More than 2 symptoms must be present for atleast 1 month period and one of
the symptoms must either be delusions, hallucinations or disorganized speech

• Other symptoms: Grossly disorganized or catatonic behavior;. Negative

symptoms (i.e., diminished emotional expression or avolition).

• Level of functioning in (e.g.) work, relations, self-care, below level prior to onset
(or failure to achieve expected level)

• Present for atleast > 6 months; from which > 1 month symptoms Criterion A
(i.e., active- phase symptoms), may include prodromal or residual symptoms
(e.g. only negative symptoms, or less severe A symptoms).

• Should Not be part of Schizoaffective, depressive, bipolar disorder or E.

substance

• If ASD/communication disorder, additional schizophrenia only when really clear

• Differences between DSM Diagnosis

• Delusional disorder  only delusions, but no other psychotic symptoms

• Brief psychotic disorder 1 day-1 month

• Schizophreniform disorder  less than 6 months, no decline in functioning(not

as bad as schizo)

• Schizophrenia  > 6 months, > 1 month active phase

• Schizoaffective disorder  mood episode & active-phase together, preceded or

followed by atleast > 2 weeks delusions/hallucinations without mood symptoms
Causes of Schizophrenia

- Genetic
- Monozygotic twins and Children with 2
Schizophrenic parents have the
highest chance of developing
schizophrenia if one of the has
schizophrenia

Intervention

- Medication
- Tends to reduce the strength of
delusions and hallucinations (positive
symptoms)
- Family therapy
- Reduce the criticism and stress
caused by family to avoid relapse
- CBT
- Alter jumping to conclusions (has to
with delusion, whether their delusions
are real)
- Change the interpretation of the delusions or hallucinations

Schizophrenia and Cannabis

- Cannabis use is higher in Schizophrenia than in general population

- Cannabis use increases the risk of psychosis
- Schizophrenia increases the risk to use of cannabis
- Self medication?
- Twin study Power 2014
- - Sample 1: 6265 (23-39 yos)
- - Sample 2: 9688 (18-91 yos)
- Total: 14087 (overlap), from which 7172 genotyped
- 1) Did you ever use marijuana?
- 2) How old .. first time
- 3) How many times in your life
- Does schizophrenia causes usage of cannabis or is it the other way around?
- If both twin use cannabis, there’s a higher risk of developing Schizophrenia
- Suggesting genetic factors and not cannabis
- Cannabis increases risk but doesn’t not necessarily cause Schizophrenia (especially if
there’s no genetic risk)
-