Taak 1 Classification and Aetiology of Personality Disorders
1. What are PDs? What are important features (e.g. 3 P`s, 3 clusters, ego-syntonic,
polythetical classification)?
- DSM-5: ‘an enduring pattern of inner experience and behaviour 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 and impairment’
2. In what ways are personality disorders similar to, and different from, Axis I
disorders? What is the evidence that some PDs may lie on a spectrum with Axis I
disorders?
Krueger
CLINICAL AND PERSONALITY DISORDERS: SIMILARITIES
- six broad areas: stability, age of onset, treatment response, insight, comorbidity and
symptom specificity, and etiology.
- Stability: PDs are conceptualized as relatively more stable over time when compared
with CDs. stability, in the sense of likelihood of remission/recovery (a period of 8
weeks when no more than two criteria were present) using a comparable categorical
conceptualization of disorder, does not appear to reliably distinguish PDs and CDs in
this head–to–head comparison. people may fluctuate around a general level of
personality pathology over time, yet this phenomenon masks a general, rank–order
stability in personality pathology over time. the general picture that emerges from
research on the stability of PDs is that the underlying factors that give rise to manifest
PD symptomatology are generally consistent over time. Nevertheless, the underlying
latent factors that give rise to common CDs also appear stable. Thus, stability is not an
especially compelling differentiator of PDs and CDs, particularly when transient and
unsystematic sources of variation in psychopathology are controlled for by using latent
variable models.
- Age of onset: early age of onset is a fundamental basis for the putative distinction
between CDs and PDs. age of onset appears inadequate to differentiate CDs from PDs,
in the sense that both sorts of disorders appear to be prevalent in younger persons.
Moreover, PDs have been studied in conjunction with CDs in adolescence as
predictors of young adult PD, and the likelihood of a PD in young adulthood is
enhanced in the presence of comorbidity between CDs and PDs in adolescence. This
suggests an intertwining of CDs and PDs throughout the course of pre–adult
development that is incompatible with the idea that CDs and PDs are developmentally
distinctive, with markedly different ages of onset.
- Treatment response: PDs are less amenable to treatment when compared with CDs.
There has also been a related historical presumption that PDs call for
psychotherapeutic intervention, whereas CDs call for psychopharmacologic
intervention. treatment response is not a compelling differentiator of CDs and PDs.
DSM–defined mental disorders, including PDs, respond to various interventions, the
presence of PD comorbidity in treating a CD may not result in diminished treatment
efficacy, interventions aimed at CDs also affect PDs, and pharmacologic intervention
can be conceptualized as influencing systems that transcend CDs, PDs, and “normal-
range” personality. Thus, the continued division of mental disorders into CDs and PDs
1
, is more likely to reinforce misleading notions of differential treatment efficacy than to
promote novel thinking about interventions for mental disorders in general.
- Insight: PDs are typically assumed to be “ego–syntonic,” such that persons with a PD
see the PD as part of their “natural selves,” and hence, have little insight into the fact
that their PD may be causing distress for themselves and others. In comparison, the
“ego–dystonic” symptoms of CDs are often presumed to cause obvious distress for
persons, such that they would be likely to have the insight that something is
psychologically amiss. the literature is too sparse to draw firm conclusions regarding
the role of insight in differentiating PDs and CDs, as a comprehensive study
comparing the role of insight in a range of PDs and CDs is lacking. Nevertheless, there
is a literature on the role of insight in CDs, most notably schizophrenia, and some
studies of insight in OCD have connected variation in insight with variation in PD
status. This suggests that instrumentation and ideas regarding the role of insight in
CDs could be brought to bear on our understanding of PDs. Given evidence for
variations in insight within DSM–defined CDs, insight may be best conceptualized as
a separable dimension of variation that can intersect with psychopathology per se in
potentially complex and revealing ways.
- Comorbidity and symptom specificity: CDs and PDs tend to co–occur and they
encompass related symptomatology. Thus, statistical independence and distinctiveness
of symptoms are not realistic bases for distinguishing CDs and PDs. It seems clear that
it would be more useful to focus on articulating models of how and why these domains
are so interconnected, as opposed to focusing on ways of further splitting apart CDs
and related PDs. in both clinical and epidemiological samples, CDs and PDs appear to
co–occur at greater than chance rates, a finding that challenges the idea that CDs and
PDs are highly distinctive types of mental disorders. CDs and PDs are also indistinct
in the sense that they share similar symptoms.
- Etiology: CDs as more genetic in etiology, and hence presumably more amenable to
pharmacologic intervention, whereas PDs were regarded as more environmental in
etiology, and hence presumably more amenable to psychotherapy. personality
pathology is significantly heritable. CDs and PDs are not well distinguished in terms
of the role of genetic factors in their etiology. Contrary to earlier speculation that
personality pathology might be primarily environmental in nature, personality
pathology, like other psychopathology, is significantly influenced by genetic factors.
Nevertheless, genetic influences do not provide the entire story with respect to the
etiology of psychopathology. The future of behavior genetic inquiry in this area lies in
better understanding the interplay of genetic and environmental influences.
THE JOINT STRUCTURE OF NORMAL AND ABNORMAL PERSONALITY
- The findings indicate that normal and abnormal personality constructs can be
integrated within the same structural model. Rather than representing highly separate
domains of human individual differences, normal and abnormal personality measures
can be located in the same factor space. In addition, the findings speak to the
importance of the FFM (five factor model) in understanding the joint structure of
normal and abnormal personality. The FFM appears to represent the “base” of the
higher– order structure that links normal and abnormal personality, as there was no
compelling evidence for factors beyond the five. However, there was evidence for
2
, structures above the five, and these structures resemble major conceptions of
personality that complement the FFM conception. This helps in integrating various
models and addressing questions of which dimensional model might be most
empirically compelling
- it would be incorrect to conclude that the FFM level of the personality hierarchy
provides all of the information necessary to capture personality variation
-
3. Classification of PDs? How does the DSM classify PDs? What are the advantages
and disadvantages of the DSM-IV’s categorical system of PD classification? What
are the alternatives to the DSM-IV’s categorical system? What is the empirical
evidence for these models?
Davey
- DSM-IV-TR listed 10 diagnostically independent personality disorders and these were
organized into three primary clusters (A) odd/eccentric personality disorders, (B)
dramatic/ emotional personality disorders, and (C) anxious/ fearful personality
disorders.
- Cluster A are (1) paranoid personality disorder, (2) schizotypal personality disorder,
and (3) schizoid personality disorder.
- Cluster B: (1) antisocial personality disorder (APD), (2) borderline personality
disorder (BPD), (3) narcissistic personality disorder, and (4) histrionic personality
disorder.
- Cluster C: (1) avoidant personality disorder, (2) dependent personality disorder and (3)
obsessive compulsive personality disorder
Problems with the Traditional Categorical Model
- The disorders are dimensional: personality disorders may not be disorders as such, but
simply represent extreme cases on conventional personality dimensions.
- Many overlapping characteristics
- a number of the existing personality disorder categories are particularly rare in the
general population
3
1. What are PDs? What are important features (e.g. 3 P`s, 3 clusters, ego-syntonic,
polythetical classification)?
- DSM-5: ‘an enduring pattern of inner experience and behaviour 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 and impairment’
2. In what ways are personality disorders similar to, and different from, Axis I
disorders? What is the evidence that some PDs may lie on a spectrum with Axis I
disorders?
Krueger
CLINICAL AND PERSONALITY DISORDERS: SIMILARITIES
- six broad areas: stability, age of onset, treatment response, insight, comorbidity and
symptom specificity, and etiology.
- Stability: PDs are conceptualized as relatively more stable over time when compared
with CDs. stability, in the sense of likelihood of remission/recovery (a period of 8
weeks when no more than two criteria were present) using a comparable categorical
conceptualization of disorder, does not appear to reliably distinguish PDs and CDs in
this head–to–head comparison. people may fluctuate around a general level of
personality pathology over time, yet this phenomenon masks a general, rank–order
stability in personality pathology over time. the general picture that emerges from
research on the stability of PDs is that the underlying factors that give rise to manifest
PD symptomatology are generally consistent over time. Nevertheless, the underlying
latent factors that give rise to common CDs also appear stable. Thus, stability is not an
especially compelling differentiator of PDs and CDs, particularly when transient and
unsystematic sources of variation in psychopathology are controlled for by using latent
variable models.
- Age of onset: early age of onset is a fundamental basis for the putative distinction
between CDs and PDs. age of onset appears inadequate to differentiate CDs from PDs,
in the sense that both sorts of disorders appear to be prevalent in younger persons.
Moreover, PDs have been studied in conjunction with CDs in adolescence as
predictors of young adult PD, and the likelihood of a PD in young adulthood is
enhanced in the presence of comorbidity between CDs and PDs in adolescence. This
suggests an intertwining of CDs and PDs throughout the course of pre–adult
development that is incompatible with the idea that CDs and PDs are developmentally
distinctive, with markedly different ages of onset.
- Treatment response: PDs are less amenable to treatment when compared with CDs.
There has also been a related historical presumption that PDs call for
psychotherapeutic intervention, whereas CDs call for psychopharmacologic
intervention. treatment response is not a compelling differentiator of CDs and PDs.
DSM–defined mental disorders, including PDs, respond to various interventions, the
presence of PD comorbidity in treating a CD may not result in diminished treatment
efficacy, interventions aimed at CDs also affect PDs, and pharmacologic intervention
can be conceptualized as influencing systems that transcend CDs, PDs, and “normal-
range” personality. Thus, the continued division of mental disorders into CDs and PDs
1
, is more likely to reinforce misleading notions of differential treatment efficacy than to
promote novel thinking about interventions for mental disorders in general.
- Insight: PDs are typically assumed to be “ego–syntonic,” such that persons with a PD
see the PD as part of their “natural selves,” and hence, have little insight into the fact
that their PD may be causing distress for themselves and others. In comparison, the
“ego–dystonic” symptoms of CDs are often presumed to cause obvious distress for
persons, such that they would be likely to have the insight that something is
psychologically amiss. the literature is too sparse to draw firm conclusions regarding
the role of insight in differentiating PDs and CDs, as a comprehensive study
comparing the role of insight in a range of PDs and CDs is lacking. Nevertheless, there
is a literature on the role of insight in CDs, most notably schizophrenia, and some
studies of insight in OCD have connected variation in insight with variation in PD
status. This suggests that instrumentation and ideas regarding the role of insight in
CDs could be brought to bear on our understanding of PDs. Given evidence for
variations in insight within DSM–defined CDs, insight may be best conceptualized as
a separable dimension of variation that can intersect with psychopathology per se in
potentially complex and revealing ways.
- Comorbidity and symptom specificity: CDs and PDs tend to co–occur and they
encompass related symptomatology. Thus, statistical independence and distinctiveness
of symptoms are not realistic bases for distinguishing CDs and PDs. It seems clear that
it would be more useful to focus on articulating models of how and why these domains
are so interconnected, as opposed to focusing on ways of further splitting apart CDs
and related PDs. in both clinical and epidemiological samples, CDs and PDs appear to
co–occur at greater than chance rates, a finding that challenges the idea that CDs and
PDs are highly distinctive types of mental disorders. CDs and PDs are also indistinct
in the sense that they share similar symptoms.
- Etiology: CDs as more genetic in etiology, and hence presumably more amenable to
pharmacologic intervention, whereas PDs were regarded as more environmental in
etiology, and hence presumably more amenable to psychotherapy. personality
pathology is significantly heritable. CDs and PDs are not well distinguished in terms
of the role of genetic factors in their etiology. Contrary to earlier speculation that
personality pathology might be primarily environmental in nature, personality
pathology, like other psychopathology, is significantly influenced by genetic factors.
Nevertheless, genetic influences do not provide the entire story with respect to the
etiology of psychopathology. The future of behavior genetic inquiry in this area lies in
better understanding the interplay of genetic and environmental influences.
THE JOINT STRUCTURE OF NORMAL AND ABNORMAL PERSONALITY
- The findings indicate that normal and abnormal personality constructs can be
integrated within the same structural model. Rather than representing highly separate
domains of human individual differences, normal and abnormal personality measures
can be located in the same factor space. In addition, the findings speak to the
importance of the FFM (five factor model) in understanding the joint structure of
normal and abnormal personality. The FFM appears to represent the “base” of the
higher– order structure that links normal and abnormal personality, as there was no
compelling evidence for factors beyond the five. However, there was evidence for
2
, structures above the five, and these structures resemble major conceptions of
personality that complement the FFM conception. This helps in integrating various
models and addressing questions of which dimensional model might be most
empirically compelling
- it would be incorrect to conclude that the FFM level of the personality hierarchy
provides all of the information necessary to capture personality variation
-
3. Classification of PDs? How does the DSM classify PDs? What are the advantages
and disadvantages of the DSM-IV’s categorical system of PD classification? What
are the alternatives to the DSM-IV’s categorical system? What is the empirical
evidence for these models?
Davey
- DSM-IV-TR listed 10 diagnostically independent personality disorders and these were
organized into three primary clusters (A) odd/eccentric personality disorders, (B)
dramatic/ emotional personality disorders, and (C) anxious/ fearful personality
disorders.
- Cluster A are (1) paranoid personality disorder, (2) schizotypal personality disorder,
and (3) schizoid personality disorder.
- Cluster B: (1) antisocial personality disorder (APD), (2) borderline personality
disorder (BPD), (3) narcissistic personality disorder, and (4) histrionic personality
disorder.
- Cluster C: (1) avoidant personality disorder, (2) dependent personality disorder and (3)
obsessive compulsive personality disorder
Problems with the Traditional Categorical Model
- The disorders are dimensional: personality disorders may not be disorders as such, but
simply represent extreme cases on conventional personality dimensions.
- Many overlapping characteristics
- a number of the existing personality disorder categories are particularly rare in the
general population
3
