Study Questions w5 650

Week 5 Discussion Questions

· 1. Review the diagnostic clusters of personality disorders. Choose cluster A B or C and discuss the challenges of conducting research on that cluster.

Cluster A: Includes paranoid, schizoid, and schizotypal personality disorders. People with these disorders often seem odd or eccentric, with unusual behavior ranging from distrust and suspiciousness to social detachment.

· Notes: This study estimated that about 10 percent of the population exhibits at least one personality disorder, with 5.7 percent in Cluster A, Since their entry into the DSM in 1980, the personality disorders have been coded on a separate axis, Axis II. This was because they were regarded as different enough from the standard psychiatric syndromes (which were coded on Axis I) to warrant separate classification. However, in DSM-5, the multiaxial system was abandoned. Personality disorders are now included with the rest of the disorders we discuss in this textbook. Even with structured interviews, the reliability of diagnosing personality disorders typically is less than ideal. Most researchers today agree that a dimensional approach for assessing personality disorders would be preferable.

· ● It is difficult to determine the causes of personality disorders as categories because most people with one personality disorder also have at least one more and because most studies to date are retrospective.

Difficulties Doing Research On Personality Disorders

Before we discuss the clinical features and causes of personality disorders, we should note that several important aspects of doing research in this area have hindered progress relative to what is known about many other disorders. Two major categories of difficulties are briefly described.

Difficulties in Diagnosing Personality Disorders

A special caution is in order regarding the diagnosis of personality disorders because more misdiagnoses probably occur here than in any other category of disorder. There are a number of reasons for this. One problem is that diagnostic criteria for personality disorders are not as sharply defined as they are for most other diagnostic categories, so they are often not very precise or easy to follow in practice. For example, it may be difficult to diagnose reliably whether someone meets a given criterion for dependent personality disorder such as “goes to excessive lengths to obtain nurturance and support from others” or “has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.” Because the criteria for personality disorders are defined by inferred traits or consistent patterns of behavior rather than by more objective behavioral standards (such as having a panic attack or a prolonged and persistent depressed mood), the clinician must exercise more judgment in making the diagnosis than is the case for many other disorders.

With the development of semistructured interviews and self-report inventories for the diagnosis of personality disorders, certain aspects of diagnostic reliability increased substantially. However, because the agreement between the diagnoses made on the basis of different structured interviews or self-report inventories is often rather low, there are still substantial problems with the reliability and validity of these diagnoses (Clark & Harrison, 2001 ; Livesley, 2003 ; Trull & Durrett, 2005 ). This means, for example, that three different researchers using three different assessment instruments may identify groups of individuals with substantially different characteristics as having a particular diagnosis such as borderline or narcissistic personality disorder. Of course, this virtually ensures that few obtained research results will be replicated by other researchers even though the groups studied by the different researchers have the same diagnostic label (e.g., Clark & Harrison, 2001 ).

Given problems with the unreliability of diagnoses (e.g., Clark, 2007 ; Livesley, 2003 ; Trull & Durrett, 2005 ), a great deal of work over the past 20 years has been directed toward developing a more reliable and accurate way of assessing personality disorders. Several theorists have attempted to deal with the problems inherent in categorizing personality disorders by developing dimensional systems of assessment for the symptoms and traits involved in personality disorders (e.g., Clark, 2007 ; Krueger & Eaton, 2010 ; Trull & Durrett, 2005 ; Widiger et al., 2009 ). However, a unified dimensional classification of personality disorders has been slow to emerge, and a number of researchers have been trying to develop an approach that will integrate the many different existing approaches (e.g., Markon et al., 2005 ; Krueger, Eaton, Clark et al., 2011a ; Widiger et al., 2009 , 2012 ).

The model that has perhaps been most influential is the five-factor model. This builds on the five-factor model of normal personality mentioned earlier to help researchers understand the commonalities and distinctions among the different personality disorders by assessing how these individuals score on the five basic personality traits (e.g., Clark, 2007 ; Widiger & Trull, 2007 ; Widiger et al., 2009 , 2012 ). To fully account for the myriad ways in which people differ, each of these five basic personality traits also has subcomponents or facets. For example, the trait of neuroticism is comprised of the following six facets: anxiety, angry-hostility, depression, self-consciousness, impulsiveness, and vulnerability. Different individuals who all have high levels of neuroticism may vary widely in which facets are most prominent—for example, some might show more prominent anxious and depressive thoughts, others might show more self-consciousness and vulnerability, and yet others might show more angry-hostility and impulsivity. And the trait of extraversion is composed of the following six facets: warmth, gregariousness, assertiveness, activity, excitement seeking, and positive emotions. (All the facets of each of the five basic trait dimensions and how they differ across people with different personality disorders are explained in Table 10.2 on p. 335.) By assessing whether a person scores low, high, or somewhere in between on each of these 30 facets, it is easy to see how this system can account for an enormous range of different personality patterns—far more than the 10 personality disorders currently classified in the DSM.

Within a dimensional approach, normal personality trait dimensions can be recast into corresponding domains that represent more pathological extremes of these dimensions: negative affectivity (neuroticism); detachment (extreme introversion); antagonism (extremely low agreeableness); and disinhibition (extremely low conscientiousness). A fifth dimension, psychoticism, does not appear to be a pathological extreme of the final dimension of normal personality (openness)—rather, as we will discuss later in the chapter in the section on schizotypal personality disorder, it reflects traits similar to the symptoms of psychotic disorders (e.g., schizophrenia) (Watson et al., 2008 ).

With these cautions and caveats in mind, we will look at the elusive and often exasperating clinical features of the personality disorders. It is important to bear in mind, however, that what we are describing is merely the prototype for each personality disorder. In reality, as would be expected from the standpoint of the five-factor model of personality disorders, it is rare for any individual to fit these “ideal” descriptions. And, as the Thinking Critically About DSM-5 box below illustrates, this situation will not change in DSM-5.

Reference:

Butcher, J. N., Hooley, J. M., & Mineka, S. (2014). Abnormal Psychology (16th ed.). Boston MA: Pearson

2. Summarize the etiology of addiction within the current substance use-misuse-abuse continuum. Provide an example of a person in the media who is at the abuse stage of addiction. Support your answer with peer-reviewed research.

NOTES: Even with structured interviews, the reliability of diagnosing personality disorders typically is less than ideal. Most researchers today agree that a dimensional approach for assessing personality disorders would be preferable.

It is difficult to determine the causes of personality disorders as categories because most people with one personality disorder also have at least one more and because most studies to date are retrospective.

Remarkable Recoveries from Life-Threatening Substance Abuse Lyle Prouse was born in Wichita, Kansas, in 1938 of American Indian heritage. As a child he was very interested in aviation and won his first airplane ride by writing an essay for Beechcraft Aircraft Company. Prouse, who grew up in the Indian community in Wichita, had a serious, long-term substance abuse problem, as did his parents, both of whom died from alcohol abuse. Many of his friends and associates were heavy alcohol abusers. After he finished high school he joined the U.S. Marines, became a pilot, and served in the Vietnam War. He was awarded several medals for his service in Vietnam. He left the military and obtained a flying position at Northwest Airlines, where he attained the rank of captain and worked for 22 years, flying Boeing 727 passenger aircraft. In 1990, Captain Prouse and his flight crew enjoyed a night of heavy drinking while on a layover in Fargo, North Dakota. Prouse consumed a number of rum-and-Diet-Cokes, and his crew drank several pitchers of beer and apparently were very loud and belligerent. Although his crew left the bar earlier, Prouse remained longer and continued drinking. During their drinking binge the flight crew angered a customer in the pub, who later called the FAA, warning them against the problem drinking of the crew. The next morning the Northwest crew continued their flight to Minneapolis and were arrested and given substance use tests. They showed high levels of alcohol in their bloodstreams and were charged with violating a federal law, which included prison time as a result of operating a public transportation carrier under the influence of drugs or alcohol. Captain Prouse and his crewmembers served 12 months of the 16-month sentence they received. All three pilots lost their jobs and their pilot’s licenses as a result of the substance use violations. Captain Prouse felt a great deal of depression and shame at the problems that he created for himself and others following the loss of the aviation career that he loved. He also experienced a great deal of financial problems from his employment termination. On several occasions he contemplated committing suicide. Captain Prouse entered inpatient substance abuse treatment not long after the incident. After completing his recovery in an inpatient substance abuse treatment center, Prouse began a long and difficult process of rehabilitation and effort to restore his life without using alcohol. He made many public speeches describing his substance abuse and later wrote a book detailing what he had gone through (Prouse, 2001). Throughout his recovery he was determined to regain his flying status. It was necessary for him to retrain and retake all of the FAA licensing examinations in order to have his qualifications restored because he was required to requalify for every one of his licenses and ratings. Captain Prouse was assisted in his recovery by a number of people who were impressed by his public disclosure of wrong-doing and his high motivation to recover from his substance abuse. After he appealed to the court to allow him the opportunity to obtain recertification, the court waived the legal restrictions that had been placed upon him at the trial. A friend of his who owned a trainer aircraft allowed him to earn the necessary flying time needed to be relicensed as a pilot. The CEO of Northwest Airlines, John Dasburg, who himself had grown up in a family with alcoholic abuse problems, took personal interest in Prouse’s struggle and encouraged his return to duty. He returned to flying with Northwest Airlines. Captain Prouse’s efforts and success at rehabilitation were indeed impressive. In 2001 he was granted a presidential pardon by President Clinton. Interestingly, another one of the pilots on the Northwest “drunk pilots” flight, flight engineer Joe Balzer, who also spent 12 months in federal prison, also rehabilitated himself. He became involved with Alcoholics Anonymous and, over time, requalified for the aviation certification, eventually returning to the cockpit as a pilot for American Airlines (see his autobiographical account in Balzer, 2009). The extensive problem of substance abuse and substance dependence in our society has drawn both public and scientific attention. Although our present knowledge is far from complete, investigating these problems as maladaptive patterns of adjustment to life’s demands, with no social stigma involved, has led to clear progress in understanding and treatment. Such an approach, of course, does not mean that an individual bears no personal responsibility in the development of a problem. On the contrary, individual lifestyles and personality features are thought by many to play important roles in the development of substance-related disorders and are central themes in some types of treatment. Substance-related disorders can be seen all around us: in extremely high rates of alcohol abuse and dependence, and in tragic exposés of cocaine abuse among star athletes and entertainers. Addictive behavior—behavior based on the pathological need for a substance—may involve the abuse of substances such as nicotine, alcohol, Ecstasy, or cocaine. Addictive behavior is one of the most prevalent and difficult-to-treat mental health problems facing our society today. The most commonly used problem substances are those that affect mental functioning in the central nervous system (CNS)—psychoactive substances: alcohol, nicotine, barbiturates, tranquilizers, amphetamines, heroin, Ecstasy, and marijuana. Some of these substances, such as alcohol and nicotine, can be purchased legally by adults; others, such as barbiturates or pain medications like OxyContin (or marijuana in some states), can be used legally under medical supervision; still others, such as heroin, Ecstasy, and methamphetamine, are illegal. The material described in this chapter was designed to provide both a historic and contemporary view of important research and theoretical strategies in understanding addictive disorders thus we will, in places, refer to the substance abuse versus substance dependence distinction. The following distinctions are important to understanding and diagnosing substance-related disorders: • Substance abuse generally involves an excessive use of a substance resulting in (1) potentially hazardous behavior such as driving while intoxicated or (2) continued use despite a persistent social, psychological, occupational, or health problem. • Substance dependence includes more severe forms of substance-use disorders and usually involves a marked physiological need for increasing amounts of a substance to achieve the desired effects. Dependence in these disorders means that an individual will show a tolerance for a drug and/or experience withdrawal symptoms when the drug is unavailable. • Tolerance—the need for increased amounts of a substance to achieve the desired effects—results from biochemical changes in the body that affect the rate of metabolism and elimination of the substance from the body. • Withdrawal refers to physical symptoms such as sweating, tremors, and tension that accompany abstinence from the drug.

Reference: Butcher, J. N., Hooley, J. M., & Mineka, S. (2014). Abnormal Psychology (16th ed.). Boston,

            MA: Pearson

3. Describe the effectiveness of treatment in substance abuse as evidenced in research studies.

4. Describe the biopsychosocial as it relates to the development of substance abuse disorders.

5. What are three reasons for the high frequency of misdiagnoses of personality disorders?

6. Why Were No Changes Made to the Way Personality Disorders Are Diagnosed?

NOTES: DSM-5 THINKING CRITICALLY about DSM-5: Why Were No Changes Made to the Way Personality Disorders Are Diagnosed?

Many new and innovative proposals were offered for inclusion in the personality disorders section of DSM-5. Indeed, the proposed revisions were among the most radical for any of the disorders covered in this book. The details were hotly debated, although the general goal was to incorporate a more dimensional approach to the assessment and diagnosis of personality pathology (Livesley, 2011 ; Skodol et al., 2011 ; Widiger et al., 2009 ).

In the end, the DSM-5 task force proposed revisions that reflected a hybrid dimensional–categorical model. This consisted of both categorical components and dimensional components. This model includes a set of general criteria for all personality disorders, an overall dimensional measure of the severity of personality dysfunction, a limited set of personality disorder types, and a set of pathological personality traits that could be specified in the absence of one of the personality disorder types. The proposed categorical component also retained 6 of the original 10 specific personality disorder types (antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal).

The greatest change to the status quo came from the incorporation of dimensional components. The new personality domain was intended to describe personality characteristics of all patients, even those without a specific personality disorder. The proposals would have allowed clinicians to rate the level of impairment in personality functioning, reflecting aspects of both identity (having a stable and coherent sense of self and the ability to pursue meaningful life goals) and interpersonal functioning (the capacity for empathy and intimacy). In addition, diagnosticians could indicate the degree to which the patient showed substantial abnormality on five trait domains (negative affectivity, detachment, antagonism, disinhibition, and psychoticism), which are based primarily on the five-factor trait model discussed in this chapter.

In the end, however, the Board of Trustees of the American Psychiatric Association vetoed all of the proposed changes and decided to retain the old categories of personality disorders. In other words, personality disorders in DSM-5 are the same as they were in DSM-IV. Why were no changes accepted? We cannot be sure. But, as you may have gathered from our description above, the new system was very complicated. Although it may have led to a better classification system, the fact that it was not very intuitive or user-friendly may have been a problem. The primary audience for the DSM is clinicians who diagnose and treat people with mental disorders. We suspect that the new proposed system was rejected because it was quite cumbersome and judged too time-consuming for overworked clinicians to learn and use. Moreover clinicians probably would not have found the proposed system to be user-friendly in part because the idea of rating people on dimensions is foreign to the way clinicians have been taught to think. The new proposals were not dismissed entirely, however. They now appear in Section III of DSM-5, which describes disorders in need of further study. This may have been a wise course of action. Perhaps with more time and more research, it will become apparent whether or not the new approach provides enough benefits to make people willing to accept the challenges learning to use it will require.

Reference:

Butcher, J. N., Hooley, J. M., & Mineka, S. (2014). Abnormal Psychology (16th ed.). Boston MA: Pearson

7. What are the features of antisocial personality disorder and psychopathy?

Antisocial Personality Disorder

Individuals with antisocial personality disorder (ASPD) continually violate and show disregard for the rights of others through deceitful, aggressive, or antisocial behavior, typically without remorse or loyalty to anyone. They tend to be impulsive, irritable, and aggressive and to show a pattern of generally irresponsible behavior. This pattern of behavior must have been occurring since the age of 15, and before age 15 the person must have had symptoms of conduct disorder, a similar disorder occurring in children and young adolescents who show persistent patterns of aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violation of rules at home or in school

· ● A person with psychopathy shows elevated levels of two different dimensions of traits: (1) an affective-interpersonal set of traits reflecting lack of remorse or guilt, callousness/lack of empathy, glibness/superficial charm, grandiose sense of self-worth, and pathological lying, and (2) antisocial, impulsive, and socially deviant behavior; irresponsibility; and parasitic lifestyle. A person diagnosed with ASPD is primarily characterized by traits from the second dimension of psychopathy.

· ● Genetic and temperamental, learning, and adverse environmental factors seem to be important in causing psychopathy and ASPD.

· ● Psychopaths also show deficiencies in fear and anxiety as well as more general emotional deficits.

· ● Treatment of individuals with ASPD psychopathy is difficult, partly because they rarely see any need to change and tend to blame other people for their problems.

8. What is drug abuse and dependence?