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Understanding Personality Disorders: PSYC353 Lecture Notes

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Rachel Campanile@rachelcampanile_ievt
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Personality disorders are enduring patterns of behavior and inner experience that significantly deviate from cultural expectations, causing distress and impairment across various aspects of life. These complex conditions affect how people perceive themselves and interact with others, typically emerging during adolescence or early adulthood.
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Understanding Personality Disorders

Personality disorders involve enduring patterns of behavior that are inflexible, pervasive across different situations, and lead to significant distress or functional impairment. These patterns affect multiple areas including how people think, feel, relate to others, and control impulses.

What makes personality disorders unique is their early onset (typically adolescence or early adulthood) and their stability over time. Unlike some other mental health conditions that may come and go, personality disorders tend to be long-lasting and influence many aspects of a person's life.

The DSM organizes personality disorders into three clusters. Cluster A includes paranoid, schizoid, and schizotypal personality disorders, which affect approximately 1-1.5% of the population each. These disorders are characterized by odd or eccentric behavior and thinking patterns.

🔑 Key Insight: Personality disorders differ from other mental health conditions because they affect multiple domains of functioning (thinking, emotions, relationships, and impulse control) and typically begin early in life.

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Personality Disorder Clusters

Cluster B personality disorders include histrionic, narcissistic, antisocial, and borderline. These disorders are marked by highly emotional or erratic behavior. Antisocial personality disorder is more common in males (3%) than females (1%), while borderline personality disorder affects about 1.4% of the population.

Cluster C disorders include avoidant (2.5%), dependent (1%), and obsessive-compulsive personality disorders (2.1%). People with these disorders often experience persistent anxiety and fearfulness in their daily lives.

Borderline Personality Disorder (BPD) is characterized by instability in relationships, self-image, emotions, and behavior. To be diagnosed, a person must show at least five symptoms, including fear of abandonment, unstable relationships that swing between idealization and devaluation, and an unstable sense of self.

💡 Remember: Each personality disorder cluster has a distinctive pattern - Cluster A (odd/eccentric), Cluster B (emotional/erratic), and Cluster C (anxious/fearful).

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Borderline Personality Disorder In Depth

People with BPD often struggle with impulsive behaviors that can be self-damaging, such as reckless spending, substance abuse, or binge eating. They may experience suicidal thoughts or engage in self-harm behaviors, alongside intense emotional instability that can shift rapidly within hours.

BPD is the most researched personality disorder, with serious implications for those affected. Between 25-70% of people with BPD have attempted suicide at least once, and 8-10% die by suicide. The condition frequently occurs alongside other mental health conditions like major depression, bipolar disorder, anxiety disorders, PTSD, and substance use problems.

Unfortunately, stigma creates significant barriers for people with BPD. Many struggle to find treatment providers willing to work with them or to form effective therapeutic relationships. One promising approach to reducing this stigma is through educational workshops for professionals that combine information about BPD and treatment approaches with personal testimonies from individuals with lived experience.

🚨 Important: BPD has one of the highest suicide rates among mental health conditions, making effective treatment crucial. Despite this, stigma often prevents people from receiving the help they need.

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Dialectical Behavioral Therapy (DBT)

Dialectical Behavioral Therapy (DBT) is a leading treatment for BPD that balances acceptance and change. This comprehensive approach includes four key components: skills training groups, individual therapy, telephone consultation, and therapist team meetings.

DBT was originally created for people with BPD and suicidal behaviors but has been adapted for various other conditions. While effective, it's resource-intensive and sometimes offered with varying levels of faithfulness to the complete model.

The skills training component teaches practical tools organized into modules. The mindfulness module helps people develop "what skills" (observe, describe, participate) and "how skills" (non-judgmentally, one-mindfully, effectively). These skills help individuals stay present and respond thoughtfully rather than react impulsively.

🌟 Try This: Practice the DBT concept of "Wise Mind" by noticing when you're in either pure emotion or pure reason, then try to find the balanced middle ground that incorporates both.

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DBT Skills for Emotional Management

The concept of Wise Mind is central to DBT, representing the balance between emotional mind (hot, mood-dependent) and reasonable mind (cool, rational, fact-based). When in wise mind, you access your inner wisdom by integrating both emotion and reason to find the middle path.

Interpersonal effectiveness skills help people clarify their goals in social situations and develop strategies to achieve them. These goals might involve getting something you want (objective), maintaining relationships (relationship), or preserving self-respect (self-respect).

Emotion regulation skills teach individuals to identify and understand their emotions, increase positive experiences in life, and reduce vulnerability to negative emotions. A key component involves using mindfulness to accept and tolerate painful feelings rather than trying to eliminate them.

💪 You've Got This: Learning to identify and label your emotions is the first step toward managing them more effectively. With practice, these skills become easier and more natural.

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Advanced DBT Strategies

The Opposite Action skill is a powerful emotion regulation technique based on the principle that every emotion drives an urge to act in a specific way. By deliberately doing the opposite of what your emotion is pushing you to do, you can actually change the emotion itself. For example, if fear makes you want to avoid something, approaching it can reduce the fear.

When facing emotional situations, DBT teaches a decision-making process: First, ask if the emotion fits the facts of the situation. If it does, consider whether acting on it would be effective. If the emotion doesn't fit the facts or acting on it wouldn't be helpful, opposite action or problem-solving might be more appropriate.

The PLEASE skills help reduce vulnerability to negative emotions by addressing physical needs: treating Physical illness, balancing Eating, Avoiding mood-altering substances, balancing Sleep, and getting Exercise. Taking care of your body creates a stronger foundation for emotional stability.

🔄 Practice Point: Next time you feel a strong urge to avoid something that isn't actually dangerous, try the opposite action skill by gradually approaching it instead. Notice how your emotion changes.

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DBT Structure and Narcissistic Personality Disorder

Distress tolerance skills in DBT help people survive crisis situations without making things worse. These include distraction, self-soothing, and improving the moment. Beyond just surviving crises, DBT teaches acceptance of painful emotions through mindfulness, radical acceptance, and understanding the difference between pain and suffering.

The individual therapy component of DBT focuses on addressing life-threatening behaviors, therapy-interfering behaviors, quality-of-life issues, skill development, trauma responses, and building self-respect. Telephone consultation allows clients to call therapists when needed, especially before potential self-harm. The therapist consultation team provides emotional support and helps maintain therapist motivation.

Narcissistic Personality Disorder (NPD) is characterized by a pattern of grandiosity, need for admiration, and lack of empathy. To be diagnosed, a person must show at least five symptoms from criteria including an inflated sense of self-importance, fantasies of unlimited success, belief in being special or unique, requiring excessive admiration, and displaying arrogant attitudes.

🧠 Understanding NPD: While people with NPD may seem supremely confident, their grandiose behavior often masks fragile self-esteem that requires constant external validation.

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Narcissistic Personality Disorder

NPD presents in two main forms: grandiose narcissism (overtly self-important and entitled) and vulnerable narcissism (more sensitive to criticism while maintaining a sense of entitlement). It often occurs alongside depression, substance use disorders, or bipolar disorder and is more common in men than women.

Relationships with people with NPD can be challenging. While "narcissistic abuse" is a popular term online, clinically it's more accurate to focus on specific harmful behaviors. Though NPD isn't as strongly linked to violence as other risk factors like substance use, certain traits can increase risk, including emotional dysregulation, sense of entitlement, impulsivity, and co-occurring antisocial personality disorder.

Treatment for NPD has limited research compared to other conditions. Current approaches include addressing co-occurring disorders, transference-focused therapy (which examines emotions toward the therapist and in relationships), and adaptations of cognitive-behavioral therapy and dialectical behavior therapy.

⚠️ Important Context: Despite popular perceptions, not everyone with narcissistic traits has NPD. The disorder requires persistent patterns causing significant distress or impairment, not just occasional self-centered behavior.

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Treatment Approaches for NPD

Treatment for Narcissistic Personality Disorder remains an evolving field with limited research compared to other personality disorders. Most treatment plans begin by addressing co-occurring conditions like depression or substance use that often accompany NPD.

Transference-focused therapy shows promise for NPD by examining how the patient's feelings toward the therapist mirror their relationship patterns outside therapy. This approach helps individuals recognize and modify problematic interpersonal dynamics while developing greater emotional awareness.

Modified versions of Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) are also being adapted for NPD. These adaptations focus on challenging distorted thinking patterns, building empathy skills, and improving emotional regulation while maintaining the individual's sense of self-worth.

🔑 Treatment Reality: Effective NPD treatment requires a delicate balance - challenging grandiose thinking and harmful behaviors while maintaining therapeutic engagement, which can be difficult when criticism triggers defensive reactions.

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