Stressisaprocessofadjustingtocircumstancesthatdisruptorthreatentodisruptperson Sequilibrium

DISSOCIATIVEANDSOMATOFORMDISORDERSI

Whatisstress?

• Stressisaprocessofadjustingtocircumstancesthatdisruptorthreatentodisruptperson’sequilibrium.

•Scientistsdefinestressasanychallengingeventthatrequiresphysiological,cognitive,orbehavioral adaptation.

• Stressisanunavoidable,andinsomecasesadesirable,factofeverydaylife.

•Somestressors,however,aresocatastrophicandhorrifyingthattheycancauseseriouspsychological harm.

•Suchtraumaticstressis definedinDSM-IV-TRasaneventthatinvolvesactualor threateneddeathor seriousinjurytoselforothersandcreatesintensefeelingsoffear,helplessness,orhorror.

1-Acutestress disorder (ASD) occurs within 4 weeks after exposure to traumatic stress andischaracterizedbydissociativesymptoms,re-experiencingoftheevent,avoidanceofremindersofthe trauma,andmarkedanxietyorarousal.

2-Posttraumaticstressdisorder(PTSD)isalsodefinedbysymptomsofre-experiencing,avoidance,andarousal,butinPTSDthesymptomseitherarelongerlastingorhaveadelayedonset.

SymptomsofASDandPTSD

1-Peoplewho have beenconfrontedwithatraumaticstressorre-experiencetheevent inanumberofdifferent ways.

2-ManypeoplewithASDorPTSDhaverepeatedandintrusiveflashbacks,suddenmemoriesduring whichthetraumaisreplayedinimagesorthoughts—oftenatfullemotionalintensity.

3-Inrarecases,re-experiencingoccursasadissociativestate,andthepersonfeelsandactsasifthetrauma actuallywererecurringinthemoment.

4-MarkedorpersistentavoidanceofstimuliassociatedwiththetraumaisanothersymptomofASDandPTSD. Example

1-December2004tsunamitrauma

2-September11th2001trauma

3-October8thtrauma

Traumavictimsmayattempttoavoidthoughtsorfeelingsrelatedtotheevent,ortheymayavoidpeople, places,oractivitiesthatremindthemofthetrauma.

5-InPTSD,theavoidancealsomaymanifestitselfasa generalnumbingofresponsiveness.

PeoplesufferingfromPTSDoftencomplainthattheysufferfrom“emotionalanesthesia”—theirfeelings seemdampenedorevennonexistent.

6-PeoplewithASDandPTSDalsoexperienceincreasedarousalandanxietyfollowingthetrauma,a symptomwhichpredictsa worseprognosiswhenitis moresevere.

7-AnumberofpeoplewithPTSDorASDalsohaveanexaggerated startleresponse,excessive fearreactions to unexpectedstimuli,suchasloudnoises.

8-Otherpeopleexperiencedepersonalization,feelingcutofffromthemselvesortheirenvironment.People withthissymptommayreportfeelinglikearobotorasiftheyweresleepwalking.

9-Derealizationischaracterizedbyamarkedsenseofunrealityaboutyourselfortheworldaroundyou.

ASDalsomaybecharacterizedbyfeaturesofdissociativeamnesia,specificallytheinabilitytorecallimportantaspectsofthetraumaticexperience.

DSM-IV-TRlistsa senseofnumbingor detachmentfromothersas dissociativesymptomsthat characterize acutestressdisorder.

DiagnosisofASDandPTSD

Maladaptivereactionstotraumaticstresshavelongbeenofinteresttothemilitary.

Historically,mostofthemilitary’sconcernhasfocusedonmenwholeavethefieldofactionasaresultof whathasbeencalled“shellshock”or“combatneurosis.”

ThebasicdiagnosticcriteriaforPTSD—re-experiencing,avoidance,andarousal—haveremainedmoreor lessthesameinrevisionsof theDSM.

However,twosignificantchangesintheclassification oftraumaticstressdisordersweremadewiththe publicationofDSM-IVin1994:Acutestressdisorderwasincludedasaseparatediagnosticcategory,and thedefinitionoftraumawas altered.

PreventionandTreatmentofASDandPTSD

Mountingevidencesupportstheeffectivenessofvariouscognitivebehavioraltreatments.

ArecentconsensusstatementonthetreatmentofPTSDconcludedthatantidepressantmedicationand psychotherapyinvolvingtherapeuticre-exposurearethetwo“first-line”therapiesforPTSD.

Letustalkaboutdissociativedisorders.

• Isitpossibletoforgetwhoareyou?

• Itisreallypossibletoforgetyourpast?

• Canyouhavenorecollectionofyourfamilyatall?

• Isitactuallypossibletohavenomemoryofyourpersonalidentityorfamilyorworkrole?

• Andisittruethattherearemorecasestodaythanevenbefore?

DissociativeDisorders

Individualswith a dissociativedisorderexperiencea severedisruptionor alterationof their identity, memory,orconsciousness.Itisbasedontheunbelievable.

Example

Ahousewifeforgetshernameherentirepastlifehasdissociativedisorder. Apoliceman,whoabandonedhisfamily,hasdissociativedisorder.

Theyarecharacterizedbypersistent,maladaptivedisruptionsintheintegrationofmemory,consciousness, oridentitythepersonwithadissociative disordermaybeunabletoremember manydetailsaboutthepast; heorshemaywanderfarfromhomeandperhaps assume anewidentity; ortwoormorepersonalitiesmay coexistwithinthesameperson.

Dissociativedisordersoncewereviewedasexpressionsofhysteria.

InGreek,hysteriameans“uterus,”andthetermhysteriareflectsancientspeculationthatthesedisorders werecausedbyfrustratedsexualdesires,particularlythedesiretohaveababy.

JanetwasaFrenchphilosophyprofessorwhoconductedpsychologicalexperimentsondissociationand both Janet andFreudwereeagertoexplainandtreat hysteria,andtheproblemledbothofthemtodevelop theoriesaboutunconsciousmentalprocesses.

Janetsawdissociationasanabnormalprocess.

Incontrast,Freudconsidereddissociationasanormalprocess,aroutinemeansthroughwhichtheego defendeditselfagainstunacceptableunconsciousthoughts.

Freudsawdissociationandrepressionassimilarprocesses,andinfact,heoftenusedthetwoterms interchangeably.

Hypnosisisinwhichsubjectsexperiencelossofcontrolovertheir actionsinresponsetosuggestionsfrom thehypnotist,isatopicofhistoricalimportanceandcontemporarydebateabouttheunconsciousmind.

Allagreethatdemonstrationsofthepowerofhypnoticsuggestionareimpressive.

However, some experts assert that hypnosis is the dissociative experience of an altered state of consciousness.

SymptomsofDissociativeDisorders

1-The symptoms of dissociative disorders apparently involve mental processes that occuroutsideofconsciousawareness.

2-Extremecasesofdissociation includeasplitinthefunctioning oftheindividual’s someresearchers andcliniciansarguethatDIDislinkedwithapasttrauma,particularly withchild’sphysicalorsexual abuse.

Arelatedissueisverycontroversialtopicofrecoveredmemories,dramaticrecollectionsoflong-agotraumaticexperiencessupposedlyblockedfromtheconsciousmindbydissociation.

3-Depersonalizationisaform ofdissociationwhereinpeoplefeeldetachedfromthemselvesor theirsocialorphysicalenvironment.

4-Amnesia—thepartialorcompletelossofrecallforparticulareventsorforaparticularperiodof time.

5-Braininjuryordiseasecancauseamnesia.

6-ButPsychogenicAmnesia(psychologically causedamnesia)resultsfromtraumaticstressorother emotionaldistress.

• Psychogenicamnesiamayoccuraloneorinconjunctionwithotherdissociativeexperiences.

7-Itiswidelyacceptedthatfugueandpsychogenic amnesiaareusuallyprecipitatedbytrauma,thus providinganotherlinkbetweendissociationandtraumaticstressdisorders.

• Muchmorecontroversialistherolethattraumamightplayindissociativeidentitydisorder(DID).

DiagnosisofDissociativeDisorders

Forcenturies,theoristsconsidereddissociativeandsomatoformdisordersasalternativeformsof hysteria.

•However,thedescriptiveapproachto classificationintroducedin DSM-III(1980)ledto the separationofdissociativeandsomatoformdisordersintodiscretediagnosticcategories.

•ThedistinctionispreservedinDSM-IV-TR(2000),becausethesymptomsofthetwodisorders differgreatly.

•Thetypesofdissociativedisordersdiscussedinthislecturearedissociativeamnesia,dissociative fugue,dissociativeidentitydisorderanddepersonalizeddisorder.Althoughdissociativedisorders

typicallyinvolvedisruptionofidentity,dissociativeamnesiacaninvolvelossofmemorywithout lossofidentity.

•Thetermpsychogenicwasusedinthenamesofthesedisorders-asinpsychogenicamnesiaand psychogenicfugue-toindicatethatthefugueormemorylossisnotphysicallycaused.

1- DissociativeAmnesia

•Eachofus,throughoutourlives,hasforgotten certain things-aperson’sname,afriend’sbirthday, theneedtostopatastoreonthewayhome.Forgetfulness,however,isnotyetthesameas memoryloss.Thepersonwithmemorylossisunabletorecallimportant personalinformationtoo extensivetobeviewedintermsofforgetfulness. Whenthereisactualdamagetothebrain,from injuryordisease,theinformationthatisn’trecalledislostforever.

•Butindissociative(psychogenic) amnesia,thememorysystemisnotphysicallydamaged,yetthere isselectivepsychologicallymotivatedforgetting.Often,whathasbeenforgottenistraumaticfor theindividual.Itcansometimesberetrievedfrommemory.

•Therearetwomaintypesofamnesia:selectiveandgeneralized.Incasesofselectivedissociative amnesia,apersonforgetssomebutnotofwhathappenedduringacertainperiodoftime.

•Incontrasttotheselectivedissociativeamnesia,thepersonwhoissufferingfromgeneralized dissociativeamnesiaforgetsone’sentirelifehistory.

•Whatdidyoueatforbreakfasttoday?Whenisyourbirthday?Thesequestionsdonottaxour memorysystemandappeareasy toanswer. Whenyoureadatextbookbutstruggletoanswerexamquestions,youmightcomplainthatjust“can’tremember.”Why?

1-Forgettinghappensasaroutinepartoflife,andthereareseveralexplanations forwhyyouforget. Decaytheorymaintainsthatlossofmemoryisaresult ofdisuse andthepassageoftime;ifinformationis notusedorrehearseditfadesovertime.

2-Interference theorysuggeststhatmemoryhasalimitedcapacity;whenitscapacityisreached;youare susceptibletoconfusionandforgetting.

3- Anothertheorysuggeststhat forgettingoccurs when there is failurein the process of retrieving information.Theinformation isthere,storedaway,butitappearstohavebeenforgottenbecauseyou cannotretrieveit.

•Repression,then,ismotivatedforgetting,ortheburyingofunwantedmemoriesintheunconscious wheretheystaylargelyunreachable.

2- Dissociativefugue

Thefuguestateinvolvesphysicalretreat;duringafugue,theindividual suddenlyandunexpectedly departs.Twoimportantfeaturesfordiagnosingdissociative(psychogenic)fuguearelistedinDSM-

IV: asuddenunexpected travelawayfromhomeorworkwithaninabilitytorecallone’spast,and confusionaboutpersonalidentity.Markedconfusionaboutpersonalidentityinterfereswithroutine daily activities,so,inaneffort toadjustandrelatetoothers,the personassumesanew identity.Despite the new assumed identity, characteristicsof the “old self” are recognizable. Often, complicated behaviorsarecarriedoutduringthefugue.Avictimmaydrivealongdistance,findaplacetolive, obtainemployment,andbeginanewlife.

WhoisAffectedwithDissociative AmnesiaandFugue?

Bothdissociativeamnesiaandfugue arerare.Reportsofcasesuggestthatthesedisorderscanappearatanypointinthelifespan,thoughlessamongtheelderly.Amnesia ismostfrequentamongadolescent andyoungwomen,butitsincidenceincreasesslightlyamongmen.

Treating Dissociative AmnesiaandFugue

Not surprisingly,apersonin anamnesicor in afuguestate whoisunawareof importantfactsabouthisorherownidentityisoftenequallyuninformed abouttheneedfortherapy.Typically,dissociative amnesicandfuguepatientsdonotseektreatmentthemselvesbut,rather,arereferredtoatherapistafteranepisodehas occurred.Thetherapyitselfoftenaddressesclients’needfor moreadaptivewaysto managepersonaldistressandconflict.

• Stressmanagementprograms,maybeusedtotreatdissociativeamnesiaandfugue.

3- DissociativeIdentityDisorder(DID)

•Alsoknownasmultiplepersonalitydisorder,ischaracterizedbytheexistenceoftwoormore distinctpersonalitiesinasingleindividual.

•Atleasttwoofthesepersonalitiesrepeatedlytakecontroloftheperson’sbehavior,andthe individual’sinabilitytorecallinformationistooextensivetobeexplainedbyordinaryforgetfulness.

•Theoriginal personalityespeciallyislikelytohaveamnesiaforsubsequentpersonalities,which may ormaynotbeawareofthe“alternates.”

•DIDhasreceivedconsiderablepublicattention,butwheredoesitfitamongthemanydifferent typesofpsychologicaldisorders?Readersmaywonderwhetheritisrelatedto the personalitydisorders. Itisnot:UnlikeDID,personality disorders involveclustersofbehavioral traitsthatareexcessive, maladaptive,lifelong,andpervasive.Also,althoughDIDmay resemblea“splitmind,”whichisthe literaltranslationofthewordschizophrenia.

Examples

1-“Sybil,”agirlwithsixteenpersonalities,DIDischaracterizedbythepresenceoftwoormoredistinct personalitiesofpersonalitystateswithinoneindividualpatterns.

2-TheThreeFacesofEve,whodescribesaclient,whosethreedifferentpersonalitiesvirtualoppositesintermsoftheiremotionalandbehavioralpatterns.EveWhitewasthequiet,polite,hard-working, and conservative motherofayoungdaughter;EveBlackwasseductive,impulsive,risk-taking,and adventure-seeking.Jane,thethirdpersonality,wasaconfidentandcapablewoman.

WhoIs AffectedwithDID?

DIDhasbeenfoundtooccurmanytimemoreofteninwomenthaninmen(estimatedratesarethree toninetimeshigherinwomen).Themostcommonexplanationsofferedforthisvariancearethatwomenaretypicallymoreexposedtosexualabuse,womenmayhandletheirpsychologicaltraumasin“internal”waysandfinallywomentendtoseekhelpmorethanmendo.

TreatingDID

Antidepressants and anti-anxiety drugs would be the medications commonly used in these circumstances.OnceDIDisdetected,however,thetypicaltreatmentinvolvespsychotherapyaimedathelpingreplacethepatients’internaldivisionwithaunityofpersonalities(Putnam,1989).

4- Depersonalizationdisorder

•Depersonalizationdisorder isalessdramatic problem thatischaracterizedbysevereandpersistent feelingsofbeingdetachedfromoneself.

•Depersonalizationexperiencesincludesuchsensationsasfeelingasthough youwereinadreamor werefloatingaboveyourbodyandobservingyourselfacted.

DiagnosisofDissociativeDisorders(continued)

Occasionaldepersonalizationexperiencesarenormalandarereportedbyabouthalfofthepopulation.

CausesofDissociativeDisorders

Theonsetofdissociativeamnesiaandfugueusuallycanbetracedtoaspecifictraumaticexperience.

DISSOCIATIVEandSOMATOFORMDISORDERSII

Individualswithadissociative disorderexperience aseveredisruption oralteration oftheiridentity, memory,orconsciousness.Itisbasedontheunbelievablethings.

Example

Ahousewifeforgetshernameherentirepastlifeshehasdissociativedisorder.

KindsofDissociativedisorders

Thetypesofdissociativedisordersdiscussedinthislecturearedissociativeamnesia,dissociativefugue,dissociativeidentitydisorderanddepersonalizeddisorder.Althoughdissociativedisorderstypicallyinvolve disruptionofidentity,dissociativeamnesiacaninvolvelossofmemorywithoutlossofidentity.

DiagnosisofDissociativeDisorders

•Forcenturies,theoristsconsidereddissociativeandsomatoformdisordersasalternativeformsof hysteria.

•However,thedescriptiveapproachto classificationintroducedin DSM-III(1980)ledto the separationofdissociativeandsomatoformdisordersintodiscretediagnosticcategories.

•ThedistinctionispreservedinDSM-IV-TR(2000),becausethesymptomsofthetwodisorders differgreatly.

1-Thesymptoms ofdissociative disordersapparentlyinvolvementalprocessesthatoccuroutsideof consciousawareness.

2-Extremecasesofdissociationincludea splitinthefunctioningofindividual’ssenseofself.

3-Depersonalizationisaformofdissociationwhereinpeoplefeeldetachedfromthemselvesortheirsocialorphysicalenvironment.

4-Amnesia—the partialorcompletelossofrecallforparticulareventsorforaparticularperiodof time.

5-Braininjuryordiseasecancauseamnesia.

6-ButPsychogenicAmnesia(psychologicallycaused)resultsfromtraumaticstressorotheremotional distress.Psychogenicamnesiamayoccuraloneorinconjunctionwithotherdissociativeexperiences.

7-Itiswidelyacceptedthatpsychogenic fugueandpsychogenic amnesiaareusuallyprecipitated by trauma,thusprovidinganotherlinkbetweendissociationandtraumaticstressdisorders.

Someresearchers andcliniciansarguethatDIDislinkedwithapasttrauma,particularlywithchild’s physical or sexual abuse. The term psychogenic was used in the names of these disorders- as in psychogenicamnesiaandpsychogenicfugue- toindicatethatthefugueor memoryloss is not physicallycaused.

1-DissociativeAmnesia eachofus,throughoutourlives,hasforgottencertainthings-a person’sname,afriend’sbirthday,theneedtostopata storeonthewayhome.Forgetfulness,however, isnotyet thesameasmemoryloss. Thepersonwithmemoryloss isunabletorecallimportantpersonal information tooextensivetobeviewedintermsofforgetfulness.Whenthereisactualdamagetothe brain,frominjuryordisease,theinformationthatisn’trecalledislostforever.

•Butindissociative(psychogenic) amnesia,thememorysystemisnotphysicallydamaged,yetthere isselectivepsychologicallymotivatedforgetting.Often,whathasbeenforgottenistraumaticfortheindividual.Itcansometimesberetrievedfrommemory.

•Therearetwomaintypesofamnesia:selectiveandgeneralized.Incasesofselectivedissociative amnesia,apersonforgetssomebutnotofwhathappenedduringacertainperiodoftime.

•Incontrasttotheselectivedissociativeamnesia,thepersonwhoissufferingfromgeneralized dissociativeamnesiaforgetsone’sentirelifehistory.

2-Dissociativefugue thefuguestateinvolvesphysicalretreat;duringafugue,theindividual suddenly and unexpectedly departs. Two important features for diagnosing dissociative (psychogenic)fuguearelistedinDSM-IV: asuddenunexpectedtravelawayfromhomeorwork withaninability torecallone’spast,andconfusion aboutpersonal identity.Markedconfusion about personalidentityinterfereswith routinedaily activities,soinanefforttoadjustandrelate toothers,the personassumesanewidentity.Despitethenewassumedidentity,characteristics ofthe“oldself”are recognizable.Often, complicatedbehaviorsarecarriedoutduringthefugue.Avictimmaydrivealong distance,findaplacetolive,obtainemployment,andbeginanewlife.

3-Dissociative identitydisorder(DID),alsoknownasmultiplepersonalitydisorder,is characterizedbytheexistenceoftwoormoredistinctpersonalitiesinasingleindividual.

•Atleasttwoofthesepersonalitiesrepeatedlytakecontroloftheperson’sbehavior,andthe individual’sinabilitytorecallinformationistooextensivetobeexplainedbyordinaryforgetfulness.

•Theoriginal personalityespeciallyislikelytohaveamnesiaforsubsequentpersonalities,which may ormaynotbeawareofthe“alternates.”

• Examples

1-“Sybil,”agirlwithsixteenpersonalities,DIDischaracterizedbythepresenceoftwoormoredistinct personalitiesofpersonalitystateswithinoneindividualpatterns.

2-TheThreeFacesofEve,whodescribeaclient,whosethreedifferentpersonalities virtualoppositesin termsoftheiremotionalandbehavioralpatterns.EveWhitewasthequiet,polite,hard-working,andconservative motherofayoungdaughter;EveBlackwasseductive,impulsive,risk-taking,and adventure-seeking.Jane,thethirdpersonalitywasa confidentandcapablewoman.

4-Depersonalizationdisorderisalessdramaticproblemthatischaracterizedbysevere andpersistent feelingsofbeingdetachedfromoneself.

•Depersonalizationexperiencesincludesuchsensationsasfeelingasthough youwereinadreamor werefloatingaboveyourbodyandobservingyourselfas acting.

SomatoformDisorders

•Dosomeindividualsreallyneedacabinetfullofmedicinestodealwiththeirmanyailments,orthey mightbenefitmorefrompsychologicalcounseling?

• Dowesometimesrespondphysically-forexample,by becomingparalyzed-to psychologicalstress?

•Whenmind-bodyinteractionsaremaladaptive,asomatoformdisordermayresult.Somatoform disordersinvolvephysicalsymptoms,intheabsenceofphysicalillnessforwhichthereisnoadequateexplanation.(Somameansbody,andsomatoformmeans“bodylike.” Onepatientwitha somatoform disordermayreportbeingblindbutaccordingtomedicaltests,havenormal functioningeyes.

Somatoformdisordersareproblemscharacterizedbyunusualphysicalsymptomsthatoccurintheabsenceofaknownphysicalillness.

1-Thereisnodemonstrablephysicalcauseforthesymptomsofsomatoformdisorders.Theyare somatic(physical)informonly—theirname.

2-Allsomatoform disordersinvolvecomplaintsaboutphysicalsymptoms,butnotcausedbyphysical impairments.Thereisnothingphysicallywrongwiththepatient.

3-Thephysicalproblemisveryrealin themind,thoughnot thebody, of thepersonwith asomatoform disorder.

4-Thephysicalsymptomscantakeanumberofdifferentformssubstantial impairmentofasomatic system,particularlyasensoryormuscularsystem.Thepatientwillbeunabletosee,forexample,orwill reporta paralysisinonearm.

5-Inothertypesofsomatoformdisorder,patientsexperiencemultiplephysicalsymptomsusuallynumerous,complaintsaboutsuchproblemsaschronicpain,upsetstomach,anddizziness.

6-Finally,sometypesofsomatoformdisorderaredefinedbyapreoccupation

A-Withaparticularpartofthebodysayeyesorstomachor

B-Withfearsaboutaparticularillness.

Thepatientmayconstantlyworrythatheorshehascontractedsomedeadlydisease,forexample,and theanxietypersistsdespitenegativemedicaltestsandclearreassurancebyaphysician.

7-Peoplewithsomatoformdisorderstypicallydonotbringtheirproblemstotheattentionofamental healthprofessional.

Instead,theyrepeatedlyconsulttheirphysiciansabouttheir“physical”problems.Thisoftenleadsto unnecessarymedicaltreatment.

KindsofSomatoformDisorders

DSM-IV-TRlistsfivemajorsubcategoriesofsomatoformdisorders: (1)Conversiondisorder

(2)Somatizationdisorder

(3)Hypochondriasis

(4)Paindisorder

(5)BodyDysmorphicdisorder

1- ConversionDisorder

•Thesymptomsofconversiondisorderoftenmimicthosefoundinneurologicaldiseases,andthey canbedramatic.

•“Hysterical”blindnessor“hysterical”paralysisareexamplesofconversionsymptoms.Although conversion disorders often resemble neurological impairments, they sometimes can be distinguishedfromthesedisordersbecausetheymakenoanatomicsense.Thetermconversion disorderaccuratelyconveysthecentralassumptionofthediagnosis—the ideathatpsychological conflictsareconvertedintophysicalsymptoms.

•One ormore symptomsordeficitsaffectingvoluntarysensoryor motorfunctioningthatcannotbe explainedbyaneurologicalorgeneralmedicalcondition(afterappropriateinvestigation)andisnotaculturallysanctionedbehavior.Psychological factors(thoughnotintentional)arejudgedtobe involvedbecausesymptomsareexacerbated understressandthesymptomsareusefulforthe patient’savoidanceof stress.Thesymptomsordeficitscauseclinicallysignificantdistressor impairmentinsocial,occupational,otherimportantareasoffunctioning.

2-Somatizationdisorder

•Somatizationdisorderis characterizedby ahistoryofmultiplesomaticcomplaintsin the absenceof organicimpairments.

•Inordertobediagnosedwithsomatizationdisorder,thepatientmustcomplainofatleasteight physicalsymptomsandmustinvolvemultiplesomaticsystems.

•Patientswithsomatizationdisorderssometimespresenttheirsymptomsinahistrionicmanner—a vaguebutdramatic,self-centered, andseductivestyle.Patientsalsomayexhibitlabelleindifference (“beautifulindifference”),aflippantlackofconcernaboutthephysicalsymptoms.

3-Hypochondriasis

•Hypochondriasisisaproblem characterizedbyafearorbeliefthatoneissufferingfromaphysical illness.

• Hypochondriasisismuchmoreseriousthannormalandfleetingworries.

• Thepreoccupationwithfearsofdiseaseextendsoverlongperiodsoftime.

•Inaddition,inhypochondriasis,athoroughmedicalevaluationorexaminationdoesnotalleviate thefearofthedisease.

•Basedonmisinterpretationsofbodilyreactions,thesuffererispreoccupiedwithfearsofhavinga seriousdisease.Thoughnotadelusion, thefearpersistsdespitemedicalevaluations. The preoccupationcausesclinicaldistressofatleastsixmonthsduration.

4-Paindisorder

• Paindisorderischaracterizedbypreoccupationwithpain.

• Complaintsseemexcessiveandapparentlyaremotivatedatleastinpartbypsychologicalfactors.

•As with hypochondriasisand somatizationdisorder, pain disorder can lead to the repeated, unnecessaryuseofmedicaltreatments.

5-Bodydysmorphicdisorder

•Bodydysmorphicdisorderisasomatoformdisorderinwhich thepatientispreoccupiedwithsome imagineddefectinappearance.

•Thepreoccupationtypicallyfocusesonsomefacialfeature,suchasthenoseormouth,andinsome casesmayleadtorepeatedvisitstoa plasticsurgeon.

• Preoccupationwiththebodypartfarexceedsnormalworriesaboutphysicalimperfections.

•Preoccupationwithandimagineddefectin appearancecausesclinicallysignificantdistressor impairmentinsocial,occupational,orotherimportantareasoffunctioning.

5-Somatoform disordersmustbedistinguishedfrommalingering,pretendingtohaveasomatoform disorderinordertoachievesomeexternalgain,suchas adisabilitypayment.

6-Arelateddiagnosticconcernisfactitiousdisorder,afakeconditionthat,unlikemalingering, is motivatedprimarilybyadesiretoassumethesickroleratherthanadesireforexternalgain.

7-Arare,repetitivepatternoffactitiousdisorderissometimescalledMunchausen syndrome,named afterBaronKarlFriedrichHieronymusvonMunchausen,aneighteenth-century writerknownforhis tendencytoembellishthedetailsofhislife.

FrequencyofSomatoformDisorders

Conversiondisordersarerare,perhapsasinfrequentas50casesper100,000population.Mostothersomatoform disordersalsoappeartoberelativelyrare.Forexample,onestudyfounda0.7percent prevalenceofbodydysmorphicdisorder.

Hypochondriasisis also quite rare, although less severe worrying about physical illness is quite common.Thelifetimeprevalenceofsomatization disorderintheUnitedStatesisonly0.13percent. Withtheexceptionofhypochondriasis,allotherformsofsomatoform disorderaremorecommon amongwomen.Thisisparticularlytrueofsomatization disorder,whichmaybeasmuchas10times morecommonamongwomenthanmen.

Inadditiontogender,socioeconomic statusandculturearethoughttocontributetosomatization disorder.IntheUnitedStates,somatization ismorecommonamonglowersocioeconomicgroupsand people with less than a high school education. It is four times more common among African Americans.Somatoform disorderstypicallyoccurwithotherpsychological problems,particularly depressionandanxiety.Finally,somatization disorderhasfrequentlybeenlinkedwithantisocial personalitydisorder,alifelongpatternofirresponsiblebehaviorthatinvolveshabitualviolationsof socialrules.

Thetwodisordersdonot typicallyco-occurinthesameindividual,buttheyoftenarefoundindifferent members of the same family. An obvious—andpotentially critical —biological consideration in somatoformdisordersisthepossibilityofmisdiagnosis. Apatientmaybeincorrectlydiagnosedas sufferingfromasomatoformdisorderwhen,infact,heorsheactuallyhasarealphysicalillnessthatis undetectedorisperhapsunknown.Becausementalhealthprofessionals cannotdemonstrate psychologicalcausesofphysicalsymptomsobjectivelyandunequivocally, theidentification of somatoformdisordersinvolvesaprocesscalleddiagnosisbyexclusion.

Thephysicalcomplaintisassumedtobeapartofasomatoform disorderonlywhenvariousknown physicalcausesareexcluded orruledout.Initially,bothFreudandJanetassumed thatconversion disorderswerecausedbyatraumaticexperience.Freudlatercametobelievethatdissociationand other intrapsychic defensesprotectedindividualsfromtheirunacceptable sexualimpulses,notfromtheir intolerable memories.InFreud’sview,conversion symptomswereexpressions ofintolerable unconsciouspsychologicalconflicts.InFreudianterminology,thisistheprimary gain ofthesymptom. Freudalsosuggestedthathystericalsymptomscouldproducesecondarygain,forexample,avoiding workorresponsibilityortogainattentionandsympathy.

Socialandculturaltheoristsofferastraightforward explanationofthephysicalsymptomsof somatization disorder, hypochondriasis, and pain disorder. Patients with these disorders are experiencing somesortofunderlyingpsychological distress.However,theydescribetheirproblemsas physicalsymptomsand,tosomeextent,experiencethemthatwaybecauseoflimitedinsightand/orthe lackofsocialtoleranceofpsychologicalcomplaints.

TreatmentofSomatoformDisorders

1-Cognitivebehaviortherapyiseffectiveinreducingphysicalsymptomsinsomatizationdisorder,hypochondriasis,andbodydysmorphicdisorder.

2-Recentevidencealsoindicatesthatantidepressantsmaybehelpfulintreatingsomatoformdisorders.

PERSONALITYDISORDERSI

Weoftenhearremarks thatsomepeoplehaveapleasingpersonality whileothershavecharming and fascinatingpersonality. Somepoliticalleadershavecharismaticpersonality whileothershaverepulsive andannoyingpersonality.Sothequestioncomestoyourmindthat

Whatispersonality?

Personalityrefersto characteristicwaysa personbehavesandthinks. Example

• Aisshyandtimid.

• Bissensitiveandgetsupseteasily.

• Cissuspiciousoffriendsandfamily.

• Disconfidentandsuccessful.

Definitionof Personality

Personalityreferstoenduringpatternsofthinkingandbehaviorthatdefinethepersonanddistinguishhimorherfromotherpeople.

Thesepatternsare waysofexpressingemotionas well aspatternsofthinkingaboutourselvesandother people.Whenenduring patterns ofbehavior andemotion bringtheperson intorepeated conflictswith others,andwhentheypreventthepersonfrommaintaining closerelationships withothers,an individual’spersonalitymaybeconsidereddisordered.

Allofthepersonalitydisordersarebasedonexaggeratedpersonalitytraitsthatarefrequentlydisturbing orannoyingtootherpeople.InordertoqualifyforapersonalitydisorderdiagnosisinDSM-IV-TR, a personmustfitthegeneraldefinitionofpersonality disorder (whichappliestoall10subtypes) andmust alsomeetthespecificcriteriaforaparticular typeofpersonalitydisorder. Thespecificcriteria consistofa listoftraitsandbehaviorsthatcharacterize thedisorder.Thegeneraldefinitionofpersonalitydisorder presentedinDSM-IV-TR emphasizes thedurationofthepatternandthesocialimpairmentassociated withthetraitsinquestion.

Thepatternmustbeevidentintwoormoreofthefollowingdomains:

1-Cognition(suchaswaysofthinkingabouttheselfandotherpeople)

2-Emotionalresponses

3-Interpersonalfunctioning

4-Impulsecontrol.

Thispatternofmaladaptiveexperienceandbehaviormustalsobe:

1-Inflexibleandpervasiveacrossabroadrangeofpersonalandsocialsituations,

2-Thesourceofclinicallysignificantdistressorimpairmentinsocial,occupational,orother importantareasoffunctioning,

3-Stableandoflongduration,withanonsetthatcanbetracedbackatleasttoadolescenceor earlyadulthood.

Theconceptofsocialdysfunction playsanimportantroleinthedefinitionofpersonalitydisorders.It providesalargepartofthejustification fordefiningtheseproblemsasmentaldisorders.Personality disordersareamongthemostcontroversialcategoriesindiagnosticsystemformentaldisorders.

1-Theyaredifficulttoidentifyreliably,theiretiologyispoorlyunderstood,andthereisrelativelylittleevidencetoindicatethattheycanbetreatedsuccessfully.

2-Althoughtheyaredifficulttodefineandmeasure,butpersonalitydisordersarealsoimportantinthe fieldofpsychopathology.

Severalobservationssupportthisargument.

• First,personalitydisordersareassociatedwithsignificantsocialandoccupationalimpairment.

•Second,thepresenceofpathologicalpersonalitytraitsduringadolescenceisassociatedwithan increasedriskforthesubsequentdevelopmentofothermentaldisorders.

•Third,insomecases,personalitydisorders actually representthebeginningstagesoftheonsetofa moreseriousformofpsychopathology.

•Finally,thepresenceofacomorbidpersonalitydisordercaninterferewiththetreatmentofa disordersuchasdepression.

Mostotherformsofmentaldisorder, suchasanxietydisorders andmooddisorders,areego-dystonic; thatis,peoplewiththesedisordersaredistressedbytheirsymptomsanduncomfortable withtheir situations.Personalitydisordersareusuallyego-syntonic—the ideasorimpulseswithwhichtheyare associatedare acceptableto the person.Peoplewithpersonalitydisordersfrequentlydo not see themselves asbeingdisturbed.Wemightalsosaythattheydonothaveinsightintothenatureoftheir ownproblems.

Theego-syntonicnatureofmanyformsofpersonalitydisorderraisesimportantquestionsaboutthelimitationsofself-reportmeasures—interviewsandquestionnaires—fortheirassessment. Manypeople withpersonalitydisordersareunabletoviewthemselvesrealisticallyandareunawareoftheeffectthattheirbehaviorhasonothers.Thespecificsymptomsthatareusedtodefinepersonalitydisorders representmaladaptivevariationsinseveralofthebuildingblocksofpersonality.

CausesofPersonalityDisorders

Thesecausesincludemotives,cognitiveperspectivesregardingtheselfandotherstemperamentand personalitytraits.

1- Motive

• Theconceptofamotivereferstoaperson’sdesiresandgoals.

•Motives(eitherconsciousorunconscious)describethewaythat the personwouldlike thingsto be, andtheyhelptoexplainwhypeoplebehaveinaparticularfashion.

•The most importantmotivesin understandinghumanpersonalityareaffiliation—thedesirefor close relationshipswithotherpeople—andpower—thedesireforimpact,prestige,ordominance.

•Individualdifferenceswithregardtothesemotiveshaveanimportantinfluenceonaperson’s healthandadjustment.

•Manyofthesymptomsofpersonalitydisorderscan bedescribedinterms ofmaladaptivevariations withregardtoneedsforaffiliationandpower.

2-CognitivePerspectives

•Oursocialworldalsodependsonmentalprocessesthatdetermineknowledgeaboutusandother peoplewhichincludesthementalprocessofperception.Whendistortionstakeplaceinthesemechanismswecomeacrosspersonalitydisorders.

•Whenwemisperceivetheintentionsandmotivesandabilitiesofotherpeople,ourrelationships canbeseverelydisturbed.

•Manyelementsofsocialinteractionalsodependonbeingabletoevaluatethenatureofour relationships withotherpeopleandthentomakeaccuratejudgmentsaboutappropriate and inappropriatebehaviors.

3-TemperamentandPersonalityTraits

•Temperamentreferstoaperson’smostbasic,characteristicstylesofrelatingtotheworld,especially thosestylesthatareevidentduringthefirstyearoflife.

•Expertsdisagreeaboutthebasicdimensionsoftemperamentandpersonality.Sometheoriesare relativelysimple,usingonlythreeorfourdimensions. Whileothersaremorecomplicated and considerasmanyas30or40traits.

•Onepointofviewthathascometobewidelyacceptedisknownasthefivefactormodelof personality.

•Thebasictraits(alsoknownasdomains)includedinthismodelareneuroticism,extraversion, opennesstoexperience,agreeableness,andconscientiousness.

•Takenasawhole,thefive-factormodelprovidesarelativelycomprehensivedescriptionofany person’sbehavior.

•TheauthorsofDSM-IV-TRhaveorganizedtenspecificformsofpersonalitydisorderintothree clustersonthebasisof broadlydefinedcharacteristics.

•ThebehaviorofpeoplewhofitthesubtypesinclusterAistypicallyodd,eccentric,orasocial.All threetypessharesimilaritywiththesymptomsofschizophrenia.

•OneimplicitassumptionintheDSM-IV-TRsystemisthatthesetypesofpersonality disordermay representbehavioraltraitsorinterpersonalstylesthatprecedetheonsetoffull-blownpsychosis.

•Because of their close associationwith schizophrenia,they are sometimescalled schizophrenia spectrumdisorders.

1- ParanoidPersonality

Paranoid personality disorder is characterized by the pervasive tendency to be inappropriately suspiciousofotherpeople’smotives andbehaviors. Becauseparanoid peopledonottrustanyone,they havetroublemaintainingrelationshipswithfriendsandfamilymembers.

2-SchizoidPersonality

Schizoidpersonalitydisorderisdefinedintermsofapervasivepatternofindifference tootherpeople, coupledwithadiminishedrangeofemotionalexperienceandexpression.Thesepeopleareloners;they

prefersocialisolationtointeractionswithfriendsorfamily.

3-SchizotypalPersonality

Schizotypalpersonalitydisordercentersonpeculiarpatternsofbehaviorratherthanontheemotionalrestrictionandsocialwithdrawal thatareassociated withschizoidpersonalitydisorder. Peoplewiththisdisordermayreportbizarrefantasiesandunusualperceptualexperiences. Theirspeechmaybeslightly difficult tofollowbecause theyusewordsinanoddwayorbecausetheyexpress themselvesinavague ordisjointedmanner.Inspiteoftheiroddorunusualbehaviors,peoplewithschizotypal personality disorderarenotpsychoticoroutoftouchwithreality.AccordingtoDSM-IV-TR, thesedisordersare characterizedbydramatic,emotional,orerraticbehavior,andallareassociatedwithmarkeddifficultyin sustaininginterpersonalrelationships.

4- AntisocialPersonality

Antisocialpersonalitydisorderisdefinedintermsofapersistent patternofirresponsibleandantisocial behaviorthatbeginsduringchildhoodoradolescenceandcontinuesintotheadultyears. TheDSM-IV-

TRdefinitionis basedon featuresthat,beginninginchildhood,indicatea pervasivepatternofdisregard for,andviolationof,therightsofothers.Oncethepersonhasbecomeanadult,thesedifficulties includepersistentfailuretoperformresponsibilities thatareassociatedwithoccupationalandfamily roles.

5- BorderlinePersonality

Borderline personality disorderisadiffusecategorywhoseessentialfeatureisapervasive patternof instabilityinmoodandinterpersonal relationships. Peoplewiththisdisorderfinditverydifficulttobealone.

Theyformintense,unstablerelationships withotherpeopleandareoftenseenbyothersasbeing manipulative. Manycliniciansconsideridentitydisturbance tobethediagnostic hallmarkofborderline personalitydisorder.Peoplewiththisdisturbancepresumablyhavegreatdifficultymaintaininganintegratedimageofthemthatsimultaneouslyincorporatestheirpositiveandnegativefeatures.

6-HistrionicPersonality

Histrionicpersonalitydisorderischaracterizedbyapervasivepatternofexcessiveemotionalityandattention seeking behavior.Peoplewiththisdisorderthriveonbeingthecenterofattentionandthey want the spotlighton them at all times. They are self-centered,vain, and demanding,and they constantly seek approval from others. The concept of histrionic personality disorder overlaps extensivelywithothertypesofpersonalitydisorder,especiallyborderlinepersonalitydisorder.There mayalsobeanetiologicallinkbetweenhistrionicandantisocialpersonalitydisorders.Bothmayreflecta common,underlyingtendency towardlackofinhibition. Peoplewithbothtypesofdisorderform shallow,intenserelationshipswithothers,andtheycanbeextremelymanipulative.

7-NarcissisticPersonality

Theessentialfeatureofnarcissistic personality disorderisapervasivepatternofgrandiosity,needfor admiration,andinabilitytoempathizewithotherpeople.

• Narcissisticpeoplehaveagreatlyexaggeratedsenseoftheirownimportance.

• Theyarepreoccupiedwiththeirownachievementsandabilities.

•Thereisaconsiderable amountofoverlapbetweennarcissisticpersonalitydisorderandborderline personalitydisorder.

•Bothtypesofpeoplefeelthatotherpeopleshouldrecognizetheirneedsanddospecialfavorsfor them.

• Theymayalsoreactwithangeriftheyarecriticized.

•Thedistinctionbetweenthesedisordershingesontheinflatedsenseofself-importancethatis foundinnarcissisticpersonalitydisorderandthedeflatedordevaluedsenseofselffoundinborderlinepersonalitydisorder.

• Thecommonelementinallthreedisordersispresumablyanxietyorfearfulness.

• Thisdescriptionfitsmosteasilywiththeavoidantanddependenttypes.

•Incontrast,obsessive–compulsivepersonalitydisorderismoreaccuratelydescribedintermsof preoccupationwithrulesandwithlackofemotionalwarmththanintermsofanxiety.

8-AvoidantPersonality

•Avoidantpersonalitydisorderischaracterizedbyapervasivepatternofsocialdiscomfort,fearof negativeevaluation,andtimidity.

•Peoplewiththisdisordertendtobesociallyisolatedwhenoutsidetheirownfamilycirclesbecause theyareafraidofcriticism.

•Unlikepeoplewithschizoidpersonalitydisorder,theywanttobelikedbyothers,buttheyare extremelyshy—easilyhurtbyevenminimalsignsofdisapprovalfromotherpeople.

• Thustheyavoidsocialandoccupationalactivitiesthatrequiresignificantcontactwithotherpeople.

• Avoidantpersonalitydisorderisoftenindistinguishablefromgeneralizedsocialphobia.

• Someexpertshavearguedthattheyareprobablytwodifferentwaysofdefiningthesamecondition.

•Othershavearguedthatpeoplewithavoidantpersonalitydisorderhavemoretroublethanpeople withsocialphobiainrelatingtootherpeople.

9-DependentPersonality

•Theessentialfeatureofdependentpersonalitydisorderisapervasivepatternofsubmissiveand clingingbehavior.

•Peoplewiththisdisorderareafraidofseparatingfromotherpeopleonwhomtheyaredependent foradviceandreassurance.

•Oftenunabletomakeeverydaydecisionsontheirown,theyfeelanxiousandhelplesswhenthey arealone.

10- Obsessive–CompulsivePersonalityDisorder(OCPD

•Obsessive–compulsive personality disorder (OCPD) is defined by a pervasive pattern of orderliness,perfectionism,andmentalandinterpersonalcontrol,attheexpenseofflexibility,openness,andefficiency.

•Peoplewiththisdisordersetambitiousstandardsfortheirownperformancethatfrequentlyareso highastobeunattainable.

•Thecentralfeaturesofthisdisordermayinvolveamarkedneedforcontrolandlackoftolerance foruncertainty.

PERSONALITYDISORDERSII

Personalityreferstoenduringpatternsofthinkingandbehaviorthatdefinethepersonanddistinguish himorherfromotherpeople.

Theseenduringpatterns arewaysofexpressingemotion aswellaspatterns ofthinking aboutourselves andotherpeople.Whenenduring patternsofbehavior andemotion bringthepersonintorepeated conflictswithothers,andwhentheypreventthepersonfrommaintaining closerelationships with others,anindividual’s personality maybeconsidereddisordered. Personality disordersareamongthe mostcontroversialcategoriesinthediagnosticsystemformentaldisorders.

1-Theyaredifficulttoidentifyreliably,theiretiologyispoorlyunderstood,andthereisrelativelylittle evidencetoindicatethattheycanbetreatedsuccessfully.

2-Althoughtheyare difficultto defineand measure,butpersonalitydisordersare importantinthefieldofpsychopathology.

Severalobservationssupportthisargument.

• First,personalitydisordersareassociatedwithsignificantsocialandoccupationalimpairment.

•Second,thepresenceofpathologicalpersonalitytraitsduringadolescenceisassociatedwithan increasedriskforthesubsequentdevelopmentofothermentaldisorders.

•Third,insomecases,personalitydisorders actually representthebeginningstagesoftheonsetofa moreseriousformofpsychopathology.

•Fourth,thepresenceofaco-morbidpersonalitydisordercaninterferewiththetreatmentofa disordersuchasdepression.

•The specific symptoms that are used to define personality disorders represent maladaptive variationsinseveralofthebuildingblocksofpersonality.

• Theseinclude

1-Motives

2-Cognitiveperspectivesregardingtheselfandothers

3-Temperamentandpersonalitytraits.

•TheauthorsofDSM-IV-TRhaveorganizedtenspecificformsofpersonalitydisorderintothree clustersonthebasisof broadlydefinedcharacteristics.

•ThebehaviorofpeoplewhofitthesubtypesinclusterAistypicallyodd,eccentric,orasocial.All threetypessharesimilaritywiththesymptomsofschizophrenia.

• Thecloseassociationwithschizophrenia,theyaresometimescalledschizophreniaspectrumdisorders.

1- ParanoidPersonality

•Paranoidpersonalitydisorderischaracterizedbythepervasivetendencytobeinappropriately suspiciousofotherpeople’smotivesandbehaviors.

•Paranoidpeopledonottrustanyone;theyhavetroublemaintainingrelationshipswithfriendsand familymembers.

Example

ClientAwasfrequentlycomplainingaboutherboss,co-workers,teachers,fatherandfriends.Shewatchedeveryoneclosely,didnotacceptfoodormedicinefromanyoneforthefearthatitwould containpoison.Shedidnotgooutwithfriendsandco-workersthattheymightkillher.

2- SchizoidPersonality

•Schizoidpersonalitydisorderisdefinedintermsofapervasivepatternofindifferencetoother people,coupledwithadiminishedrangeofemotionalexperienceandexpression.

• Thesepeopleareloners;theyprefersocialisolationtointeractionswithfriendsorfamily.

Example

ClientBwouldfollowherclassmatestoschoolbutwouldhurrybacktoherhostelroomwhereshewouldstayalonemostofthetimeandwascompletelyuninterestedinothers.

3- SchizotypalPersonality

Schizotypalpersonalitydisordercenters on peculiar patterns of behaviorrather than on theemotionalrestrictionandsocialwithdrawalthatareassociatedwithschizoidpersonalitydisorder. Peoplewiththisdisordermayreportbizarrefantasiesandunusualperceptualexperiences.

Example

ClientAwasayoungmanwithvaguecomplaintsofstuttering,feelingofindifferencetowardsone’s selfandwantedtostudystars.Hehadpeculiar,oddlanguageandperceptualexperiences.

• TheclusterB includesAntisocial,Borderline,Histrionic,andNarcissisticPersonality disorders.

•AccordingtoDSM-IV-TR,theclusterBdisordersarecharacterizedbydramatic,emotional,orerratic behavior,andallareassociatedwithmarkeddifficultyinsustaininginterpersonalrelationships.

4-AntisocialPersonality

Antisocialpersonalitydisorderisdefinedintermsofapersistent patternofirresponsibleandantisocial behaviorthatbeginsduringchildhoodoradolescenceandcontinuesintotheadultyears.

Thepatternshowsdisregardfor,andviolationoftherightsofothers.

Once the person has become an adult, these difficulties include persistent failure to perform responsibilitiesthatareassociatedwithoccupationalandfamilyroles.

Example

ClientDisayoungmanwho hasjustknockedoutaman withhisbeer bottle becausehethinksthathe wasinsulted.

Thesameclienthashistoryofbeingkickedoutofschool,fightingwithneighborsandhedoeswhatpleaseshimnotwhatisrightorwrong.

5-BorderlinePersonality

•Borderlinepersonalitydisorderisadiffusecategorywhoseessentialfeatureisapervasive patternofinstabilityinmoodandinterpersonalrelationships.

• Peoplewiththisdisorderfinditverydifficulttobealone.

•Theyformintense,unstablerelationshipswithotherpeopleandareoftenseenbyothersas beingmanipulative.

Example

ClientCis a manwhohasbeenthrownout of his father’shousebecauseof badtemperand undependability.Heisdepressedtothepointofsuicidalfeelings.

6-Histrionicpersonality

•Histrionicpersonality disorder ischaracterizedbyapervasivepatternofexcessiveemotionality andattentionseekingbehavior.

•Peoplewiththis disorderthriveonbeingthecenterof attentionand theywant the spotlighton thematalltimes.

• Theyareself-centered,vain,anddemanding,andtheyconstantlyseekapprovalfromothers.

Example

ClientC isanattractivewomanwithalovelysmileusedbyhertogettheattentionofpeople.Herhabit oftryingtobethecentreofattentionisannoyingtoothers.Sheismoodyandseemedtoover- dramatizeminorproblems.

7-NarcissisticPersonality

•Theessentialfeatureofnarcissisticpersonalitydisorderisapervasivepatternofgrandiosity, needforadmiration,andinabilitytoempathizewithotherpeople.

• Narcissisticpeoplehaveagreatlyexaggeratedsenseoftheirownimportance.

• Theyarepreoccupiedwiththeirownachievementsandabilities.

Example

ClientDisalawyerofoutwardcharmandgoodlookswhohaswonthebarelections.Hehaswritten booksandhas amediafollowing.Heisa manpreoccupiedbyappearance,wealth,powerandfame.

8-AvoidantPersonality

•Avoidantpersonalitydisorderischaracterizedbyapervasivepatternofsocialdiscomfort,fear ofnegativeevaluation,andtimidity.

•Peoplewiththisdisordertendtobesociallyisolatedwhentheyareoutsidetheirownfamily circlebecausetheyareafraidofcriticism.

Example

ClientDisawomanwhohastakenajobinnightshiftwhereshecanhaveminimalcontact.Offduty shespendstimealone,worryinglessthatshemaybehavestupidly.

9-DependentPersonality

•The essentialfeatureofdependentpersonalitydisorderisapervasivepatternof submissiveand clingingbehavior.

•Peoplewiththisdisorderareafraidof separatingfromotherpeopleonwhomtheyare dependentforadviceandreassurance.

•Oftenunabletomakeeverydaydecisionsontheirown,theyfeelanxiousandhelplesswhen theyarealone.

Example

ClientAhaslackedselfconfidencesincechildhood,relyingonhermothertochoosewhattowear, whatfriendstohave,whichcoursesandclassestostudy.

10- Obsessive–CompulsivePersonality

•Obsessive–compulsivepersonality disorder (OCPD) is defined by a pervasive pattern of orderliness,perfectionism, andmentalandinterpersonalcontrol,attheexpenseofflexibility, openness,andefficiency.

•Peoplewiththisdisordersetambitiousstandardsfortheirownperformancethatfrequentlyare sohighastobeunattainable.

•Thecentralfeaturesofthisdisordermayinvolveamarkedneedforcontrolandlackof toleranceforuncertainty.

•Obsessive–compulsivepersonalitydisordershouldnotbeconfusedwithobsessive–compulsive disorder (OCD),atypeofanxietydisorder. Apatternofintrusive,unwanted thoughts accompanied byritualisticbehaviorsisusedtodefineOCD.Thedefinitionofobsessive– compulsivepersonalitydisorder,in contrast,is concernedwith personalitytraits, such as excessivelyhighlevelsofconscientiousness.

Example

ClientAhasa reputationofbeingcarefulandconscientiousandcareful.

Heworkslonghoursandbringsalotofmoneytothefirmbutheishumorlessbuttakesalottimein proceduraldetailsinstaffmeetings.

Thecommonelementinallthreedisordersispresumablyanxietyorfearfulness.

Thisdescription fitsmosteasilywiththeavoidantanddependenttypes.Incontrast,obsessive–compulsive personalitydisorderismoreaccuratelydescribedintermsofpreoccupation withrulesandwithlackof emotionalwarmththanintermsofanxiety.Likepeoplewithavoidantpersonality disorder,theyareeasily hurtbycriticism,extremelysensitivetodisapproval,andlackinginselfconfidence.Onedifferencebetween themisthatpeoplewhoareavoidanthavetroubleinitiatingarelationship(becausetheyarefearful).People whoaredependenthavetroublebeingaloneorseparatingfromotherpeoplewithwhomtheyalreadyhave a closerelationship.

TheDiagnosis

ThediagnosisofPersonalityDisordersisnotaneasyandsimpletaskbecause

1-TherearealotofpeoplewithseriouspersonalityproblemswhodonotfittheofficialDSM-IV-TRsubtypes.

2-Anotherfrequentcomplaintaboutthedescriptionofpersonalitydisordersisthe considerableoverlap amongcategories.

3-Manypatientsmeetthecriteriaformorethanonetype.

Thus,fordiagnosisofpersonality disordersmanyexpertsfavortheproposaltousethefive-factor model of personality as the basic structure for a comprehensive description of personality problems.

4-Thereisalsoextensiveoverlapbetweenpersonalitydisordersanddisordersthatarediagnosedon AxisIofDSM-IV-TR.

Approximately75percentofpeoplewhoqualifyforadiagnosisonAxisIIalsomeetcriteriafora syndromesuchasmajordepression,substancedependence,orananxietydisorder.

GenderDifferences

Theoverallprevalenceofpersonalitydisordersisapproximatelyequalinmenandwomen.

Antisocialpersonalitydisorderisunquestionablymuchmorecommonamongmenthanamongwomen.

Almost nothingisknown abouttheextentofpotentialgenderdifferencesfortheothertypesofpersonality disorder.

Borderlinepersonalitydisorderanddependentpersonalitydisordermaybesomewhatmoreprevalent amongwomenthanmen,buttheevidenceisnotstrong.

StabilityofPersonalityDisordersoverTime

Temporalstabilityisoneofthemostimportantassumptionsaboutpersonalitydisorders.

Evidence for the assumption that personality disorders appear during adolescence and persist intoadulthoodhas,untilrecently,beenlimitedprimarilytoantisocialpersonalitydisorder.

Therateofpersonalitydisorderswasrelativelyhighinthissample:Seventeenpercentoftheadolescents receivedadiagnosisofatleastonepersonalitydisorder.

Viewedfromadimensional perspective,themaladaptivetraitsthatrepresentthecorefeaturesofthe disordersremainedrelativelystablebetweenadolescenceandyoungadulthood.

Severalstudieshaveexamined thestabilityofpersonality disordersamongpeoplewhohavereceived professional treatmentfortheirproblems,especiallythosewhohavebeenhospitalized forschizotypalor borderlinedisorders.

Recoveryratesarerelativelyhighamongpatientswithadiagnosisofborderlinepersonalitydisorder.