Chapter 5 Anxiety Disorders Fear: - Physical: flight of fight response to perceived danger. - Present-oriented - Innate alarm response to a real or perceived current threat Anxiety: - Feel threatened about a future event; reaction to a future threat. Fear & Anxiety: Associated Symptoms Fear - Surges of arousal necessary for “fight or flight” - Thoughts of immediate danger - Escape behaviours Anxiety - Muscle tension - Vigilance in preparation for future danger - Cautious/avoidant behaviours … DSM-5, APA, (2013) Normal vs. Abnormal Anxiety - Experiencing anxiety is normal and can be beneficial at certain levels E.g., Yerkes-Dodson Law - Anxiety is considered abnormal when it impairs functioning and interferes with well-being o Unrealistic
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Chapter 5 Anxiety Disorders
Fear:
- Physical: flight of fight response to perceived danger.
- Present-oriented
- Innate alarm response to a real or perceived current threat
Anxiety:
- Feel threatened about a future event; reaction to a future threat.
Fear & Anxiety: Associated Symptoms
Fear
- Surges of arousal necessary for “fight or flight”
- Thoughts of immediate danger
- Escape behaviours
Anxiety
- Muscle tension
- Vigilance in preparation for future danger
- Cautious/avoidant behaviours
… DSM-5, APA, (2013)
Normal vs. Abnormal Anxiety
- Experiencing anxiety is normal and can be beneficial at certain levels
E.g., Yerkes-Dodson Law
- Anxiety is considered abnormal when it impairs functioning and interferes with well-being
o Unrealistic
o Excessive
o Persistent (typically 6 months or more)
For each anxiety disorder, the main criteria in the DSM to distinguish normal and abnormal anxiety
1. Severe distress
2. Impairs daily life
Components of Anxiety
**Know a few for each category.
Behaviors play a key role in whether or not anxiety persists.
Anxiety Disorders
- Panic Disorder
- Agoraphobia
- Specific Phobia
- Social Phobia
- Generalized Anxiety Disorder
- *Obsessive Compulsive Disorder
- *Post-Traumatic Stress Disorder
*No longer classified under Anxiety Disorders in DSM-5
DSM-V:
- OCD is now in OC & related disorders
- PTSD is in trauma & stressor-related disorders
- Separation anxiety disorder added
- Selective mutism added
To differentiate anxiety disorders, consider:
- The types of situations feared
- Content: thoughts and beliefs associated with anxiety
Panic Attacks
- Abrupt sense of intense fear or discomfort; peaks within minutes
- Must have ≥4 of the following physical/cognitive symptoms
o Racing heart
o Sweating
o Trembling or shaking
o Shortness of breath or smothering sensations
o Feelings of choking
o Chest pain/discomfort
o Nausea or abdominal distress
Types of Panic Attacks
- Expected: obvious cue or trigger
- Unexpected: occurs for no apparent reason, out of the blue. Ex: nocturnal panic
It’s VERY important to know if panic attacks are expected or not for diagnosis.
Panic Disorder - Recurrent (at least two), unexpected panic attacks
- At least one attack followed by ≥1 month of ≥1 of:
o Persistent concern/worry about additional attacks or their consequences
o Significant maladaptive change in behavior related to the attacks (e.g., avoidance of
exercise)
Cognitive Perspectives
- Catastrophic Misinterpretation Theory
o Selective attention bodily sensations
o Misinterpretation of bodily sensations
o Snowballing catastrophic thinking
- Anxiety Sensitivity Theory
o Enduring belief that symptoms of anxiety have harmful consequences. Fear of fear.
Phobias
Effect all sorts of people
- Persistent and excessive fear to certain situations/things
- Symptoms include:
o Feelings of panic, dread, horror, or terror
o Reactions that are automatic and uncontrollable: take over the person’s thoughts
o Physical symptoms in face of feared object/situation
o Avoidance of the feared object or situation: overwhelming desire to flee the situation
Imagined or exaggerated fear.
Fear is a normal response to a genuine danger.
Divided into three categories based on the cause of the fear/avoidance
1. Agoraphobia
2. Specific phobias
3. Social anxiety disorder.
Agoraphobia “Fear of the market place”
- Fear and anxiety about (2 or more) places where it seems escape would be difficult to
escape or get help in case of emergency
o Using public transportation
o Being in open spaces
o Being in enclosed places
o Standing in line or being in a crowd
o Being outside of the home alone
- Situations are avoided, require companion, or endured with distress
DSM-V separated agoraphobia and panic disorder, but they often appear together.
Most people get agoraphobia after first experiencing panic attacks (but not everyone).
Specific Phobias
- Fear/anxiety about or avoidance of specific objects or situations (or places)
- Categories o Animal type: specific animals or insects o Natural environment type: events or situations in the natural environment (e.g.,
storms, heights) o Situational type: public transportation, bridges, flying, elevators, etc. o Blood-injection-injury type: blood, injuries, injections o Other: ex: situations that lead to vomiting
Avoidance is key. Symptoms must interfere with everyday life.
It’s common for people to have multiple specific phobias (for individuals who have any, the average
is 3). You are very likely to develop a phobia of something else in the same category that you already
have one in.
Anxiety is immediate and intense when they encounter their phobia. Anxious at the thought of an
encounter with the phobia, they go to great lengths to avoid an encounter.
Must be persistent for six months.
Social Anxiety Disorder (Social Phobia)
- Fear/anxiety about or avoidance of social interactions and situations that involve the possibility
of being scrutinized
o Social interactions
o Being observed
o Performing in front of others
- Specify if: Performance only
More likely to disrupt the individual’s life.
Performance only impacts the individual’s professional life more than their personal life
(usually)
- Being negatively evaluated by others
- Being embarrassed, humiliated or rejected
- Offending others
Look beyond the feared situation and at the NATURE of that fear to distinguish agoraphobia vs.
social anxiety.
Social Anxiety Disorder
Rapee & Spence (2004)
The DSM uses a categorical approach, but mild social anxiety is not really different than severe anxiety,
just less intense. The main difference is in the individual’s perception of how much it impairs their
quality of life.
During diagnosis, consider the combined effect of level of social anxiety as well as the extent to which he
or she believes it causes distress and impairments.
Life Interference: Social Anxiety Disorder usually becomes apparent during adolescence because there’s
a shift from spending all time with family and increased social interactions.
Generalized Anxiety Disorder (GAD)
- Persistent and excessive anxiety and worry about various domains (e.g., work/school
performance) that the individual finds difficult to control
- ≥3 physical symptoms:
o Restlessness
o Easily fatigued
o Difficulty concentrating
o Irritability
o Muscle tension
o Sleep disturbance
Anxious almost all of the time, in almost every situation. Worry about many different things.
Experience these symptoms most days for at least six months.
*Obsessive Compulsive Disorder (now in obsessive compulsive and related disorders)
Presence of obsessions, compulsions, or both
Obsessions:
- Recurrent unwanted intrusive thoughts, urges, or images
- Attempts at suppression or neutralization
Compulsions:
- Repetitive behaviors or mental acts
- Aimed at preventing anxiety or a dreaded event
OCD Cycle
*Posttraumatic Stress Disorder - Exposure to traumatic event
- Intrusion symptoms
- Avoidance of associated stimuli
- Negative changes in thought and mood
- Changes in arousal and reactivity
- > 1 month duration of symptoms
No longer an anxiety disorder. Now trauma & stressor-related disorders.
Traumatic event:
- Exposure to actual or threatened death, serious injury, or sexual violence in one of the
following ways:
o Directly experiencing
o Witnessing it occur to others
o Finding out it happened to a family member or close friend
o Repeated exposure to aversive details of traumatic event (police officer with child
abuse cases)
Intrusion:
- Recurrent memories, dreams, feeling disconnected from oneself (flashbacks)
Different from anxiety disorders because there’s anxiety/distress AFTER the event.
PTSD
- Understanding risk/resilience to PTSD after traumatic events will help inform treatment and
clinician specifies why full criteria not met (not 2 weeks, too few symptoms, etc)
Unspecified Depressive Disorder: same as above except clinician does not specify why person failed
to meet full criteria
- Categories when it should probably be dimensional
Depression: DSM-5 Specifiers - With anxious mood
- With mixed features: 3 or more hypo/manic features
- With melancholic features: lack of reaction; loss of pleasure
- With atypical features: laughing a lot; mood reactivity; sleep more; weight gain; heavy limbs.
- With psychotic features: ECT candidate: delusion of badness.
- With catatonia: stopping and starting paralysis in posture
- With peripartum onset (postpartum depression)
o 3-6% of women are depressed during pregnancy and for the weeks following birth.
Often experience severe anxiety and panic attacks.
- With seasonal pattern (seasonal affective disorder- SADS): regular, temporal onset of
depression. Sunlight.
o Northern hemisphere more SADS, not as many in the Southern hemisphere.
o Become depressed in the fall, and then less in the spring.
o Wake in the early morning and can’t sleep
o Psychomotor agitation
“Going, Going, Gone”: The Strange Case of Depressive Personality Disorder
A. Pervasive pattern of depressive cognitions and behaviors that begins by early adulthood,
present in a variety of contexts, as indicated by 5+ of the following:
- usual mood that is dejection, gloominess, unhappy
- self-concept beliefs of inadequate & low self-esteem
- high self-criticalness & blame
- brooding & worrisome
- negative, critical & judgmental toward others
- pessimistic
- tendency to feel guilt or remorse
B. Doesn’t occur just during MDE or is better accounted for by dysthymic disorder
Significant impairment in functioning and distress.
DPD Dysthymia
- Chronic negativity & lack of interest/pleasure (anhedonia)
- Neuro-vegetative symptoms absent - Criticalness towards others is stronger
- Persistent sadness - Neuro-vegetative symptoms are
present
Reasons why not in the DSM-V dropped DPD:
- Very high comorbidity
- DSM-V working group decided DPD is better seen as traits than a type
- It’s as stable as other PDs but does not meet the threshold.
- Not all depression is episodic - ICD-10 does not have DPD - DSM-IV had DPD in provisional category, DSM-V eliminated it completely - 2% of general population have DPD - It’s hard to treat - Second most common personality disorder seen by clinicians
Self-Reported Depressive Symptoms
Illustrates the dimensional nature of depression (not categories) because of the overlap in the
curves.
Major depression mean: 22.9 symptoms
Non-clinical mean: 13.31 symptoms
No such thing as indigenous (?) vs. reactive depression.
- Dependent: you contribute to the event (stress). (Stressful environment at work)
- Chronic stressors: single parent, drug-addicted father. (Single parent, drug addicted partner)
- Episodic: you did nothing to contribute to this event. It happened out of the blue. (Severe
car accident, severe head trauma etc.) Major contributor to depression
Stress generation:
- Depression can effect life events
- Depression itself can generate stress
Depression Trigger: Negative Life Events.
Events influence the onset and intensity.
- Severe major life events cause depression onset, especially loss or exit events. The more severe
the life event, the harder it is to treat the depression (ex: motorcycle accident)
- Depression more severe when associated with life events
- Daily stress + disadvantaged economic status predict depression
- Mixed evidence about the role of minor life events or daily hassles
- Having life stressors while in treatment reduces treatment effectiveness
- Life events after recovery increase the risk of relapse
Freud: A depression-prone individual becomes fixated at the oral stage and becomes excessively
dependent on others for self-esteem. Depression happens when:
- Excessively dependent
- Experience a loss
o 80% of depression had experienced a major life event in the 6 months to 1 year
prior. Life events cause 29-69% of depression
Most toxic events: Loss or threatened loss (exit events)
Stress-generation: life event and depression cause each other. Not one way.
Not the Whole Story
INTERACTION between the negative life event and diathesis.
Diathesis-stress: pre-existing, enduring disposition that increases the probability of onset of a
depression episode when there’s a negative life event.
We need to take into account more variables to see who becomes depressed.
Factors:
- Neuroticism
- Social dependency
- Low self-esteem
- Negative attribution style
- Trait rumination
Beck’s Cognitive Theory of Depression: a diathesis-stress model
- An underlying cognitive vulnerability
In depression, the self-schema is very important. It influences how we see ourselves, others, and the
world.
Schema: internal representation. Enduring mental framework of knowledge and experience.
We develop schemas through experience.
Cognitive errors: we tend to see things black and white, personalize, and overgeneralize.
Cognitive errors + negative automatic thoughts are biased information processing (contribute to
depressive symptoms & makes them worse by cycling).
Cognitive Vulnerability
Example of exaggerated core belief: I need the love, approval, acceptance, and admiration of EVERY
person I come into contact with.
The Depression Gene
Genetics accounts for 30-40% of depression.
Caspi et al. (2003) discovered the depression gene through a longitudinal study from age 3-26.
Genetic analysis. Divided into three groups:
Group A: 2 copies of short allele 5-HTTLP (which regulates/transports serotonin). BAD.
Group B: 1 copy of the short allele. BAD.
Group C: 1 copy of long allele. BEST.
The short allele is associated with low serotonin transcription (which is bad), but kids with
depression also needed a negative life event (interaction).
Clarke et al. (2010) serotonin transporter gene (5-HTTPLR) may interact with neuroticism, not
negative life events, to increase depression.
EXAM: Describe the depression gene. Is it “dead”? - Many researchers think 5-HTTPLR is still the best candidate to influence depression.
- 1 or 2 copies of the short allele 5-HTTLP (which regulates/transports serotonin) are
BAD
- Having 1 long copy of the allele is best because the short allele is associated with low
serotonin transcription (which is bad), but kids with depression also needed a
negative life event (interaction).
- 5-HTTPLR might interact with trait neuroticism, not negative life events
The Depressed Brain
Documented brain changes with antidepressants and CBT Talking changes our brain! It’s unclear
how the brain of a clinically depressed individual differs from a sadness-induced brain.
ACC is LESS activated: important in effortful (conscious) emotion fixing (to feel better)
Amygdala (midbrain) is MORE activated: critical for processing emotion/memories
The dorsolateral prefrontal cortex is LESS activated when depressed (deals with regulations of
emotion, reasoning, thinking, judgment).
Cognitive Endophenotype for Depression
We have 25,000 genes.
Genetic basis to depression is a polymorphism (combination of many genes)
Gene environment interaction activates a negative information processing bias.
Three way interaction between gene, environment, and cognition (Gibb et al., 2013).
Psychological process is in the endophenotype. Stress reactivity activates the
endophenotype.
An endophenotype is “intermediate” between the microscopic world of genes/nerve cells and the experiential and psychological world of symptoms
1. The endophenotype is associated with illness in the population. 2. The endophenotype is heritable. 3. The endophenotype is primarily state-independent (manifests in an individual
whether or not illness is active). 4. Within families, endophenotype and illness co-segregate
Percent of Untreated Depression
(Australia, Canada & USA): Almost half of depressed people don’t get treatment. Maybe because of
stigmatization?
Cognitive Intervention: Depression
Elements of CBT:
1. Psycho-education
2. Problem-solving approach: generate problem list
3. Identify and evaluate negative thinking
4. Generate alternate thinking
5. Behavioral experiments (conversation with husband, exercise)
6. Evaluate outcome
7. Master & pleasure activities
You would be depressed because of the way you think after losing your job, not because you
lost the job. It is the negative thinking that matters.
Defining Suicide
Starts off as intentional.
Women are 3x more likely to attempt suicide
Men are 4x more likely to commit suicide.
Different methods.
Gender differences exist across all age groups.
15% of people with MDE commit suicide
90% of people who have completed suicide have a mental disorder
89% of people attempted suicide had MDE in last 12 months
Suicide: a deliberate act of self-harm taken with the expectation that it will be fatal
A behavior; not a mental illness.
Types of Suicide:
- Death seekers--- clearly and explicitly seek to end their lives
- Death initiators--- believe they are hastening an inevitable death: terminal illness
Suicide is the fourth leading cause of death for individuals between the ages of 15 and 44.
In 2009 there were 3890 suicides in Canada, second leading cause of death between the ages of 15-
24.
Suicide is the leading cause of death for First Nations individuals between the ages of 10 and 44.
(Rates of suicide are 2-4x greater for First Nations individuals: isolation, lack of hope)
Country Differences in Completed Suicides by Gender: Sociological aspect of suicide.
Threshold model for suicidal behaviour
The threshold model of suicidal behavior is an integrative model that seeks to explain how different
types of risk and protective factors interact to produce a threshold for suicidal behaviour. The
different types of factors are:
Long term predisposing risk factors that can be present at birth or soon after birth
- these identify people who are in risk groups: genetic vulnerability, serotonin transporter
gene (5-HTT); also impulsivity, pathological aggression, perfectionism, (personality
traits), problem-solving deficits
Short term risk factors that can develop later in life
- these may predict when someone is most likely to commit suicide (e.g., presence of
depression, schizophrenia, bipolar disorder, suicidal ideation, hopelessness, social
disconnection,, loss experiences,
Protective factors that may be long or short term
- These can offset risk factors
Precipitating risk factors
- occur due to a recent life event or access to a method of committing suicide
- These are events that may tip the balance when a person is at risk.
Joiner’s Interpersonal Theory of Suicide
A proclivity to commit suicide is the product of two interpersonal constructs. These are:
(a) Thwarted need to belong: increased risk when people feel excluded and alienated from
others (“I’m all alone”).
(b) Perceived burdensome: increased risk when people perceive they are burden to others
and so family/loved ones would be better off without them. There does seem to be a
link between perceived burden and other indices of suicidality.
(c) Capability: suicide occurs when people have both the desire and the ways to commit
suicide (i.e., high tolerance for physical pain through nonsuicidal self-injury; high distress
tolerance). Capability differentiates between the suicide ideators and those who
actually attempt or commit suicide. Question: Does this model explain the high suicide
rate among Canadian soldiers and veterans?
(d) Also the interpersonal model suggests a way towards prevention; that in schools and
elsewhere focus on “need to belong” (i.e., social support).
Myths about Suicide
- People who discuss suicide won’t commit the act: At least ¾ of those who take their own
lives have communicated their intention beforehand, perhaps as a cry for help.
- Suicide is committed without warning: The person usually gives many warnings, such as
saying that the world would be better off without him or her, or making unexpected and
inexplicable gifts to others.
- Suicidal people clearly want to die: Most people who contemplate suicide appear to be
ambivalent about their own deaths. For many people, the suicidal crisis passes, and they
are grateful for having been prevented from self-destruction
- The motives for suicide are easily established: The truth is that we do not fully understand
why people commit suicide. For example, just because a severe financial loss precedes a
suicide does not mean that it adequately explains the suicide.
- All who commit suicide are depressed: This misperception may be due to not seeing the
signs of impending suicide. Many people who take their lives are not depressed; some even
appear calm and at peace with themselves.
- Improvement in emotional state means lessened risk of suicide: Those who commit
suicide, especially those who are depressed, often do so after their spirits and energy begin
to rise.
Chapter 9 Schizophrenia Spectrum & Other Psychotic Disorders Psychosis: lack of contact with reality. A mental state characterized by severe impairment or distortion
of reality.
Schizophrenia impacts ALL areas of functioning.
Key Features of Psychotic Disorders
Schizophrenia: can be defined by abnormality in 5 domains. Complex disorder and varies by individual.
Delusions
- Fixed implausible beliefs: individuals adapt their thinking to fit the belief.
- Themes o Persecutory: belief that they will be harmed/harassed by organizations, individuals, or
groups. o Referential: ordinary events have personal meaning. Ex: Comments are directed at you. o Grandiose: belief of exceptional abilities, fame. Ex: Ability to talk to God, control others,
believe that they are God or Jesus.
- Bizarre delusions: to be considered “bizarre” they must not make sense to an individual of the
same culture, clearly implausible, not from ordinary life experiences. o Thought withdrawal o Thought insertion o Behaviors controlled by external force
Even if they’re proven wrong they don’t change their mind.
Preoccupied with the thinking
The “Truman Show” Delusion Gold & Gold, 2012 Cognitive Neuropsychiatry
- Five people have similar delusions of thinking they are on a TV broadcast.
- Taped continuously as a national broadcast.
- Delusion themes remain constant across cultures over time. The form remains constant but the
content changes.
Hallucinations Disturbances of perception occurring without an external stimulus.
15% of mentally healthy college students have had them (but don’t have a psychotic disorder)
- Auditory: most common in schizophrenia (voices).
- Visual
- Tactile: feeling something on your body (outside your body)
- Somatic: inside your body, worms are eating your organs.
Vivid & clear. Hard to differentiate from reality.
Types remain the same across cultures but content varies.
Disorganized Thinking (Speech) Disturbance of thought form, inferred from speech
- Environmental support for use of the substance: people around you influence your attitudes
about drugs and alcohol; hanging out at bars.
Causes:
- Genetics explain 40-60% of variance (not everything, just an underlying biological
vulnerability).
- Learning
Beliefs and behavior influence one another.
Assessment
- Substance use (SCID-IV): semi-structured interview
o Quantity, frequency/duration, severity
- Other problems: Comorbidity. Mental health, health, family, legal problems.
- Motivation: How motivated is the individual to change? This says a lot about how treatment is
going to go.
- CBT functional analysis: Substance use patterns. Antecedents, triggers, associations,
consequences.
- Partner/family: roles in substance use. Do they use with them? Are they supportive?
Treatment Components
- Motivational Interviewing o Goal: to get clients to recognize they want to change instead of telling them they need
to. Help the client identify values and see that the substance won’t or doesn’t with the
values. o Technique: decisional balance. Identify pros + cons of drinking. Addressing the patient’s
ambivalence about changing.
- Cognitive-Behavioral strategies: o Skills training to change the individual’s environment to avoid high risk situations (going
to a bar). o Learning how to manage situations o Modifying unrealistic expectations of drug (only way to be happy) o Learning how to cope with cravings o Developing other ways to obtain positive reinforcers (other stress managers) o Learning how to refuse: assertive communication.
- Partner/family involvement: individuals are more likely to succeed when there’s involvement of
a social support system
- Self-help groups (e.g., AA): Large role for substance-use problems o Assess if a good candidate or not
Affiliative, problem solving with others, own support system isn’t there or not
enough of one.
- Relapse Prevention: o A lot of people do relapse o Identify and manage stressors that could lead to relapse o Individual taught to anticipate and deal with relapses o Deal with catastrophization – if you have one drink you don’t need to have eight. o Moderation is okay for individuals with mild to moderate alcohol problems. Reducing
the harm is sufficient, it’s not necessary to completely cut it out.
- Moderation vs. abstinence?
- Pharmacotherapy: E.g., antibuse: makes you violently ill if you drink. Methadone.
Treatment Success
Chapter 12 Personality Disorders Traits: characteristics of an individual that can be observed or measured, has cross-situational
consistency, and endurance over time. The combined expression of many traits defines one’s
personality.
Traits are maladaptive in PDs.
- Excessive
- Inappropriate
- Cause distress/impairment, especially in relationships.
- PDs are all based on personality types. This is a problem because there’s low reliability in
diagnosis.
- Treatment is difficult because these individuals often have difficulty with relationships.
- A longstanding pattern of behaviors, thoughts, and feelings that is highly maladaptive to the
individual or people around them (narcissistic and antisocial don’t experience much personal
impairment, mostly those around them experience it)
- Culture is important
- No clear beginning or end
DSM-5 Definition of Personality Disorder
An enduring patter of inner experience and behavior that deviates markedly from the expectations of
the individual’s culture,
a. is pervasive and inflexible (seen across many situations),
b. has an onset in adolescence or early adulthood,
c. is stable over time, and
d. leads to distress or impairment
Normal, Healthy Personality
DSM does not define healthy personality.
There is no consensus on an omnibus definition of optimal or even “normal” personality. Many
specific personality traits have been identified that are associated with greater happiness, life
satisfaction, productivity and well-being. A few examples are:
- Sociability or extraversion
- Optimism
- Positive affectivity
- Autonomy, self-control
- Independence
- Learned resourcefulness
- Emotional stability
More components of a healthy personality:
- Sense of playfulness
- Transcendence/spirituality
- Work ethic/desire to pursue meaningful work
- More positive than negative emotion
- A desire to enhance social relationships
DSM-5 General Personality Disorder
A. Enduring pattern of inner experience & behavior that deviates markedly from
expectations of one’s culture, and deviation manifested in 2 or more of the
following areas: 1. Cognition (perceiving & interpreting self, others, events)
2. Affectivity (range, intensity, lability, appropriateness of emotional
response)
3. Interpersonal functioning
4. Impulsive control
B. Enduring pattern is inflexible & pervasive
C. Enduring pattern leads to sign. distress or impairment
D. Pattern is stable and has long duration: traits traced to adolescence/early
adulthood. If client is under 18, symptoms must be present for over a year.
Antisocial must be diagnosed after 18.
E. Pattern not better explained by another disorder or substance
The Problem with PDs - Strong evidence PDs are dimensional, not categorical
- Low temporal stability: test-retest reliability ranges from 0.11-0.57
- High incidence of comorbid PDs
- Culture and gender bias: dependent PD is more common/likely for women; antisocial and
narcissistic PD are more common/likely for men.
- Measurement & assessment problems: PDs tend to be egosytonic: embedded in personality.
Not aware of problem, no personal distress. Individuals often lack insight so their response is
invalid.
- Overuse of “not otherwise specified” criteria: third most common PD.
- Personality structure is not completely different, just more extreme.