Personality disorders

What is a mental disorder?
Clinically significant behavioural or psychology syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significant increased risk of suffering, death, pain
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What must not merely be?
Expected or culturally sanctioned response to a particular event
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What must it be currently?
considered a manifestation of a behavioural, psychological or biological dysfunction in the individual
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What is not a disorder?
Behaviour and conflicts between individuals and society are not disorders unless the it is symptom of dysfunction
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Behaviour and conflicts between what?
Individual and society, are not disorders unless the it is symptom of dysfunction
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What can it not do?
Classify people
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What are personality traits?
enduring patterns of perceiving, relating to and thinking about the environment and oneself that are exhibited across a wide range of social and personal contexts
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What happens to these traits which leads to a personality disorder?
When these traits are inflexible, maladaptive and cause functional impairment or distress
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What is cluster A on Axis II?
Paranoid, Schizoid, Schizoptypal
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What is on Cluster B?
Antisocial personality disorder, borderline, histrionic, Narcissistic
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What is Cluster c?
Avoidant, dependent, obsessive compulsive
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What is the prevalence of Paranoid Personality disorder?
0.5%-2.5% general population, 2-10% outpatient mental health, 10-30% inpatient mental health
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When is there an increased prevalence?
If family schizophrenic and delusional
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What is it not be confused with?
members of groups for whom there is a real issue of persecution (minorities, refugees)
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Where are symptoms apparent?
from childhood and adolescence
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What must paranoid PD show?
4 or more of different characteristics
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Some example criteria?
Pervasive distrust and suspicion of others, across contexts, Suspects others are harming, deceiving or plotting (no basis) Preoccupied with doubts about trustworthiness of friends Reluctant to confide in others (due to above)
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What are some other example criteria?
persistently bears grudges, perceives attacks and reacts quickly and angrily
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What is the prevalence of a schizoid PD?
Uncommon in clincial settings, increased if family schizophrenia and schizotypal, distinguished from psychotic disorders, ASD, avoidance, OCD
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What is it not to be confused with?
Defensive interpersonal styles, symptoms apparent from childhood and adolescence: solitariness and poor peer relations (prone to Victimisation)
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What is some of the diagnostic criteria for Schizoid PD?
Pervasive detachment from social relationships, restricted emotional expression, neither ejoys or seeks close relationships, chooses solitary activities, little interest in sexual relationships, takes pleasure in V. few activities, lacks close friend
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What are the other diagnostic criteria?
Indifferent to praise/criticisms of others, emotional coldness, detachment, flattened affect
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What is the prevalence of a Schizotypal PD?
3% General population, increased prevalence if 1st degree biological
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What is it distinguished from?
Psychotic disorders, Schizoid, avoidant, ASD, language disorders
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What is it not to be confused with?
Those who have religious beliefs characterised by rituals, stable life course, very few develop schizophrenia,
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What are some diagnostic characteristics?
Odd beliefs outside norms - bizarre preoccupations / fantasies Perceptual illusions (including bodily illusions) Odd thinking and speech (e.g. I’m not talkable today) Suspicious / paranoid
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What is the prevalance of antisocial PD?
3% males: 1% females (community samples) 3-30% clinical samples Higher in drug treatment and forensic settings
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When is there an increased prevalence?
If family antisocial PD, substance abuse. Nurture also plays part in familial relationships
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What is it distinguished from?
Substance related disorder, narcissistic PD, histionic, boderline, paranoid
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What is it higher in?
Lower social economic society, maybe due to middle class judgements of acceptable behaviours
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When are symptoms apparant?
From childhood and adolescence, tend to diminish across lifespan
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What are the diagnostic criteria?
Lack of conformity to social norms. Repeated behaviours grounds for arrest Lying, aliases, conning for profit or pleasure Impulsivity, failure to plan Irritability, aggressiveness, frequent fights Reckless disregard for others’ and own safety
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What are the main criteria?
Pervasive disregard for rights of others since 15 years, over 18 years old, conduct disorder prior to 15 years, not during schizophrenia or mania
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What is a borderline PD prevalence?
2% general population 10% outpatient mental health 20% inpatient mental health 30-60% of PD clinical populations
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When is there increased prevalence?
If 1st Degree biological, substance disorders, antisocial PD, mood disorders
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What is this distinguished from
from Histrionic PD, Schizotypal, Paranoid, Nacissistic, Antisocial, Dependent
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What is it not to be confused with?
Adolescent settling into identity/relationships, symptoms most evident in early adulthood. Relative stability in 30s
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What is it not to be confused with?
Adolescent settling into identity/relationships, symptoms most evident in early adulthood, relative stability in 30s, dimensional
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What is the diagnostic criteria?
Pervasive instability of interpersonal relationships, self-image, affect. Marked impulsivity, avoid abandonment, idealisation, devaluation, identity disturbance, impulsivity, suicidal threats, reactivity of mood, emptiness, anger, paranoia
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What is the prevalance of Histrionic PD?
2-3% of general population, 10-15% inpatient and outpatient mental health, distinguished from borderline, ASPD, narcissistic, dependent, not to be confused with cultural norms of emotional expressiveness
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When is it evident from
Early adulthood
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What is the criteria for Histrionic PD?
attention seeking, excessive emotinality seeking, Uncomfortable if not centre of attention Interactions often inappropriately sexual or provocative Rapidly shifting and shallow emotional expression Gains attention via physical appearance, suggestable
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What is this distinguished from?
Histrionic, ASPD, Borderline, OCD, Schizoid, Schizotypal. Grandiose beliefs not due to Delusions.
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What is it not to be confused with?
Not to be confused with adolescent self absorption Symptoms apparent from early adulthood Dimensional (Foster & Campbell, 2007)
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What is the diagnostic criteria of a Narcissistic PD?
Pervasive grandiosity, need for admiration, lack of empathy. Show 5 (or more) of the following: Grandiosity without commensurate achievements Preoccupied with fantasies of unlimited success, power So special, few (high status) people could understand
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What else?
Requires excessive admiration Sense of entitlement Interpersonally exploitative Lacks empathy Envious of others, or believes others envy them, arrogant
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What is the prevalence of avoidant PD?
0.5-1% general population 10% outpatient mental health
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What is this distinguished from?
Distinguished from Social Phobia, Panic with Agoraphobia, Dependent, Schizoid or Schizotypal, Paranoid
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What is it not to be confused with?
expected difficulties due to immigration and childhood shyness, evident from early childhood and does not dissipate with age
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When is it evident from?
early childhood and does not dissipate with age
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WHat is the diagnostic criteria?
Pervasive social inhibition, inadequacy, hypersensitive to negative evaluation. Show 4 (or more) of the following: Avoids jobs with interpersonal contact due to fear of disapproval and rejection Will only get involved with people if certain to be lik
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What is the other criteria?
Restraint in relationships in case of being ridiculed Preoccupied with being rejected in social situations Views self as socially inept, inferior Reluctant to take risks or try something new in case of embarrassment and failure
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What is the prevalence of dependent PD?
Extremely common in mental health clinics Distinguished from Axis I, Borderline, Histrionic, Avoidant
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What is it not to be confused with?
with cultural norms of dependency in close relationships
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When is it evident from
Early adulthood
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Diagnostic criteria?
Pervasive need to be taken care of. Submissive and clingy behaviour. Show 5 (or more) of the following: Difficulty making everyday decisions without advice and reassurance from others Needs others to assume responsibility
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Diagnostic criteria?
Difficulty expressing disagreement because of fear of loss of support Difficulty initiating projects on own (lack of self-confidence) Goes to lengths to gain nurturance and support , uncomfortable when alone, urgently seeks another relationship
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Obsessive compulsive personality disorder, prevalence?
1% general population 3-10% clinical mental health Twice as common in males
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What is it distinguished from?
ASPD, narcissistic, schizoid, not to be confused with cultural norms of work ethics, evident from early adulthood, taxon
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Diagnostic criteria?
Pervasive preoccupation with orderliness, perfectionism and control at expense of flexibility. Show 5 (or more) of: Preoccupied with details, rules, lists. Big picture lost.
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Diagnostic criteria?
Perfectionism interferes with completion Excessively devoted to work to exclusion of leisure and friendships Over-conscientious and inflexible about morality / ethics Unable to discard items even if have no value
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What are the links between PD and N?
N linked with most psychiatric conditions (Costa & McCrae, 1992)
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E and PD?
associated with histrionic (+ve) & Schizoid (-ve) (Wiggins & Pincus, 1989)
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O?
can influence the type of therapy a patient will respond to
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A?
influence rapport between patient and therapist (Cost & McCrae 1992
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C?
- linked to ASPD (-ve), OCD (+ve) (Lyons et al, 1990
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P?
linked on continuum with Psychoticism through Psychopathy to Schizophrenia
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What should OCD be related to?
higher C, OCD and big 5 may also be related to depression
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What is OCD matched with?
Major depression
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Patients had what?
had high N and low E & C, average A and O compared to control statistics,
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OCD had a higher?
E, A, C than MD grou
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MD had
higher levels of neurotocism
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When depression severity was controlled across patients, what?
OCD had higher E and A, MD had a higher N
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What did OCD findings have?
No difference in C after controlling for depression severity is counter intuitive, may be due to their exceptionally high standards - and so items are being responded to not via norms of others, but of self
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But what?
Did not assess Axis II co morbidity, cross sectional design
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What was PDs with five factor model?
Community population, N=192 males, 105 females, 274 had SR data on Neo PI, 60 suse ratings, 112 had peer ratings
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What was found in cluster A?
Schizoid most likely to be rated highly in extrovertism, Paranoid self reported as high in associationism
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What was found in cluster B?
Antisocial and borderline, high in conscientiousness and associationism, Histrionic high in conscientiousness
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What was found in cluster C?
Avoidant SR high on extrovertism, dependent reported high on extrovertism and conscientiousness
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McClaren and Best (2010)
Non suicidal self injury - one of diagnostic elements of BPD 153 undergrauates (N=20 high self harm group; N=21 low self harm group, N=112 no self harm group.
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What did they find if there was a high NSSI group?
Higher Neurtocism, lower A and C than control
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What did they find if there was a low NSSI group?
Higher Neuroticism, lower A and O than control
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Those high in BPD tend to what?
score higher in N and lower in A and C
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What are the borderline estimates?
five factor models show higher borderline indicators in both NSSI groups
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ASPD and psychopathy Decuyper et al (2009)
ASPD and Psychopathy similar but distinct with different aetiologies
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What are the links with five factor model?
Hypothesised in a dimensional approach, the distinctions in links can help tease apart the disorders
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Widiger and Lynam (1998) and Widiger et al (2002) translated what?
Psychopathy and ASpd into FFM criteria
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What was performed?
A meta analytic study - looks at the effects across studies measuring the FFM and ASPD and psychopathy to see where the effects lie across the board
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What was found to be the difference between ASPD and psychopathy?
Anxiety
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Ben-Porath and Waller (1992)
Any additional measure needs to: Do all the job of existing measures if replacement, or Do additional functions to existing measures if supplement
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What is the content of assessment?
It is important but also manner of interaction with therapist/assessment
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What does a clinical assessment need to do? Ben porath and Waller
Identification of symptoms and differential diagnosis Current adjustment and stable p ersonality Treatment implications
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Can the big 5 do this?
Definitive labels not yet acheived for big 5
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Briggs 1989?
The five have yet to be defined by consensus with any degree of specifity
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What is not dealt with?
Some aspects (maturity, traditional values)
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What did Ben porath and waller say?
Protocol validity, big 5 doesnt give info on how client is cooperating
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What did Costa and McCrae say
SR is valid even when people arent removed on basis of questiona about engagement in assessment
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BP and W?
Still may not give info on single client
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Tellegen?
Depression, impulsivity and anxiety all load onto N, Depression, low positive emotionality, anxiety = high negative emotionality, impulsivity = low control
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What was Costa and McCraes big reply?
Big 5 doesnt stand alone, dont believe protocol validity checks work, when look at MMPI against observer ratings, protocol validity controls make validity worse, scales are different from facet level to domain, anxiety can be part of depressio
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What is impulsivity similar to?
Inabiity to tolerate tension and fustration
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What is the premise?
Rushton et al propose that the GFP share characteristics of g. That is, high levels of GFP are functional, lower levels are dysfunctional.
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What is the problem?
It may well be that extreme scores at either end are maladaptive (MacDonald, 1995).
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What is the evidence?
Livesley, Jang and Vernon (1998) found 4 similar phenotypic factors from PD that resembled 4 FFM domains.
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What are the four points?
Emotional dysregulation (high N), inhibition (low E), compulsivity (high C) and dissocial behaviour (low A)
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PD and the GFA, problem
High N is linked to paranoid, BPD, NPD and avoidant PD but low N is linked to glib charm associated with ASPD
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What is high E linked to?
Histrionic and dependent PDs
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What is high A related to?
Dependent PD
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O'Connor and Dyce
Examined correlations between FFM and PDs, Low N, high in E, A and C, high GPF without O is the profile of Histrionic PD, contrary to GFP theory
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Caseras et al (2001)
) N = 77 out patients of Psychiatry clinic Assessed for PDs, SPSR questionnaire, EPQ, SP scores predicted levels of Cluster C (especially OCPD) without anxiety, and distinguished between Cluster C and Clusters A&B and non-PD patients.
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Soler et al (2015)
N = 245 (100 BPD; 45 MDD; 100 HCs) Assessed for PDs, SPSR questionnaire SP and SR scores higher in BPD group than the MDD and HC groups. No differences between HC and MDD scores
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PD and reniforcement sensitivity theory, Cluster b
Cluster B with high BAS low BIS combination ( especially ASPD and HPD)
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Cluster C?
Cluster C associated with higher BIS
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Cluster A?
Cluster A associated with elevated BIS and BAS (mainly paranoid and schizotypal)
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Anxiety Disorders
Large literature showing link between elevated BIS scores and anxiety disorders
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Depression
Hyporeactivity of reward systems associated with depression. Link between reduced BAS and depression (although findings mixed) Although BIS and anxiety is the main link, some evidence for elevated BIS in depression too (probably via negative affect N
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Bipolar
Oscillations between mania and depression linked to hypersensitivity to BAS. BAS particularly associated with mania, and BIS associated with depression and depression severity
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Psychopathy
High BIS related to primary and secondary psychopathy Low BIS associated with primary psychopathy
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Substance abuse?
Strong link to high BAS sensitivity
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What was the original proposal for DSM 5?
Original proposal to replace categories of specific disorders and replace with a trait approach.
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What was it deemed?
Complex and unworkable
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What is included in the hybrid alternative in section 3 of the manual?
The trait model
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What does the hybrid methodology retain?
Borderline Personality Disorder • Obsessive-Compulsive Personality Disorder • Avoidant Personality Disorder • Schizotypal Personality Disorder • Antisocial Personality Disorder • Narcissistic Personality Disorder
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