1

Mental Illness

2

Defining Psychological Disorders

When behavior is:Deviant (atypical)DistressfulDysfunctional(and dangerous)…it is labeled as a disorder

3

Some early treatments of people with psych disorders

trephination, exorcism, being caged, being beaten, burned, castrated, mutilated, abandoned in the wild, or imprisoned

Trephination (boring holes in the skull to remove evil forces)

4

Philippe Pinel & the Medical Model

• Pinel introduced “talk therapy”• Medical Model of Mental Illness

– Diagnosed– Symptoms– Cured– Therapy (talk or pharmaceuticals)

• Brain structure/biochemistry mental illness

5

Biopsychosocial Approach

6

Culture-bound Syndromes

• Share same underlying cause, yet the manifestation is different– Anxiety (anorexia vs. susto)– Stress/guilt (koro vs. nervios)– Anger (Hwa-byung vs. borderline)

• OR diagnoses vary based on gender– ADHD versus depression

http://rjg42.tripod.com/culturebound_syndromes.htm

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Diagnostic & Statistical Manual of Mental Disorders

Are Psychosocial or Environmental Problems (school or housing issues) also present?Axis IV

What is the Global Assessment of the person’s functioning?Axis V

Is a General Medical Condition (diabetes, hypertension or arthritis etc) also present?Axis III

Is a Personality Disorder or Mental Retardation present?

Axis II

Is a Clinical Syndrome (cognitive, anxiety, mood disorders [16 syndromes]) present?Axis I

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Multiaxial ClassificationNote 16 syndromes in Axis I

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Multiaxial Classification

Note Global Assessment for Axis V

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Labeling Psychological Disorders

• Labels may stigmatize individuals– Discrimination

• Labels bias perceptions– Job interview study

• People who are told a person has a mental illness are more likely to interpret their behaviors through that lens

– David Rosenhan study (1973)• Rosenhan et al pretended to have mental illness

• Biased perceptions change others’ behaviors– “self-fulfilling prophecy”

• People treat individuals with mental illnesses differently, resulting in different interactions AND responses, compared to someone who is “normal”

11

Psychological Disorders in the U.S.

Theodore Kaczynski(Unabomber)

Approximately 25% of American adults suffer from a mental illness in a given year…

Jared Loughner(Arizona Shooter)

Anxiety Disorders

– Generalized Anxiety Disorder– Panic Disorder– Phobias– Obsessive-Compulsive Disorder– Post-Traumatic Stress Disorder– Understanding Anxiety Disorders

Anxiety Disorders

Feelings of excessive apprehension and anxiety.

1. Generalized anxiety disorder2. Panic disorder3. Phobias4. Obsessive-compulsive disorder5. Post-traumatic stress disorder

Generalized Anxiety Disorder

1. Persistent and uncontrollable tenseness and apprehension.

2. Autonomic arousal—sympathetic division

3. Inability to identify or avoid the cause of certain feelings.

Panic Disorder

Minutes-long episodes of intense dread which may include feelings of terror, chest

pains, choking, or other frightening sensations.

Anxiety is a component of both disorders. It occurs more in the panic disorder, making

people avoid situations that cause it.

Panic Disorder-Sleep Paralysis

• Related to paralysis that occurs as a natural part of REM sleep– Occurs when the brain awakes from a REM state, but the body

paralysis persists – Leaves the person fully conscious, but unable to move– May be unable to move/speak for a few seconds up to a few

minutes– Some may feel chest pressure or a sense of choking/inability to

breathe• Symptoms may also include sensations of noises, smells,

levitation, paralysis, terror, and images of frightening intruders, as a result of dream state overlaying on real physical world– Understandably results in panic in the sufferer!!

Phobias

Marked by a persistent and irrational fear of an object or situation that disrupts behavior.

Kinds of Phobias

Phobia of blood.Hemophobia

Phobia of closed spaces.

Claustrophobia

Phobia of heights.Acrophobia

Phobia of open places.Agoraphobia

Obsessive-Compulsive Disorder

Persistence of unwanted thoughts (obsessions) and urges to engage in senseless rituals

(compulsions) that cause distress.

Brain Imaging & OCD

Hyper-activity in the frontal lobe areas (anterior cingulate cortex)--monitors actions--checks for errors--ordering--hoarding

Brain image of an OCD

Hoarding & OCD

• Acquisition and failure to discard, a large number of possessions that appear to be of useless or of limited value

• Living spaces so cluttered they preclude activities for which those spaces were designed

Post-Traumatic Stress Disorder

4+ weeks of the following symptoms:

1. Haunting memories

2. Nightmares3. Social withdrawal

4. Jumpy anxiety

5. Sleep problems

Resilience to PTSD

Only about 10% of women and 20% of men react to traumatic situations and develop PTSD.

Holocaust survivors show remarkable resilience against traumatic situations.

All major religions of the world suggest that surviving a trauma leads to the

growth of an individual.

Explaining Anxiety Disorders

• Learning Perspective• Biological Perspective

Learning Perspective

• Fear conditioning– anxiety becomes associated

with other objects/events/people (stimulus generalization)

– Reinforced

• Example: You’re bitten by a dog as a child and you come to fear ALL dogs as result– May also selectively remember

interacting with only “mean dogs” and forget about the nice ones. Thus your [faulty] memory serves to reinforce your fears

The Learning Perspective

• Investigators believe that fear responses are inculcated through observational learning.– Young monkeys develop

fear when they watch other monkeys who are afraid of various stimuli

– We may learn phobias from our parents…like a fear of drowning

Biological/Evolutionary Perspective

• Twin studies suggest that our genes may be partly responsible for developing fears and anxiety. Twins are more likely to share phobias.

Somatoform & DID

• Somatoform Disorders– Conversion disorder (Freudian based)

• More extreme version of psychosomatic disorders– Anxiety is converted into a physical symptom– Makes NO sense physiologically, BUT has real physical

symptoms (i.e. they are NOT faking)– E.g. person may report losing feeling in a limb, which makes no

neurological sense BUT, if stuck with pins in that limb, would show no response

– Other examples: unexplained paralysis, blindness, inability to speak, non-epileptic seizes, etc.

More Somatoform

• Somatoform Disorders– Hypochondriasis (aka hypochondriac)

• Person regularly interprets normal symptoms as indicative of terrible disease(s)

– Continuously seeking medical care for their imagined “illness(es)”

– Sympathy or temporary relief from daily demands reinforces this behavior

– “Psychosomatic”• Physical disorder (with physical symptoms) caused/markedly

influenced by mental or emotional factors– E.g. feeling sick in a class you hate and then feeling better the

minute you leave the classroom

Dissociative Disorders

• Amnesia: Conscious awareness separated/dissociated from previous memories, thoughts, & feelings– Your running narrative of self “shuts off.” Akin to

blacking out, but you’re awake. No memory of self.

• Depersonalization: Also may have memory of self BUT– Have a sense of being unreal– Feel separated from the body– Watching yourself as if in a movie

Multiple Personality Disorder (MPD)

A type of dissociative identity disorder where a

person exhibits two or more distinct and

alternating personalities

Some supporters believe that it is a

learned response to trauma that reinforces reductions in anxiety

DID Critics

• Critics argue that the diagnosis of DID increased in the late 20th century.

• Other critics note that DID has not been found in other countries.

• Some critics believe it is role-playing by people open to a therapist’s suggestion– i.e., the therapist is

leading them to believe they have the disorder

Rates of Psychological Disorders

Mood Disorders

Mood Disorders

• Major Depressive Disorders

• Dysthymia

• Bipolar Disorder

• Mania/Manic

Mood Disorders

Emotional extremes of mood disorders come in two principal forms.

1. Major depressive disorder2. Bipolar disorder

Major Depressive Disorder

Major depressive disorder occurs when signs of depression last two weeks or more and are

not caused by drugs or medical conditions.

1. Lethargy and tiredness2. Feelings of worthlessness3. Loss of interest in family & friends4. Loss of interest in activities5. Reduced cognitive functioning

Signs include:

Dysthymic Disorder

Lies between blue mood and major depressive disorder. Characterized by depressive symptoms for most of the

day, more days than not, for at least 2 years.

Symptom-free interval cannot last longer than 2 months

Major DepressiveDisorder

Blue Mood

DysthymicDisorder

Bipolar Disorder

Formerly called manic-depressive disorder, alteration between depression

and mania signals bipolar disorder.

Multiple ideas

Hyperactive

Desire for action

Euphoria

Elation

Manic Symptoms

Slowness of thought

Tired

Inability to make decisions

Withdrawn

Gloomy

Depressive Symptoms

Bipolar Disorder

Many great writers, poets, composers suffered from bipolar disorder. During their manic phases, their creativity surged and

dropped off during their depressive phases.

Whitman Wolfe Clemens Hemingway

Bettm

ann/ Corbis

George C

. Beresford/ H

ulton Getty Pictures L

ibrary

The G

ranger Collection

Earl T

heissen/ Hulton G

etty Pictures L

ibrary

Explaining Mood Disorders

Lewinsohn et al., (1985, 1995) note that a theory of depression should explain:

1. Behavioral and cognitive changes2. Common causes of depression

Theory of Depression

3. Gender differences

Theory of Depression

4. Depressive episodes self-terminate.5. Stressful events often precede depression.6. Depression is increasing, especially in the

teens.

Post-partum depression

Desiree N

avarro/ Getty Im

ages

Suicide

The most severe form of behavioral response to depression is suicide. Each year some 1 million people commit suicide worldwide.

Women are more likely to attempt suicide, however, men are 2-4 times more likely to succeed because they use more lethal methods.

Biological Perspective

Genetic Influences: Mood disorders run in families. Rates of depression is higher in

identical (50%) than fraternal twins (20%).

Neurotransmitters & Depression

Post-synapticNeuron

Pre-synapticNeuron

Serotonin

Reduction of serotonin has been

implicated in depression.

Drugs that alleviate mania

reduce norepinephrine.

The Depressed Brain

PET scans show that brain energy consumption rises and falls with manic

and depressive episodes.

Courtesy of L

ewis B

axter an Michael E

. P

helps, UC

LA

School of M

edicine

Social-Cognitive Perspective

The social-cognitive perspective suggests that depression arises partly from self-defeating

beliefs and negative explanatory styles.

Depression Cycle

1. The negative stressful events.

2. Pessimistic explanatory style.

3. Hopeless depressed state.

4. Hampers the way the individual thinks and acts, and thus fuels personal rejection.

Symptoms of Schizophrenia

Literal translation “split mind”. A group of severe disorders characterized by:

1. Disorganized and delusional thinking.

2. Disturbed perceptions. 3. Inappropriate emotions

and actions.

Symptoms of Schizophrenia

Positive symptoms: the presence of inappropriate behaviors (hallucinations, disorganized or delusional talking)

Negative symptoms: the absence of appropriate behaviors (expressionless faces, rigid bodies)

Other forms of delusions include, delusions of persecution (“someone is following me”)

or grandeur (“I am a king”).

Disorganized & Delusional Thinking

This morning when I was at Hillside [Hospital], I was making a movie. I was surrounded by movie stars … I’m Marry Poppins. Is this room painted blue to get me upset? My grandmother died four weeks after my eighteenth birthday.”

This monologue illustrates fragmented, bizarre thinking with distorted beliefs, called delusions (“I’m Mary Poppins”).

Disorganized & Delusional Thinking

Many psychologists believe disorganized thoughts occur because of selective attention failure (fragmented and bizarre thoughts).

In other words, they have difficulty ignoring irrelevant stimuli (e.g. the hum of machinery, the texture of the wall, etc.)

Disturbed Perceptions

A schizophrenic person may perceive things that are not there (hallucinations). Frequently

such hallucinations are auditory and lesser visual, somatosensory, olfactory, or gustatory.

L. B

erthold, Untitled. T

he Prinzhorn Collection, U

niversity of Heidelberg

August N

atter, Witches H

ead. The Prinzhorn C

ollection, University of H

eidelberg

Photos of paintings by K

rannert Museum

, University of Illinois at U

rbana-Cham

paign

Inappropriate Emotions & Actions

A schizophrenic person may laugh at the news of someone dying or show no

emotion at all (flat affect or apathy).

Patients with schizophrenia may continually rub an arm, rock a chair, or remain motionless for hours (catatonia).

Onset and Development of Schizophrenia

Nearly 1 in a 100 suffer from schizophrenia, and throughout the world over 24 million

people suffer from this disease (WHO, 2002).

Schizophrenia strikes young people as they mature into adults. It affects men

and women equally, but men suffer from it more severely than women.

Chronic and Acute Schizophrenia

When schizophrenia is slow to develop (chronic/process) recovery is doubtful. Such schizophrenics usually displays

negative symptoms.

When schizophrenia rapidly develops (acute/reactive) recovery is better. Such

schizophrenics usually shows positive symptoms.

Warning Signs

Early warning signs of schizophrenia include:

Birth complications, oxygen deprivation and low-birth weight.

2.

Short attention span and poor muscle coordination.

3.

Poor peer relations and solo play.6.

Emotional unpredictability.5.

Disruptive and withdrawn behavior.4.

A mother’s long lasting schizophrenia.1.

Subtypes of SchizophreniaSchizophrenia is a cluster of disorders. Subtypes share some features but there are other symptoms that differentiate

these subtypes.

Understanding Schizophrenia

Brain scans show abnormal activity in frontal cortex, thalamus and amygdala of schizophrenic patients. Also adolescent

schizophrenic patients show brain lesions.

Paul T

hompson and A

rthur W. T

oga, UC

LA

Laboratory of N

euro Im

aging and Judith L. R

apport, National Institute of M

ental Health

Viral Infection

Schizophrenia has also been observed in individuals who contracted a viral

infection (flu) during the middle of their fetal development.

Genetic Factors

The likelihood of individuals suffering from schizophrenia is 50% if their identical twins

have the disease (Gottesman, 1991).

0 10 20 30 40 50Identical

Both parents

Fraternal

One parent

Sibling

Nephew or niece

Unrelated

Genetic Factors

Prevalence of schizophrenia in identical twins as seen in different countries.

Psychological Factors

Psychological and environmental factors can trigger schizophrenia if the individual was genetically predisposed (Nicols & Gottesman,

1983).

Genain Sisters

PersonalityDisorders

Personality trait• An enduring pattern of

perceiving, relating to, and thinking about the environment and others.

Personality disorders• Ingrained patterns of

relating to other people, situations, and events with a rigid and maladaptive pattern of inner experience and behavior, dating back to adolescence or early adulthood.

The Nature of Personality Disorders

A longstanding maladaptive pattern of inner experience and behavior dating back to adolescence or adulthood that is manifest in at least two of the following areas:

1. Cognition2. Affectivity3. Interpersonal functioning4. Impulse control

The Nature of Personality Disorders

At present, each personality disorder is categorized distinctly in that a person’s symptoms either fit it or they don’t.

Researchers who argue for a dimensional approach point out that the most commonly assigned Axis II diagnosis is personality disorder not otherwise specified.

DSM-IV Personality Disorder Clusters

• CLUSTER A – The Eccentric Ones• CLUSTER B – The Dramatic Ones• CLUSTER C – The Anxious Ones

The DSM-IV includes a set of separate diagnoses grouped into three clusters based on shared characteristics:

The Dramatic Ones Antisocial Personality Disorder

Borderline Personality Disorder

Histrionic Personality Disorder

Narcissistic Personality Disorder

Because Cluster B disorders have been the most extensively researched, we’ll start with them.

ANTISOCIAL PERSONALITY DISORDER

A personality disorder characterized by a lack of regard for society's moral or legal standards.

                                              

History– Philippe Pinel (1801)

- Defect of moral character– Hervey Cleckley (1941)

- Psychopathy– Robert Hare (1997)

- Psychopathy Check List– DSM

Goes beyond psychopathy traits

ANTISOCIAL

ANTISOCIAL

Associated Behaviors– Deceitfulness– Impulsivity– Unlawfulness– Recklessness– Aggressiveness– Manipulativeness– Lack of remorse

Important Distinctions

• Adult Antisocial Behavior

Criminal

Illegal or immoral behavior such as stealing, lying, or cheating

A legal term, not a psychological concept.

BIOLOGICAL– Various brain abnormalities

– Diminished autonomic response to social stressors

– Possible genetic causes

Perspectives onAntisocial Personality

Perspectives onAntisocial Personality

PSYCHOLOGICAL Neurological deficits related to

psychopathic symptoms Response modulation hypothesis Unable to process information not

relevant to their primary goals Low self-esteem

SOCIOCULTURAL

• Family variables

• Childhood abuse

• Childhood neglect                                               

Perspectives onAntisocial Personality

TREATMENT OF ANTISOCIAL PERSONALITY DISORDER

• Address low self-esteem

• Confrontational techniques

• Group therapy

BORDERLINE PERSONALITY DISORDER

Instability is evident in mood, interpersonal relationships, and self-image.

Often sufferers are confused about their own identity or concept of who they are.

A personality disorder characterized by pervasive instability with a

pattern of poor impulse control.

BORDERLINEObserved characteristics:

– Intense interpersonal relationships– Splitting– Feelings of emptiness– Anger, rage– Identity confusion– Shifting goals, plans, partners– Poor boundaries with others– Risk taking, self injurious behaviors– Parasuicidal

PERSPECTIVES ON BORDERLINE PERSONALITY

BIOPSYCHOSOCIAL– Vulnerable temperament– Traumatic early childhood experiences– Triggering events in adulthood

BIOLOGICAL– Hippocampus smaller– Amygdala smaller

• Physical or sexual abuse

• Childhood caregiver interaction– Emotionally unavailable – Inconsistent treatment– Failed to validate their thoughts and feelings– Failed to protect from abuse– Anxious attachment style with mother

PERSPECTIVES ON BORDERLINE PERSONALITY

PSYCHOLOGICAL

• Poor ego development

• Caregiver overinvolved yet inconsistent

• Distorted perception of others

PERSPECTIVES ON BORDERLINE PERSONALITY

PSYCHODYNAMIC

• Splitting• Low sense of self-

efficacy• Lack of confidence• Low motivation• Inability to seek long-

term goals

PERSPECTIVES ON BORDERLINE PERSONALITY

COGNITIVE-BEHAVIORAL

Modern pressures on family

Diminished social cohesion and mental cohesion

Unstable family patterns

• CHALLENGING AND COMPLEX– Unlikely to remain in treatment long– Unstable relationships with therapist

• TECHNIQUES– Confrontive or – Supportive– Dialectical Behavioral Therapy– May need medication

TREATMENT OF BORDERLINE PERSONALITY

HISTRIONIC PERSONALITY

DISORDER

A personality disorder characterized by exaggerated emotional reactions, approaching theatricality, in everyday behavior. Melodramatic.

The term histrionic is derived from a Latin word meaning “actor.”

HISTRIONIC• Dramatic, attention-getting behavior

• Fleeting, shifting emotional states

• More commonly diagnosed in women

• Flirtatious and seductive

• Need for immediate gratification

• Easily influenced by others

• Lack analytical ability

• Superficial relationships

– Feelings of inadequacy and need for others

– Global nature of thinking underlies diffuse, exaggerated and changing emotional states

• TREATMENT GOALS– Learn how to think more objectively and precisely

– Learn self-monitoring strategies

– Learn impulse control

– Acquire assertiveness skills

VIEWS AND TREATMENT OF HISTRIONIC PERSONALITY

COGNITIVE-BEHAVIORAL

NARCISSISTIC PERSONALITY

DISORDER

Named for Greek legend of Narcissus.

Personality disorder characterized by an unrealistic, inflated sense of self-importance and lack of sensitivity to other people’s needs:

• egotistical• arrogant• exploitative of others

NARCISSISTIC SUBTYPESNoting the many types of behaviors involved, Millon and colleagues proposed subtypes:

• elitist• amorous• unprincipled• compensatory

THEORIES OF NARCISSISTIC PERSONALITY

Freudian– Stuck in early psychosexual stages

Cognitive-Behavioral– Lack insight into or concern for feelings of others

– Grandiose sense of self clashes with real world failures

PSYCHODYNAMIC and COGNITIVE-BEHAVIORAL therapies overlap in their goals for the client:

Reduce grandiose thinking. Develop more realistic view of self. Develop more realistic view of others. Enhance ability to relate to others Avoid demands for special attention

TREATMENT OF NARCISSISTIC PERSONALITY

The Eccentric Ones

Paranoid Personality

Schizoid Personality

Schizotypal Personality

PARANOID PERSONALITY DISORDER

• SUSPICIOUSNESS

• GUARDEDNESS

• PROJECTION OF NEGATIVITY AND DAMAGING MOTIVES ONTO OTHERS

• ATTRIBUTION OF THEIR PROBLEMS TO OTHERS

• LOW SELF-EFFICACY

COGNITIVE BEHAVIORAL – COUNTER ERRONEOUS THINKING

– ESTABLISH TRUSTING RELATIONSHIP

– INCREASE FEELINGS OF SELF-EFFICACY

– REDUCE VIGILANT AND DEFENSIVE STANCE

– INSIGHT INTO OTHERS’ PERSPECTIVES

– APPROACH CONFLICT ASSERTIVELY

– IMPROVE INTERPERSONAL SKILLS

TREATMENT OF PARANOID PERSONALITY

SCHIZOID PERSONALITY

DISORDERMain characteristic: Indifference to social

relationships, as well as a very limited range of emotional experience and expression.

SCHIZOID

• INDIFFERENCE TO SOCIAL AND SEXUAL RELATIONSHIPS

• SECLUSIVE; PREFER TO BE ALONE• NO DESIRE TO LOVE OR BE LOVED• COLD, RESERVED, WITHDRAWN• INSENSITIVE TO FEELINGS OF OTHERS

TREATMENT: Unlikely to seek or respond to therapy.

SCHIZOTYPAL PERSONALITY

DISORDER

Main characteristic: Peculiarities and eccentricities of thought, behavior, appearance, and interpersonal style.

SCHIZOTYPAL PERSONALITY

DISORDER

CONSTRICTED, INAPPROPRIATE AFFECT IDEAS OF REFERENCE, MAGICAL THINKING SOCIAL ISOLATION PECULIAR COMMUNICATION

TREATMENT: Parallels interventions commonly used in treating schizophrenia.

The Anxious Ones

Avoidant Personality

Dependent Personality

Obsessive-Compulsive

AVOIDANT PERSONALITY DISORDER

Most prominent feature:

The individual desires, but is fearful of, any involvement with other people and is terrified at the prospect of being publicly embarrassed.

COGNITIVE-BEHAVIORAL Hypersensitive due to parental criticism Feel unworthy of others’ regard Expect not to be liked Avoid getting close to avoid expected

rejection Distorted perceptions of experiences with

others

AVOIDANT - THEORIES

COGNITIVE-BEHAVIORAL– BREAK NEGATIVE CYCLE OF

AVOIDANCE– CONFRONT AND CORRECT

DYSFUNCTIONAL ATTITUDES AND THOUGHTS

– GRADUATED EXPOSURE TO SOCIAL SITUATIONS

– LEARN SKILLS TO IMPROVE CHANCE OF INTIMACY

TREATMENT OF AVOIDANT PERSONALITY

DEPENDENT PERSONALITY DISORDER

Main characteristic: This individual is extremely passive and tends to cling to other people to the point of being unable to make any decisions or to take independent action.

Others may characterize them as “clingy.”

DEPENDENT

• Fear of abandonment• Despondent without others• Unable to initiate activities• Insecure about making decisions without

others• Go to extreme to get approval from others• Devastated when relationships end

DEPENDENT - THEORIES

Theories• PSYCHODYNAMIC

– Fixated at oral psychosexual stage because of parental overindulgence or neglect

• OBJECT RELATIONS– Insecure attachment to parents led to fear of

abandonment– Low self-esteem leads them to rely on others

• COGNITIVE-BEHAVIORAL– Thinking they are inadequate and helpless, they find

someone to take care of them

COGNITIVE-BEHAVIORAL – Therapist and client develop structured

ways to increase client independence in daily activities

– Identify skill deficits and improve functioning

– Therapist must avoid becoming an authority figure or making client dependent on therapist

TREATMENT OF DEPENDENT PERSONALITY

Main characteristic: Perfectionistic

So overwhelmed with their concern for neatness and minor details that they have trouble making decisions or getting things accomplished.

OBSESSIVE-COMPULSIVE

• RIGID BEHAVIORAL PATTERNS

• FANATICAL CONCERN WITH SCHEDULES

• STINGY WITH TIME AND MONEY

• TENDENCY TO HOARD WORTHLESS OBJECTS

• LOW LEVEL OF EMOTIONALITY

THEORIES OFOBSESSIVE-COMPULSIVE

• FREUDIAN– Fixation at anal psychosexual stage

• OBJECT RELATIONS– Insecure parent-child attachments

• COGNITIVE-BEHAVIORAL – Distorted world view– Unrealistic standard of perfection

TREATMENT: Difficult to treat. Therapy may reinforce ruminative tendencies.

And in conclusion . . . ?

Personality disorders are

• Chronic and persistent

• Hard to explain

• Difficult to treat

• Subject to much further study