3.3 Personality disorders

Question 1

What is personality?

Answer 1

cluster of relatively predictable patterns of:
thinking
feeling
behaviour

generally consistent across time ,space, and context
multi-dimensional spectrum

Question 2

What are the 5 dimensions of personality? (OCEAN/CANOE)

Answer 2

extraversion 
agreeableness
conscientiousness
neuroticism 
openness

Question 3

What is the definition of personality disorder?

Answer 3

A: An enduring pattern of inner experience and behaviour that deviates from culture +++. Manifested in 2 or more of:

1. cognitions
2. affectivity: the range, intensity, lability, appropriateness of emotional response
3. interpersonal functioning
4. impulse control

B. The enduring pattern = inflexible, pervasive across ++ range of personal and social situations

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Question 4

What is the onset of personality disorder?

Answer 4

Onset can be traced back at least to adolescence or early adulthood. There is a stable and long pattern.

Question 5

What is the attribution of personality disorder?

Answer 5

Not better explained by another mental disorder

Not attributed to physiological effects of substance, or another medical condition (trauma).

Question 6

What characterises anakastic personality disorder?

Answer 6

Feelings of excessive doubt/caution
preoccupation +++ details, rules, lists, order, organization, schedule
perfectionism that interferes with task completion
excessive conscientiousness, scrupulousness
undue preoccupation with productivity/ to exclusion of pleasure and interpersonal relationship
excessive pedantry and adherence to social conventions
rigid/stubborn
unreasonable insistence that others submit exactly to their way of doing things, or unreasonable reluctance to allow others to do things

Question 7

What is the difference between personality trait and disorder?

Answer 7

traits are common, and sometimes cause problems

disorders are pervasive, and cause distress/impaired functioning in most areas

Question 8

What is the aetiology of antisocial personality disorder?

Answer 8

Most PD are interactions between genes, person, and environment
From twin studies:
-additive genetics- 0.32
-non-additive genetics 0.09
-shared environmental influences 0.16
-non-shared environmental influences 0.43

Question 9

Which are the most heritable personality disorders?

Answer 9

1. Anxious and fearful- 0.62 (obsessive compulsive is 0.78, avoidant)
2. dramatic and emotional - 0.60(borderline and histrionic)
3. odd and eccentric- 0.37(schizoid, paranoid)

Question 10

What proportion of people in general population have a personality disorder?

Answer 10

10.6% (this is more than DM, IBD, MS, Epilepsy, RA, Asthma, individually!)
more than half of these are personality disorder nor otherwise specified

Question 11

What are the 3 most common personality disorders in rank order?

Answer 11

1. Obsessive compuslive personality disorder
2. Schizoid personality disorder
3. Avoidant personality disorder

Question 12

What proportion of psychiatric inpatients have PD?

Answer 12

54%

Question 13

What personality disorder does this describe?

++ distrust and suspiriousness of others- their motives interpreted as malevolent; starting in early adulthood, presents in ++ contexts, indicated by 4 or more:

1. suspects without sufficient bases, that others are exploiting, harming or deceiving him/her
2. preoccupied with unjustified dbouts about loyalty/trustworthiness of friends/associates
3. reluctant to confide in others b/c unwarrested fear that info will be used against him/her
4. reads hidden demeaning/threatening meanings into benign remarks/events
5. persistently bears grudes
6. perceives attacks on their character not apparent to others
7. recurrent suspicions without justification re fidelity of spouse or sexual partner

Answer 13

Paranoid personality disorder

Question 14

Which personality disorder does this describe?
A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
1. Neither desires nor enjoys close relationships, including being part of a family.
2. Almost always chooses solitary activities.
3. Has little, if any, interest in having sexual experiences with another person. 4. Takes pleasure in few, if any, activities.
5. Lacks close friends or confidants other than first-degree relatives.
6. Appears indifferent to the praise or criticism of others.
7. Shows emotional coldness, detachment, or flattened affectivity.

Answer 14

Schizoid personality disorder

Question 15

Which personality disorder does this describe?

A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:

1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
5. Reckless disregard for safety of self or others.
6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

Answer 15

Antisocial personality disorder

Question 16

Which personality disorder does this describe?
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Answer 16

Borderline personality disorder

Factors 4/5/6/9 are significant

Question 17

What personality disorder does this describe?
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Is uncomfortable in situations in which he or she is not the center of attention.
2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
3. Displays rapidly shifting and shallow expression of emotions.
4. Consistently uses physical appearance to draw attention to self.
5. Has a style of speech that is excessively impressionistic and lacking in detail.
6. Shows self-dramatization, theatricality, and exaggerated expression of emotion.
7. Is suggestible (i.e., easily influenced by others or circumstances). 8. Considers relationships to be more intimate than they actually are.

Answer 17

Histrionic personality disorder

Question 18

What personality disorder does this describe?
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
2. Is unwilling to get involved with people unless certain of being liked.
3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
4. Is preoccupied with being criticized or rejected in social situations.
5. Is inhibited in new interpersonal situations because of feelings of inadequacy.
6. Views self as socially inept, personally unappealing, or inferior to others.
7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

Answer 18

Avoidant personality disorder

Question 19

Which personality disorder is described?
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Has difficulty making everyday decisions without an excessive amount of advice and
reassurance from others.
2. Needs others to assume responsibility for most major areas of his or her life.
3. Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include realistic fears of retribution.)
4. Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).
5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.
7. Urgently seeks another relationship as a source of care and support when a close relationship ends.
8. Is unrealistically preoccupied with fears of being left to take care of himself or herself.

Answer 19

Dependent personality disorder

Question 20

Which personality disorder is described?
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).
3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
5. Is unable to discard worn-out or worthless objects even when they have no sentimental value.
6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his
or her way of doing things.
7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
8. Shows rigidity and stubbornness.

Answer 20

Obsessive compulsive personality disorder

Question 21

What distinguishes antisocial personality disorder and psychopathy?

Answer 21

They are not the same
antisocial personality disorder is based on behaviour
psychopathy is based on emotional and cognitive functioning
60-80% of male prisoners have ASPD but only 15% have psychopathy
most psychopaths arent in prison…

Question 22

What are the 2 factors and 4 facets of psychopathy?

Answer 22

Factor 1: interpersonal/affective
Facet 1: interpersonal: superficial charm, grandiose self worth, pathological lying, conning
Facet 2: affective: lack of remorse/guilt, shallow affect, lack of empathy, failure to accept responsibility for action

Factor 2: social deviance
Facet 3: need for stimulation due to boredom, parasitic lifestyle, lack of realistic long term goals, impulsivity, irresponsibility
facet 4: antisocial: poor behavioural control, early behavioural problems, juv delinquency, going against conditions of release, criminal versatility

Question 23

What is the main treatment approach to personality disorder?

Answer 23

Treat the comorbidities- depression, anxiety, etc. - should be the focus of treatment
social skills training for some- increase self efficacy and functioning
some evidence for antidepressants
MAIN PSYCH TX: dialectical behavioural therapy

Question 24

What psychological treatment is described here?

• package of group, firm boundaries, managing interpersonal issues
• combining behavioural appraoches with bhuddist concepts such as acceptance and mindfulness
• hard work for everyone, high drop out rate
• main effect is reducing suicidal behaviour

Answer 24

Dialectical behavioural therapy

Question 25

What is mentalism?

Answer 25

Informed by psychodynamic concepts
the process by which we interpret our own actions as being meaningful based on our own mental states

IMPAIRED ABILITY TO MENTALISE is supposed to affect our ability to regulate our emotions and maintain interpersonal relationships

Question 26

What drug treatments may be used in PD?

What drug has been suggested for atypical depression + borderline personality disorder?

Answer 26

No one drug for eg. borderline personality disorder.
However, BDPD is overrepresented in those with atypical depression and MAOis may be effective for cormorbid depression and personality disorder
Antipsychotics may also have a role to play.

Question 27

What antipsychotics/antiepileptics/antideperssants have evidence to support their use in borderline personality disorder?

Answer 27

Topiramate- for anger and aggression
antidepressants- for depressive symptoms
Phenelzine- for hostility
olanzapine- for borderline personality, but weight gain
haloperidol- some evidence for borderline personality

Question 28

What treatments are advised for antisocial personality disorder?

Answer 28

psychological: group based cognitive and behavioural interventions to address impulsivity, interpersonal difficulties and antisocial behaviour

Pharmacological interventionsnot routinely used for tx of antisocial personality disorder or associated behaviours of aggression, anger and impulsivity