6. Personality & Impulse Control Disorders Flashcards
Cluster A personality disorders
Odd or eccentric behaviour
- Paranoid PD
- Schizoid PD
- Schizotypal PD
Cluster B personality disorders
Dramatic or erratic responses (emotional)
- Antisocial PD
- Boderline PD
- Histrionic PD
- Narcissistic PD
Cluster C personality disorders
Anxious and fearful behaviour
- Avoidant PD
- Dependent PD
- Obsessive compulsive PD
Ddx between PD and schizophrenia
PD patients may present with psychotic features, but have intact capacity for reality, expressing emotions, able to distinguish between thoughts of their own and others
Ddx between PD and bipolar
No hypomanic or manic episodes
Ddx between PD and anxiety disorder
PD patients use immature defences
What is paranoid personality disorder?
Persistent suspicion and worry about conspiracy against oneself, angry reactions to perceived attacks, mistrust in others
Management of paranoid personality disorder
Supportive psychotherapy
Problem solving therapy
CBT
Pharmacotherapy: symptomatic treatment
Schizoid personality disorder
Restricted affective expression, very poor social relationships and avoidance of social activities, lack of interest to socialise
Schizotypal personality disorder
- Psychoticism
- Eccentric behaviour and appearance
- Odd thoughts
- Odd beliefs or magical thinking - Detachment
- Restricted affective expression (emotional detachment)
- Withdrawal (avoidance) - Negative affect
- suspicious, paranoid of harm by others
OILIES
Odd: behaviour, perceptual experience, beliefs, speech
Ideas of reference
Lacks friends but wants
Inappropriate affect
Excessive social anxiety
Suspiciousness or paranoia
Ddx of Cluster A PD
Schizophrenia
Delusional disorder
Severe depressive disorder with psychotic features
Paranoid PD
Schizoid PD
Schizotypal PD
Boderline PD
Cluster A PDs are more common in…
1st degree relatives of schizophrenia patients
Lack of protection and support in childhood, excessive parental rage
Antisocial personality disorder
Manipulative, dishonest, lack of remorse (callous)***, hostility, criminality
Irresponsible, impulsive, risk taking
aka potential psychopath
ACID SIRR
Aggression
Compliance x
Impulsive
Deceitful
Safety planning x
Irresponsible
Remorse x
Risky behaviour
Progress to ASD
Continuum:
ODD (6-10yo) -> CD (10-15yo) -> ASD (16-18yo onwards)
Ddx of ASD PD
Temporary ASD (focal behaviour, conscience intact)
Mania/hypomania
Borderline personality disorder
IMPULSIVE mnemonic
Impulsive
Mood swings
- usually in response to environment/circumstance
- within a day
- ABRUPT & SHORT-LIVED
Paranoid/psychosis
- may have psychotic-like episodes under stress
Unstable self image
Labile intense relationships
- relationships form and fall apart very quickly
Self harm/suicide
Inappropriate Anger
- angry easily and intense degree of anger
Vulnerability to Abandonment**
- excessive acts done to prevent abandonment
Emptiness**
- chronic feelings of emptiness
Therapies for BPD
Psychotherapy
- Dialectical behaviour therapy
* highly indicated
- Metallisation based therapy
Pharmacotherapy: SSRI
- very MINIMAL role
What is an accessory feature of Borderline PD?
SPLITTING
Adopting an extreme view of that world in black and white with little in between
- People are SUPER GOOD -> idealise or SUPER TERRIBLE -> denigration
- Fails to see that each person has good and bad traits
What can arise when dealing with a Borderline PD patient?
(Transference: projects a certain image/feelings onto doctor based on patient’s own past experiences)
Counter-transference: projects a certain image/feelings onto patient based on doctor’s own past experiences
- NEVER act on your counter transference
Histrionic personality disorder
- Wants to be in the centre of attention
- Discomfort when not in the centre of attention
- Use physical appearance to draw attention to self
- Impressionistic style of speech
- Overdramatic emotions
- Considers relationship to be more intimate
Narcissistic personality disorder
Excessive self love based on self image
- Grandiosity: entitlement, self-centredness, one is better than others
- Attention seeking
- Lacks empathy
- Envious of others/believes others are envious of him
- Arrogant
- Exploitative
Avoidant personality disorder
Persistent, pervasive tension and apprehension, characterised by avoidance of interpersonal contact/social activities due to fear of criticism or rejection; excessive preoccupation with facing criticism
CRINGES
Criticism preoccupies thoughts
Restraint in relationship due to shame
Inhibited in new relationships
Needs to be sure of being liked
Gets around activities needing interpersonal contact
Embarrassment prevents risk taking
Self-view: unappealing and inadequate
Dependent personality disorder (submissive, clingy)
Uncomfortable alone
Fear of inability to self-care
Eager to please
Others needs over their own
Allows others to make decision about their own lives
Dependent personality disorder (submissive, clingy)
Uncomfortable alone
Fear of inability to self-care
Eager to please
Others needs over their own
Allows others to make decision about their own lives
Obsessive compulsive personality disorder (perfectionist)
- Rigid perfectionism
- Excessive adherence to rules
- Extreme meticulous
- Difficult to change ideas
- Willing to forgo other things
A person must be at least ___ years old for a personality disorder to be made
18
Mainstay of treatment for personality disorder is
psychotherapy
Which personality disorder has the highest admission rate?
BPD
Symptom clusters of Borderline PD
- Impaired relatedness - intense unstable relationships with others, unstable sense of self, chronic emptiness
- Affective dysregulation** - affective instability, anger, frantic efforts to avoid abandonment
- Behaviour dysregulation - Impulsivitiy, suicidality, self injurious behaviour
Affective dysregulation is the most sensitive and specific for BPD
Ddx of BPD
(reasons in comparison to BPD)
PTSD
- Not pervasive and persistent
- Interpersonal distancing (unlike intense relationships)
- No fear of abandonment
- Presence of intrusive thoughts, avoidance symptoms
Bipolar Disorder
- Mood changes are SUSTAINED (unlike in BPD)
- Mood changes are often independent of external triggers
- No feelings of emptiness (in bipolar, emotions are felt very intensely)
Issues with BPD
- high co-morbs with depression, bipolar disorder, psychotic disorder and alcohol/substance abuse
- high risk of suicide and NSSI
- high risk of psych hospitalisations
- disruptions in interpersonal relationships
- impulsive acts could lead to forensic implications
- high chance of engaging in high risk activities
What is NSSI?
Non-suicidal self injury
Deliberate, repetitive, impulsive and non-lethal harming of oneself
- not culturally sanctioned
- may be found in individuals without any mental illness
Types of NSSI
Cutting, pinching, head banging, hair pulling, punching
Approach to BPD
- Assess risk!!! and determine disposition
- Review for the presence of any disorders and treat
- Safety planning with patient and family
- Refer for Dialectical Behavioural Therapy
- Consider pharmacotherapy (SSRIs, mood stabilisers, antipsychotics)
4 components of Dialectical Behavioural Therapy
DICE
1. Distress tolerance
2. Interpersonal effectiveness
3. Core mindfulness
4. Emotional regulation
Management strategies for ASPD
- Tarasoff’s rule: inform patient’s family, police that patient plans to harm xx
- Refer patient to Institute of Mental Health for assessment and admission under Mental Health Care and Treatment Act
What defence mechanism is associated with paranoid PD?
Projection
Differences between avoidant PD and social anxiety disorder?
Avoidant PD
- personality disorder
- longer duration, since childhood
- insidious onset
- believe that they deserve such anxiety, genuinely believes to be inferior
Social anxiety disorder
- anxiety disorder
- shorter duration, usually before childhood
- acute onset
- frustrated by their anxiety, have insight that their fears are irrational
