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9. Personality Disorders > Cluster B Personality Disorders > Flashcards

Cluster B Personality Disorders Flashcards

1
Q

what is the underlying pattern in ASPD

A

pattern of DISREGARD FOR, and VIOLATION OF, the rights of others

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2
Q

what is the underlying pattern in borderline PD

A

pattern of INSTABILITY in interpersonal relationships, self image, and affects and marked IMPULSIVITY

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3
Q

what is the underlying pattern in narcissistic PD

A

pattern of GRANDIOSITY, need for ADMIRATION and LACK OF EMPATHY

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4
Q

what is the underlying pattern in histrionic PD

A

a pattern of EXCESSIVE EMOTIONALITY and ATTENTION SEEKING

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5
Q

how many features are listed in criterion A for ASPD? how many do you need to make the diagnosis?

A

3/7

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6
Q

what is criterion A for ASPD

A

a pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years as evidenced by 3+ of:

  1. failure to confirm to social norms with respect to LAWFUL behaviours, 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 or AGGRESSIVENESS, as indicated by repeated PHYSICAL FIGHTS or ASSAULTS
  5. reckless disregard for safety of self or others
  6. consistent IRRESPONSIBILITY, as indicated by failure to sustain consistent work behaviour or honor financial obligations
  7. LACK OF REMORSE, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
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7
Q

what is the prevalence of ASPD in forensic populations

A

can be above 50%

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8
Q

what is the overall incidence of ASPD

A

0.2-3.3%
more men than women

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9
Q

is ASPD more common in first degree relatives of those with ASPD

A

yes

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10
Q

combination of what 2 disorders in childhood before age 10 confers higher likelihood of developing ASPD

A

childhood onset conduct + ADHD

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11
Q

are there neuroimaging correlates in ASPD

A

?structural and functional changes to the LIMBIC SYSTEM and PARALIMBIC systems –> may be related to the core features of psychopathology and antisocial personality disorder

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12
Q

list environemntal risk factors for ASPD

A

child abuse or neglect

unstable or erratic parenting

inconsistent parental discipline

parental mental health concerns

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13
Q

how does being adopted by people without ASPD affect a childs risk of developing ASPD, if their bio parents DID have ASPD

A

children born to parents with ASPD have higher risk of developing ASPD themselves, regardless if they are raised by bio parents or adopted out to a different home

BUT

a healthy adoptive family environment can REDUCE the risk of the individual developing ASPD

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14
Q

what disorder is often present before age 15 in those who go on to develop ASPD

A

conduct disorder

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15
Q

what makes the deceitfulness/manipulation of those with ASPD particular to this PD

A

it is for PERSONAL GAIN or PLEASURE

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16
Q

how might the extreme irresponsibility seen in ASPD manifest

A

significant periods of unemployment–> despite job opportunities, abandon jobs

repeated absences from work that are not justified

financial irresponsibility–> defaulting on debts, child support, dependents

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17
Q

what are some associated symptoms with ASPD

A

● Frequently lack empathy
○ Callous, cynical, contemptuous
● Inflated
○ Inflated + arrogant self-appraisal (e.g. ordinary work beneath them)
○ Excessively opinionated, self-assured, cocky
○ Glib, superficial charm, voluble, verbally facile (technical terms, jargon)
● Psychopathy
○ Have features of lack of empathy, inflated self-appraisal, superficial charm
○ More predic ve of recidivism in prison/forensic se ngs
● Sexual rela onships → irresponsible, exploita ve
○ Many partners, no sustained monogamous rela onship
● Irresponsible as parents
○ Malnutri on of child, minimal hygiene
○ Child’s dependence of neighbors/non-resident rela ves for food/shelter
○ Failure to arrange for caretakers for young child
○ Repeated squandering of money required for household
● Social func on
○ Dishonorable discharges from armed services
○ Fail to be self-suppor ng à may become impoverished, homeless
○ Penal ins tu ons
● More likely to die prematurely by violent means
○ Suicides, accidents, homicides

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18
Q

when comparing ASPD and narcissistic PD, what elements are unique to ASPD? Narcissistic?

A

ASPD–> aggression, deceit

narc–> need admiration; envies others; no hx conduct d/o or criminal behaviour

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19
Q

how do the motivations vary between borderline and ASPD when it comes to manipulation of others?

A

borderline–> manipulate to gain nurturance

ASPD–> manipulate for pleasure and profit

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20
Q

what is a screening tool that can be used in ASPD

A

PCL-R psychopathy checklist by Robert D Hare

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21
Q

is individual psychodynamic psychotherapy recommended in ASPD

A

no

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22
Q

what pharmacological treatments are recommended in ASPD? what do they target?

A

pharm tx of AGGRESSION–> poor evidence for all meds suggested

VPA (impulsive behaviour)
carbamazepine (impulsive behaviour)
SSRIs
lithium
atypical APs
typical APs
beta blockers (aggression)

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23
Q

what psychological interventions are recommended for ASPD

A

?group CBT for specific symptoms like impulsivity, interpersonal difficulties, challenging behaviours

PEER THERAPY settings may be more effective than individual therapy

general therapy principles: set FIRM LIMITS, use MENTALIZING based approaches, therapist must manage own counter transference

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24
Q

how does ASPD change over time

A

tends to become less evident and remit esp in 30s

more likely to die prematurely due to violent means

more likely to reoffend in criminal situations

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25
Q

how many features are listed in criterion A for narcissistic PD? how many are required?

A

5/9

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26
Q

what is criterion A for narcissistic PD

A

pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by 5+ of:

  1. has a grandiose SENSE OF SELF IMPORTANCE (i.e exagerrates achievements and talents, expects to be recognized as superior without commensurate achievements)
  2. is preoccupied with fantasies of UNLIMITED SUCCESS, power, brilliance, beauty, or ideal love
  3. believes that he or she is “SPECIAL” and unique and can only be understood by, or should associate with, other special or high status people (or institutions)
  4. requires EXCESSIVE ADMIRATION
  5. has a sense of ENTITLEMENT (i.e unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations)
  6. is INTERPERSONALLY EXPLOITATIVE (i.e takes advantage of others to achieve his or her own ends)
  7. LACKS EMPATHY: is unwilling to recognize or identify with the feelings and needs of others
  8. is often ENVIOUS of others or believes that others are envious of him or her
  9. shows ARROGANT, HAUGHTY behaviours or attitudes
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27
Q

what are the two types of narcissist?

A

overt/oblivious

covert/hypervigilant

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28
Q

who coined the idea of a covert narcissist

A

Kohut

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29
Q

who coined the idea of the overt narcissist

A

Kernberg

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30
Q

what patient population was Kohut seeing that lead to his description of the covert narcissist

A

relatively well functioning outpatients who could afford psychoanalysis

professionals who described vague feelings of emptiness/depression, felt slighted by others

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31
Q

what patient population was Kernberg seeing that lead to his description of the overt narcissist

A

inpatients/outpatients who were more primitive, more arrogant, more aggressive

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32
Q

describe Kernbergs understanding of the overt narcissist

A

viewed the narcissist’s grandiosity and exploitation as evidence of ORAL RAGE which results from the EMOTIONAL DEPRIVATION caused by an indifferent and spiteful parent

when this occurs, the childs sense of being special provides an emotional ESCAPE from perceived threat/indifference by the parent

grandiosity, entitlement that develops protects a split off of the “real self”

here, the “real self” contains strong, unconscious feelings of ENVY, DEPRIVATION, FEAR and RAGE–> thus the defensive structure in narcissistic personality disorder is remarkably similar to one wiht borderline PD

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33
Q

describe Kohut’s understanding of the covert narcissist

A

Kohut believed narcissism is DEVELOPMENTALLY ARRESTED as an early stage, when an individual needs a FEEDBACK ENVIRONMENT to maintain their cohesive selves

he formulated that self-object transferences recreate the situation with parents that was not fully successful during childhood (mirroring, idealizing)

when a narcissist does not get the response they need (i.e an empathic deficit) they are prone to FRAGMENTATION OF SELF (experience a narcissistic injury)

common concepts introduced by Kohut are:
1. Mirror transference–> im great, look at me!
2. idealizing transference–> you are great, i’m great because i’m with you
3. twinship transference–> you are great and i am just like you

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34
Q

how might a covert narcissist present

A

highly SENSITIVE

INHIBITED, shy

DIRECTS ATTENTION towards OTHERS

listens carefully for evidence of SLIGHTS/CRITICISMS

easily HURT FEELINGS–> prone to feeling ASHAMED or humiliated

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35
Q

how might an overt narcissist present

A

NO AWARENESS of impact on others

arrogant and AGGRESSIVE

self ABSORBED

need to be CENTER OF ATTENTION

have “sender but no receiver”

closely matches DSM IV criteria

generally much harder to treat

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36
Q

what is the prevalence of narcissistic PD

A

0-6%

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37
Q

does the narcisstist have robust self esteem

A

no, self esteem is FRAGILE

Vulnerability in self-esteem
○ Very sensi tive to injury (from cri ticism or defeat)
○ May not show outwardly → feel humiliated, degraded, hollow, empty
○ React with disdain, rage, defiant countera ttack
○ May lead to social withdrawal
○ Appearance of humility to mask/protect grandiosity

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38
Q

how do narcissists treat those who disappoint them

A

devalue them

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39
Q

how do narcissists view the needs of others

A

when recognized at all, they are viewed disparagingly as a weakness

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40
Q

(slide with symptom presentation of narcissists in greater detail)

A
  1. Grandiose sense of self-importance
    ○ Overes mate abili es, inflate accomplishments, boas ul, preten ous
    ○ Assume others a ribute same value, surprised if not praised
  2. Fantasies of unlimited success, power, brilliance, beauty
    ○ May ruminate about “long overdue” admira on, privilege
    ○ Compare themselves favorably to famous/privileged people
  3. Believe they are superior, special, unique
    ○ Expect others to recognise them as such
    ○ Can only be understood or assoc with other special/high-status people
    ■ May a ribute “unique”, “perfect”, “gi ed” quali es to those associated
    ■ Self-esteem enhanced by idealized value they assign to those associated
    ■ Believe their needs are special, beyond ordinary people
    ○ Insist on having only the “top” person, or being affiliated with the “best”
    ○ Devalue those who disappoint them
  4. Require excessive admira on
    ○ Self-esteem very fragile
    ○ May be preoccupied with how they’re doing, how favourably regarded à need constant
    admira on
    ○ Expect arrival to be greeted with great fanfare, astonished if others do not covet their
    possessions
    ○ May fish for complements, with great charm
  5. Sense of en tlement
    ○ Unreasonable expecta on of especially favorable treatment
    ○ Expect to be catered to → frustrated if not
  6. Interpersonal exploita on (conscious or unwi ng)
    ○ Due to sense of en tlement + lack of empathy
    ○ Expect to be given whatever they want, no ma er effect on others
    ○ Only form rela onships if other person seems likely to help them
    ■ Advance their purposes, enhance their self-esteem ○ O en usurp special privileges, extra resources
  7. Lack of empathy
    ○ Difficulty recognizing desires, subjec ve experiences, feelings of others
    ○ Assume others totally concerned about their welfare
    ○ Discuss own concerns in inappropriate + lengthy detail
    ○ O en contemptuous + impa ent when others talk about themselves
    ○ May be oblivious to hur ul remarks they may inflict (“My new gf is epic!” to ex)
    ○ When recognized needs of others, they are viewed disparagingly as weakness
    ○ Emo onal coldness, lack of reciprocal interest
  8. O en envious of others, believe others envious of them
    ○ Begrudge others’ success à feel they deserve instead

○ Harshly devalue contribu ons of others
1. Arrogant/haughty behaviors, patronizing a tudes
○ Complain about others’ “rudeness” or “stupidity”
○ Condescending evalua on of physicians

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41
Q

what factors of the narcissistic personality impact interpersonal functioning

A

entitlement, need for admiration, lack of empathy

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42
Q

(associated symptoms with narcissistic PD)

A

● Vulnerability in self-esteem
○ Very sensi ve to injury (from cri cism or defeat)
○ May not show outwardly → feel humiliated, degraded, hollow, empty
○ React with disdain, rage, defiant countera ack
○ May lead to social withdrawal
○ Appearance of humility to mask/protect grandiosity
● Impaired interpersonal rela ons
○ Problems from en tlement, need for admira on, lack of empathy
● May have impaired voca onal func oning
○ Unwillingness to take risk (where defeat possible)
○ Achievement may be disrupted due to intolerance of cri cism/defeat
● Psychiatric illness
○ Sustained feelings of shame/humilia on → depressed mood
○ Sustained grandiosity → hypomania
○ Anorexia nervosa, SUDs
○ Histrionic, borderline, an social, paranoid

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43
Q

are there biological treatments for narcissistic PD

A

no

44
Q

what psychological treatments are recommended for narcissistic PD

A

mentalization-based therapy

transference-focused psychotherapy

schema-focused psychotherapy

DBT for significant self destructive behaviours

**individual psychotherapy is viewed by many as the basic treatment of choice–> can be very challenging for therapists, and confrontation and mirroring techniques are suggested

45
Q

what is the course and prognosis of narcissistic PD

A

impairment can be severe–> may include marital problems and interpersonal relationship conflicts

may face occupational difficulties and show an unwillingness to take risks in competitive or other situations in which defeat is possible

may have more difficulties in the aging process–> i.e midlife crisis

46
Q

how many features are listed in criterion A for borderline PD? how many are required

A

5/9

47
Q

what is a mnemonic to remember the criteria for borderline PD

A

I3 – A3 – ESP

Identity
Interpersonal relationships
Impulse control (in 2+ areas of life)

Affect (irritable/labile)
Anger
Abandonment

Empty
Suicidal
Paranoia (micro psychosis)

48
Q

what is criterion A for borderline PD

A

pervasive pattern of INSTABILITY in interpersonal relationships, self image, affects and marked IMPULSIVITY beginning in early adulthood, present in a variety of contexts –needs 5+ of:

  1. frantic efforts to avoid real/perceived ABANDONMENT
  2. pattern of UNSTABLE and INTENSE interpersonal relationships
  3. marked and persistently UNSTABLE SELF IMAGE or sense of self
  4. impulsivity in 2+ areas that are potentially self damaging (i.e spending, sex, substance use, reckless driving, binge eating)
  5. recurrent SUICIDAL BEHAVIOUR, gestures or threats, or self mutilating behaviour
  6. affective INSTABILITY due to MARKED REACTIVITY of mood (episodic intense dysphoria, irritability, anxiety usually lasting hours-days)
  7. chronic feelings of EMPTINESS
  8. inappropriate INTENSE ANGER or difficulty controlling anger (frequent displays of temper, constant anger, recurrent physical fights)
  9. transient stress related PARANOID IDEATION or severe DISSOCIATIVE symptoms
49
Q

what is a key heritable factor shared with parents in borderline PD

A

impulsivity

50
Q

what is the prevalence of borderline PD

A

1.6-6.6%

51
Q

what % of psychiatric inpatients meet criteria for borderline PD

A

20%

52
Q

is borderline PD more common in men or women

A

women 3:1 men

53
Q

borderline PD is how much more common amongst first degree biological relatives of those with borderline PD

A

4-10x more common

54
Q

what is the heritability of borderline PD

A

35-67% based on twin studies

55
Q

what neurobiological differences are seen in those with borderline PD

A

less effective modulation of amygdala (increased activity in amygdala)
–> when instructed to use a cognitive strategy to reduce emotional intensity, unable to fully activate regions involved in cognitive control–> DORSOLATERAL ACC, INFERIOR FRONTAL GYRUS–> leads to less effective modulation of amygdala

DEFICITS in fronto-limbic connections, frontal lobe functioning

56
Q

what is often found in the childhood histories of those wtih borderline PD

A

physical/sexual abuse

neglect

hostile conflict

early parental loss

57
Q

what % of those with borderline PD complete suicide

A

8-10%

58
Q

what often precipitates threats of suicide in borderline PD

A

threats of separation/rejection or increased responsibility

59
Q

(symptom presentation in borderline PD)

A
  1. Fran c efforts to avoid real or imagined abandonment
    ○ Percep on of impending separa on/rejec on, loss of external structure
    ○ May lead to profound changes in self-image, affect, cogni on, behavior
    ○ Very sensi ve to environmental circumstances
    ○ Intense abandonment fears + inappropriate anger
    ■ Even if me-limited separa on or unavoidable changes (e.g. end of apt, few min late
    ■ “Abandonment” implies they are “bad”
    ○ Intolerance of being alone, needing to have other people with them
    ○ Fran c efforts to avoid abandonment → may be impulsive, suicidality, self-harm
  2. Unstable + intense rela onships
    ○ May ini ally idealize caregivers/lover, demand me ++, share in mate details too early
    ○ May quickly switch to devaluing, other person doesn’t care/give enough, not “there”
    enough
    ○ CAN empathize and nurture others, but only with expecta on other person will be there
    (to meet own needs on demand)
    ○ Sudden + drama c shi s in view of others (seen as beneficent supports vs cruelly
    puni ve)

■ May reflect disillusionment with caregiver whose nurturing quali es were idealized or whose rejec on/abandonment is expected
3. Unstable self-image or sense of self
○ Sudden + drama c shi s in self-image → shi ing goals, values, voca onal aspira ons
■ Career, sexual iden ty, values, types of friends
○ Image usually based on being bad or evil
○ May feel they do not exist at all
■ Usually happens when lacking meaningful rela onship, nurturing, support ○ Worse performance in unstructured work, school situa ons
4. Impulsivity, in 2+ areas, poten al self-damaging
○ Gamble, spend irresponsibly, binge eat, abuse substances, unsafe sex, driving
5. Recurrent suicidal behavior, gestures, threats, self-mu la on
○ Completed suicides in 8-10% of such individuals
○ O en reason presen ng for help
○ Precipitated by threats of separa on/rejec on or ↑ responsibility
○ Self-harm may occur during dissocia ve experiences
■ Reaffirms ability to feel or ridding sense of being evil
6. Affec ve instability due to marked mood reac vity
○ Intense episodic dysphoria, irritability, anxiety (hours-days)
○ Baseline dysphoria → disrupted by anger, panic, despair (rarely relieved) ○ May reflect extreme reac vity to interpersonal stresses
7. Chronic feelings of emp ness
○ Easily bored, may constantly seek something to do
8. Inappropriate + intense anger, difficulty controlling anger
○ Extreme sarcasm, bi erness, verbal outbursts
○ O en when caregiver is neglec ul, withholding, uncaring, abandoning
○ O en followed by shame + guilt → contribute to feeling of being evil
1. Transient, stress-related paranoid idea on + dissocia on
○ Generally insufficient for addi onal diagnosis
○ Abandonment (real or perceived) frequently precipitates à return (real or perceived) of
caregiver’s nurturance may result in remission of Sx

60
Q

(associated symptoms in borderline PD)

A

Pa ern of undermining themselves
○ When goal about to be realized (dropping out, regressing, breaking up)
● Stress-related psycho c symptoms
○ Hallucina ons, body-image distor ons, ideas of reference, hypnagogic
○ May hear name being called, see shadowy figures/illusions
● May feel more secure with transi onal objects (vs interpersonal rela onship)
○ e.g. pets, inanimate possessions ● Premature death from suicide
○ (up to) 80% have suicidal behaviors

○ 8-10% complete
○ Especially if co-occurring depressive disorder or SUDs
○ Recurrent job loss, interrupted educa on, separa on, divorce = common

61
Q

what % of those with borderline PD have suicidal behaviours

A

up to 80%

62
Q

what comorbidities are common in borderline PD

A

mood disorders
PTSD
ADHD
eating disorders (BULIMIA)
SUDs
other PDs

*comorbidity is the rule not the exception

63
Q

are medications generally indicated in borderline PD

A

no, generally not–> only to treat comorbidities or as adjunctive to therapy

NICE guidelines–> drug treatment should not be used specifically for borderline PD or for individual sx or behaviour assoc with the disorder

cochrane–> total borderline PD severity is not influenced by any drug

64
Q

why might you consider SNRIs in borderline PD with comorbid dep/anx rather than SSRIs

A

safer in OD

65
Q

why use antidepressants in borderline PD

A

to treat comorbid disorders

may reduce anger–moderate effect

?affective instability, interpersonal sensitivity?

NO EFFECT ON MOOD (if borderline PD alone)

66
Q

when to use mood stabilizers in borderline PD

A

if comorbid bipolar

LAMOTRIGINE may reduce anger/aggression, lability, impulsivity

67
Q

when to use atypical antipsychotics in borderline PD

A

if brief psychotic symptoms

OLANZAPINE–> small to moderate effect on anger, psychotic sx, affective instability, anxiety

quetiapine–> equivocal evidence, one study = may have benefit in aggression, but 2 other negative studies

abilify, ziprasidone–> poor to no evidence

68
Q

when to use benzos in borderline PD

A

dont–more harm than benefit

69
Q

what other med/supplement might you suggest in borderline PD

A

omega 3 fatty acids

3 studies

some benefit in suicidality, depression, irritability, aggression

70
Q

what effect does comorbid borderline PD + MDD have on treatment of MDD with ECT

A

if have both, there seems to be significantly less response + earlier relapse than if have MDD alone and receiving ECT

71
Q

does rTMS help borderline PD

A

maybe–> one study found improvement in a task measuring impulsivity

72
Q

describe how the therapist acts in therapy with someone with borderline PD

A

highly active, responsive, validating

clear roles and responsibilities of therapist and patient

emphasis on ability of patient to control behaviour

limit setting

73
Q

what modalities are recommended for borderline PD psychotherapy

A

DBT–best

CBT

mentalization based, schema, transference, psychodynamic

74
Q

what is a mnemonic taught in DBT that addresses interpersonal effectiveness

A

DEARMAN

Describe

Express

Assert

REinforce

Mindful

Appear confident

Negotiate as needed

75
Q

what are the elements of DBT

A

DBT → ‘gold standard’, distress tolerance, iden fying feelings and not react, develop
coping skills
■ Mindfulness–> Wise Mind (Rati onal Mind + Emo tional Mind)
■ Distress Tolerance
■ Emo tional Regulati on
■ Interpersonal Effec tiveness–> DEARMAN: Describe, Express, Assert, Reinforce, Mindful, Appear confident, Negoti ate as needed

76
Q

what is the gold standard tx for borderline PD

A

DBT

77
Q

is psychodynamic therapy encouraged in treatment of borderline PD

A

NO

78
Q

what is schema focused therapy

A

integrative cognitive therapy–> behavioural, cognitive and experiental techniques

focus on therapeutic relationship, daily life outside therapy, past traumatic experiences

encourages ATTACHMENT between therapist and patient–> “LIMITED REPARENTING”

goal is STRUCTURAL CHANGE to PERSONALITY

addresses 4 dysfunctional schema modes

79
Q

what is the goal of schema focused therapy

A

structural change to personality

80
Q

how long does schema focused therapy last and how often are sessions

A

twice weekly x 3 years

81
Q

what are the 4 dysfunctional schema modes addressed in schema focused therapy

A

mode = negative pattern of thinking, feeling, behaving

  1. detached protector
  2. punitive parent
  3. abandoned/abused child
  4. angry/impulsive child
82
Q

what is the mechanism by which schema focused therapy attempts to instill change

A

by substituting negative patterns of thinking, feeling behaving with healthier alternatives

83
Q

what is mentalization based therapy

A

psychodynamic orientation

focus on increasing capacity for mentalization

84
Q

what is “mentalization”

A

process of imagining the thoughts and feelings in one’s own and other’s minds in order to understand interpersonal interactions

differentiation of own mental states from those of others

shapes our understanding of other and ourselves

central to human communication and relationships

enables us to understand misunderstandings

85
Q

why might mentalization therapy be helpful in borderline PD

A

borderline PD sx arise when patient stops mentalizing, leading to pathological certainty about others motives, disconnection from the grounding influence of reality, and desperate need for proof of feelings through the actions of others

attachment interactions become “hyperactivated” and feed into distress, difficulty coping rather than providing safety and security

86
Q

what is the mechanism by which mentalization based therapy addresses the deficits of borderline PD

A

stabilized borderline PD problems by strengthening the patient’s capacity to mentalize under the stress of attachment activation

therapist stance = curious, not knowing, intended to help patient assess interpersonal situations and their emotional responses, through a more grounded, flexible and benevolent lens

87
Q

what is transference focused therapy

A

a MANUALIZED, psychoanalytically oriented therapy

designed to address key features of personality disorder at the borderline level of organization –> identify DIFFUSION, primitive defense mechanisms, unstable reality testing, internall/externally expressed aggressions

patients inherent INTERPERSONAL DYNAMIC EMERGES in the transference and are jointly examined to resolve the splits between the good and bad that drive instabilities in affect and relationships

88
Q

what is the goal of transference based therapy

A

more balanced, integrated ways of thinking about oneself and others

89
Q

how often and for how long do you do transference based therapy

A

twice weekly x 3 years, typically under supervision

90
Q

should you admit the borderline patient

A

data suggests that some do regress in hospital but some do benefit from a short admission

91
Q

when in the lifespan is the impairment + risk of suicide in borderline PD the highest

A

young adult years, then wanes

92
Q

what is the typical course of borderline PD

A

considerable variability

most common = chronic instability in early adulthood

episodes of serious affective, impulsive dysregulation

high levels of health and MH resource use

sx often LIFELONG
–can improve with therapeutic intervention, often in year 1

during age 30-40–> greater stability

after 10 years—> 50% no longer meet full criteria

93
Q

which symptoms improve over the lifespan in borderline PD

A

“acute sx”–> impulsivity, self harm/SI, help seeking suicidal efforts–> resolve early

“chronic, trait based”–> chronic dysphoria, loneliness, emptiness, fear of abandonement–> improve but to a LESSER degree

94
Q

what is a screening tool for borderline PD

A

Maclean Borderline Personality Screen

95
Q

how many features are listed in criterion A for histrionic PD? how many are needed for diagnosis?

A

5/8

96
Q

what is criterion A for histrionic PD

A

a pervasive pattern of EXCESSIVE EMOTIONALITY and ATTENTION SEEKING, beginning by early adulthood and present in a variety of contexts, as indicated by5+ of:

  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 provicative behaviour
  3. displays RAPIDLY SHIFTING and SHALLOW expression of emotions
  4. consistently uses PHYSICAL APPEARANCE to draw attention to self
  5. has style of speech that is excessively impressionistic and lacking in detail
  6. shows SELF DRAMATIZATION, theatricality, and exagerrated expressions of emotion
  7. is SUGGESTIBLE
  8. considers relationships to be more intimate than they actually are
97
Q

what is the prevalence of histrionic PD

A

1.8%

F>M

98
Q

how might someone with histrionic PD come off to others at first

A

often lively, dramatic, tends to draw attention to self

may initially CHARM, with enthusiasm, openness, FLIRTACIOUSNESS

charm WEARS THIN–> continually demands attention

99
Q

what suicide risk is associated with histrionic PD

A

unknown–> clinical experience suggests increased risk of suicidal gestures

threats to get attention, coerce better caregiving

100
Q

there are increased rates of what other disorders in those with histrionic PD

A

somatic symptom disorder

conversion disorder

MDD

101
Q

(associated symptoms with histrionic PD)

A

● Difficulty achieving emoti onal in timacy (roman c, sexual)
○ O en act out a role (vic m, princess) à but unaware
■ May seek to control partner (emo tional manipulati on + seduc tion but also
dependency)
○ Impaired rela tionship with same-sex friends (sexually provoca tive .: threat)
○ May alienate friends (demanding a en on)
○ O en become depression, upset when not center of a en on
● Crave novelty, s imulati on, excitement
○ Tendency to become bored → want immediate sat sfacti on
○ O en intolerant of situa ons involving delayed gra fica on
○ Inti al enthusiasm with jobs/projects à interest may lag quickly
○ May neglect long-term rela tionships à excitement of new rela tionships
● Suicide risk = unknown
○ Clinical experience → ↑ risk of suicidal gestures
■ Threats to get a en on, coerce be er caregiving

102
Q

what is the treatment of choice for histrionic PD

A

psychotherapy

particular focus on the therapeutic alliance

behavioural techniques, assertiveness training

103
Q

what is a mnemonic to remember the criteria for ASPD

A

CALLOUS MAN

Conduct disorder before at 15
+ Current age is above 18

Antisocial acts
+commits acts that are grounds for ARREST

Lies frequently

Lacunae
+Lacks a superego

Obligations not honored

Unstable–cant plan ahead

Safety of self and others ignored

Money problems–spouse and children not supported

Aggressive
+ Assaultive

Not occurring exclusively during SCZ or mania

104
Q

what is a mnemonic to remember the features of borderline PD

A

(or use I3 A3 ESP)

I RAISED A PAIN

Identity disturbance

Relationships are unstable
Abandonment is frantically avoided
Impulsivity
Suicidal gestures
Emptiness
Dissociative symptoms

Affective instability

Paranoid ideation (stress related and transient)
Anger is poorly controlled
Idealization followed by devaluation
Negativistic (undermine themselves with self defeating behaviour)

105
Q

what is a mnemonic to remember the features of histrionic PD

A

I CRAVE SIN

Inappropriate behaviour–seductive, provocative

Center of attention
Relationships perceived to be closer than they are
Appearance most important
Vulnerable to other’s suggestions
Emotions exagerrated

Shifting emotions
+ Shallow
Impressionistic manner of speaking (lack of detail)
Novelty cravings

106
Q

what is a mnemonic to remember the features of narcissistic PD

A

A FAME GAME

Admiration required in excessive amounts

Fantasizes about unlimited success, brilliance
Arrogant
Manipulative
Envious of others

Grandiose sense of importance
Associates with special people
Me first attitude
Empathy lacking for others

9. Personality Disorders (4 decks)

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