Disordered Personalities

Question 1

18-20th century influences

Answer 1

• Idea that there are distinct personality types has existed for centuries e.g. ancient Greek philosophy
• Longstanding idea that there are pathological or maladaptive personalities, in the absence of other psychiatric symptoms.
• Pathological does not refer to being ill or mentally ill but some4thing that is deviant from normal personality
• Philippe Pinel’s “Manie sans delire”, impulsive violence without any other psychiatric symptoms.
• Pinel use the term to describe patients who did not have typical psychiatric symptoms but did have problems with regulating emotions e.g. impulsivity
• Kraepelin’s seven types of psychopathic personalities resulting from an ‘inborn defect.
  
  • Psychopathic here means abnormal or pathological or deviant
• Freud’s work connected childhood experiences to personality traits and types.
• For Freud, maladaptive personalities stemmed from early childhood experiences
• All of these emphasised behavioural difficulty that was abnormal compared to society and persists across different cultures

Question 2

21st century understanding

Answer 2

• Personality Disorders refer to a pattern of experiences and behaviour that affects cognitions, emotions, relationships, and behaviour.
• Differs from what is expected within the dominant culture
• Typically emerges by late adolescence or early adulthood and is stable and long-standing
• Causes significant personal distress or problems in functioning and is considered maladaptive
  
  • Cause impairments in peoples life e.g. cannot develop career, low self esteem, struggle socially
• Covers a wide range of experiences and behaviours relating to someone’s personality

Question 3

DSM classification

Answer 3

• A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in 2 (or more) of the following areas: cognition, affectivity, interpersonal functioning, or impulse control.
  
  • Behaviour should be very different and to what is expected of people
• B. Inflexible and pervasive across a broad range of personal and social situations
• C. Leads to clinically significant distress or impairment in social, occupational or other important areas of functioning
  
  • someone should experience mental distress in order to be diagnosed or experience significant deficits in areas of life e. for example brain injury can cause a change in personality
• D. Stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood
• E. Not better explained as a manifestation or consequence of another mental disorder.
  F. Not attributable to the physiological effects of a substance (e.g. - a drug of abuse, a medication) or another medical condition

Question 4

cluster A- odd/eccentric

Answer 4

• Paranoid
  
  • Suspicious of the motives of others
• Schizotypal
  
  • Bodily sensations that do not coincide with experiences but not strong enough to be psychosis
  • Strange thinking
• Schizoid
  
  • Restricted range of emotions
    Detached socially or emotionally

Question 5

Cluster B- Dramatic/Erratic (impulsive behaviour, not much restraint, extreme and intense emotions. All the disorders here are characterised by a lack of empathy)

Answer 5

• Antisocial
  
  • Risk taking, manipulating, deceitful
• Narcissistic
  
  • Feeling superior to others
• Histrionic
  
  • Exaggerate emotions, attention seeking often relating to seductive behaviour
• Borderline
  
  • Pattern where someone has unstable emotions and relationships e.g. going from idolising their partner to devaluing them in a short period of time
  • Intense fear of abandonment
    Also associated with disassociation- disengage with themselves or reality

Question 6

cluster c- anxious, fearful

Answer 6

• Avoidant
  
  • Relates to a fear of criticism and being negatively evaluated so avoid situations where this would happen
• Dependent
  
  • Fear about making decisions independently, relying heavily on people
• Obsessive-compulsive
  Perfectionism, following rigid rules

Question 7

prevalence

Answer 7

• Around 1 in 16 persons worldwide are given a PD diagnosis at some point (Huang et al., 2009 – 21.162 participants).
• Around 1 in 20 to 25 adults are diagnosed with a personality disorder in the UK (Coid et al., 2006; Singleton et al., 2001).
• Prevalence varies across socio-demographic factors (> in those who are separated or unemployed and live in urban areas; e.g. Coid et al., 2006)
• Far higher in healthcare and forensic settings compared to the general community (e.g., Singleton et al., 1998).
• UK prisons- 60-70% have at least 1 personality disorder- exposed to criminal disorder and stressors which cause personality disorders
  Varies cross-culturally, tends to be lowest in Western Europe (Huang et al., 2009).

Question 8

stability across raters

Answer 8

• Inter-rater reliability (IRR) assesses whether different clinicians give the same diagnosis to a given individual.
• Perfect reliability (κ = 1) means that different clinicians always arrive at the same diagnosis for a given individual.
• Can be tested in field trials.
• IRR for DSM PD diagnoses vary
• Between clinicians (e.g., Zanarini et al., 2000)
• Clusters (e.g., Tyrer et al., 2007)
  Measurement instruments (e.g., Perry, 1992)

Question 9

stability over time

Answer 9

• Test-retest reliability measures whether the same individual would be given the same diagnoses at two different points in time.
• Baca-Garcia et al (2007) studied PD diagnoses of > 10,000 patients in a Spanish hospital over time:
• Ppts were assessed based on a diagnostic classification manual (ICD-10).
• 34.1% who received a PD diagnosis in the first evaluation retained the same diagnosis in their last evaluation.
• 26.3% who received a PD diagnosis in the last evaluation received the same diagnosis in their first evaluation.
• The idea that PDs are long-standing and stable patterns of experiences is fundamental to the diagnosis.
• Symptoms for some PDs decrease over time (), symptoms for other PDs increase (e.g., D’Huart et al., 2003; Johnson et al., 2000; Seivewright et al., 2002).
• Morey & Hopwood (2013) reviewed four longitudinal studies:
  
  • Moderate differential stability, i.e. some stability in terms of persons retaining the same ‘rank’ in symptom scores.
  • Less absolute stability, i.e. symptom scores tend to decline within the individual.
    Stability depends on measures and samples used

Question 10

comorbidity

Answer 10

• High comorbidity with other PDs:
• Coid et al (2006): study in UK adults (N = 626).
• Many ppts with a cluster A PD were also diagnosed with a cluster C (48%) or B (32%) PD
• 27% of ppts with a cluster C also had a cluster B diagnosis
• High comorbidity with non-PD diagnoses:
• Those with a PD diagnosis are more likely to have three or more ‘Axis I’ diagnoses (Huang et al., 2009).
• Conceptual overlap between diagnostic criteria of PDs and other disorders in the DSM.

Question 11

dimensional perspectives

Answer 11

• Personality consists of personality traits that range on a dimension and vary in degree, not in kind.
• Thus, PD’s might be extreme variants of normal personality traits that lead to mental distress.
• Widiger & Simonsen (2005) found that DSM diagnostic criteria overlap well with high or low traits on common personality dimensions.
• FFM proposals for Personality Disorder (Widiger & Mullins-Sweat, 2009; Trull & Widiger, 2013).
• Could help account for diagnostic comorbidity and temporal stability.
• (Trull & Widiger, 2022)
• What traits can be high or low and overlap with [personality disorders
• Use extreme traits to map onto different personality disorders
• Can help explain why there is so much comorbidity, potentially improves stability, personality traits are more stable
  Good for treatment planning

Question 12

DSM 5- TR alternative model, section III

Answer 12

• A. Significant impairments in i) self-identity and ii) interpersonal (empathy or intimacy) functioning.
• Scored from 0 – 4 (no impairment – extreme impairment)
• Diagnosis requires a moderate impairment
• B. One or more pathological personality trait domains or trait facets, each consisting of sub-traits:
• Negative affectivity; Detachment; Antagonism; Disinhibition; and Psychoticism

Question 13

trauma

Answer 13

• Increasing interest in the role of early childhood trauma (e.g. physical, emotional, or sexual abuse and neglect) in mental distress.
• Kessler et al (2010): WHO mental health survey on 50,000 ppts in 21 countries
• Childhood adversities, such as childhood abuse, neglect, and parental mental health problems, were the strongest predictors of DSM-IV disorders
• Accounted for 29.8% of all forms of mental distress
• Cumulative effect, i.e. the more trauma someone is exposed to, the larger the impact on mental health (e.g. McKay et al., 2021).
• Meta-analysis of 24 studies on trauma experienced in childhood and adolescence, and mental health outcomes in adulthood.
• All forms of trauma were associated with a higher likelihood to be diagnosed with a mental health issue.
  Strongest increase in likelihood for those who had been exposed to multiple forms of trauma, and those who had been both a victim and perpetrator of specific forms of trauma (i.e. bullying).

Question 14

trauma and PD

Answer 14

• Experiences associated with the term ‘personality disorders’ are very closely associated with childhood abuse.
• Childhood trauma increases the likelihood to be diagnosed with a PD in later life (e.g., Battle et al., 2004; Bozzatello et al., 2021; Johnson et al., 2000; Hailes et al., 2019).
• Children in the Community Study (Cohen, 2005; Johnson et al., 2000):
  
  • Interviewed 639 adolescents and mothers in New York at different timepoints.
  • Ppts who experienced childhood abuse or neglect were four times more likely to be diagnosed with a DSM-IV PD in later life.
    Different types of childhood abuse related to different PDs

Question 15

maladaptive personality traits

Answer 15

• Back et al (2021) reviewed evidence for the relationship between childhood trauma, personality functioning, and maladaptive traits (N = 7):
  
  • Detachment and psychoticism associated with childhood trauma, particularly emotional abuse and neglect
  • Negative affectivity and antagonism associated with having experienced childhood trauma
  • Responses similar to trauma-associated avoidance and trauma-reactive dissociation (disconnection from thoughts, feelings, memories, identity, behaviour).
    PDs might be interpreted as a coping response to trauma, similar to PTSD.

Question 16

traumagenic models

Answer 16

• Stress-induced neurodevelopmental changes, specifically dysregulation of the HPA axis (e.g. Read et al., 2014; Teicher et al., 2016).
• Influences brain development in areas such as the frontal lobe and hippocampus.
  Buffering (or exacerbating) impact of the environment.

Question 17

early maladaptive schemas

Answer 17

• EMS (Young, 1990; Young et al., 2003) are strongly held and inflexible beliefs about the self, others, or the world.
• Develop during childhood, in response to early experiences and relationships with caregivers.
• Can lead to dysfunctional thoughts and emotions when triggered by a situational factor.
• Distinction between 18 types of EMS across five domains:
  
  • Disconnection and rejection
  • Impaired autonomy and performance
  • Impaired limits
  • Other-directedness
  • Hypervigilance and inhibition
• Carr & Francis (2010): cross-sectional study in US ppts (N = 178)
• Self-report measures for PD symptoms and EMS
• Various relationships between PD symptoms and EMS, e.g.
  
  • Paranoid PD ~ the expectation that others will be hurtful or abusing, or cheat and lie (+)
  • Schizoid PD ~ idea that one should inhibit spontaneous reactions, feeling that one is socially isolated; (+)
  • OCPD ~ Idea that you should strive for perfection to avoid criticism (+)
    Avoidant PD ~ belief that one is superior to others (-)

Question 18

limitations

Answer 18

• Variability across studies in definitions and measurement of ‘childhood trauma’.
• Studies largely rely on self-report, with the risk of biases
• Studies based on DSM categories might be unable to identify more fine-grained effects and differences due to the categorical system.
• Largely based on Western samples - there are cross-cultural differences (and biases) in the development and diagnosis of PDs.
• Difficult to disentangle the effect of different types of trauma on different types of personality traits.

Question 19

power threat meaning framework

Answer 19

(Johnstone & Boyle, 2018)
- Developed as an alternative to traditional diagnostic models
- It is a structure for identifying patterns in emotional distress, unusual experiences and troubling behaviour
- Links people’s life experiences to mental distress to help make sense of distress
- Considers the role that power and trauma play in mental distress

Question 20

diagnostic label

Answer 20

• Diagnosis can provide access to services (Perkins et al., 2018).
• One of the most stigmatised diagnostic categories, even by clinicians (e.g. Lewis & Appleby, 1988).
• Service users seen as ‘time-wasters, difficult, manipulative, bed-wasters, or attention seeking’ (NIMHE, 2003, p.20).
  Lack of specialised services for PD treatment.

Question 21

diagnostic bias

Answer 21

• White service users are more likely to be given a PD diagnosis (McGilloway et al., 2010)
• Ethnic minorities underrepresented in referrals to PD services (Garrett et al., 2011)
• DSM/ICD classifications are based on Western ideas about personality function and dysfunction
• Ethnic minorities less considered for PDs, therefore seem to be overlooked in diagnosis and treatment (McGilloway et al., 2010)
• Diagnostic criteria for PD might represent adaptive responses to environmental factors experienced by minorities (“healthy cultural paranoia”; Newhill, 1990).
• Clear gender differences in terms of PD diagnoses.
• Could be partly attributed to gender stereotypes or what is traditionally perceived as feminine or masculine (Nuckolls, 1992).
  
  • For example, HPD and ASPD
• Diagnostic criteria based on role expectations of what men and women should (and shouldn’t) be, rather than empirical evidence.
• Some diagnostic criteria might be more valid for men than for women, or vice versa.

Question 22

schema focused cognitive therapy

Answer 22

• Focuses on Early Maladaptive Schemas developed in response to early experiences (Young, 1990).
• Developed as a treatment for PDs and other forms of mental distress.
• Integrative approach, i.e. combining components of CBT, attachment theory, gestalt theory, and psychodynamic theory.
• Involves psychoeducation about EMS and to help clients cope with EMS when activated.
• Found effective for BPD treatment (e.g., Giesen-Bloo et al., 2006; Farrell et al., 20096) .

Question 23

dialectal behavioural therapy

Answer 23

• Acceptance-based form of Cognitive Behavioural Therapy (CBT).
• Developed in the 1970s for parasuicidal women with BPD, then adapted to other populations.
• Four key components: Mindfulness, Interpersonal Effectiveness, Distress Tolerance, and Emotion Regulation.
• Some meta-analytic evidence for its effects on reducing mental distress associated with PDs (e.g., Chen et al., 2021; Jones et al., 2023; Rameckers et al., 2021; Stoffers et al., 2012).
  Increasingly criticised for being overly complex and not trauma-informed.
• “Despite the majority of the individuals being sent to DBT having histories of severe childhood trauma, little about DBT treatment is “trauma-informed.”
• Rather, clinicians are trained to label feelings like suicidality, restricting food, self-injury, crying, and feeling sad as “problem behaviours” and are taught to engage in irreverent responses to clients who exhibit them.
• Talking about trauma is often shunned, and any of the aforementioned “behaviours” are commonly viewed as attention-seeking.”
• Trauma-informed interventions: Broad term to describe interventions that recognise the effects of trauma.
• Focuses on the recognition of trauma throughout and considers behaviours as an adaptive response to trauma.
• Power-Threat-Meaning Framework as a meta-framework for these treatments.
  Is starting to be adopted in practice for PD treatment (e.g., NOMS, 2015).

Question 24

what is schizophrenia

Answer 24

• A serious condition that affects how a person thinks/feels/behaves.
• Struggle to differentiate reality from thoughts.
• A constellation of psychotic/negative/cognitive symptoms.
• Often diagnosed differently in ICD-11 vs DSM-V (Valle, 2020).
• Psychotic symptoms
  
  • Hallucinations
  • Delusions
  • Thought Disorder
• Negative symptoms
  
  • Social withdrawal
  • Limited emotions
  • Loss of motivation
• Cognitive symptoms
  
  • Trouble processing/using information
    Attention deficits

Question 25

aetiology of schizophrenia- neurotransmitters

Answer 25

• The dopamine hypothesis – SZ arises from an excess of dopamine/overstimulation of dopamine receptors in the mesolimbic area of the brain.
• Symptoms also arise from a lack of dopamine and the under-stimulation of dopamine receptors in the prefrontal cortex (da Silva Alves et al., 2008).
• Positive symptoms come from increased subcortical release of dopamine, which increases D2 receptor activation (Shen et al., 2012).
• Negative symptoms come from reduced D1 receptor activation in the prefrontal cortex/nucleus caudatus (O’Donnell & Grace, 1998).
• Positives
  
  • Great deal of evidence
    
    • PET studies have found the differences in dopamine in the prefrontal cortex, cingulate cortex, and hippocampus between schizophrenia patients and controls (Patel et al., 2010).
  • Practical implications
    
    • The antipsychotic drugs chlorpromazine and haloperidol block dopamine receptors, reducing psychotic symptoms (Baumeister, 2013).
  • Animal models
    
    • Rearing rats in social isolation reduces dopamine in the prefrontal cortex (Möller et al., 2012).
• Negatives
  
  • Animal studies
    
    • How similar are rat social behaviour to human behaviours, can this be extrapolated?
    • How similar are rat brains?
    • The rats had decreased dopamine, but did they experience psychotic symptoms specifically?
  • Underpowered studies
    
    • Underpowered studies can produce false-negative (type II error) results, inflated effect sizes, and false-positive associations.
      Studies that report significant findings are more likely to be published: the file drawer effect.