L12 - Personality Disorders Flashcards
aetiology of personality disorders?
Likely multi-factorial like almost all other psychiatric diagnoses.
Genetic and environmental factors such as chaotic home environment and abuse have been implicated in development of maladaptive behavioural patterns.
Heritability of PD
For comparison heritability of normal personality traits is approximately 0.5
Molecular genetics studies of PDs indicate that genes linked to neurotransmitter pathways, particularly the serotonergic and dopaminergic systems are involved.
genetic predisposition + abhorrent events/parenting… = PD? learning a maladptive pattern of responding.. can you medicate it? probably not due to it being a congenital disorder.. it’s who you are, not what you have.
Cultural influence on personality?
Studies have found that in Norway as compared to US, Germany and UK, avoidant personality is 3-4X more prevalent, dependent personality 2-3X more prevalent and schizoid is 2X more prevalent. Borderline is <1⁄2 as frequent and antisocial is 1⁄2 as prevalent.
Pattern exhibits increased internalization personality disorders are prevalent and externalization disorders are rarer.
what are the different clusters of personality disorders?
Cluster A: suspicious, odd
Paranoid, Schizoid, Schizotypal
Cluster B: dramatic
Antisocial, borderline, histrionic, narcissistic
Cluster C:anxious
Avoidant, dependent, obsessive-compulsive
Paranoid personality disorder?
A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent.
Suspects others are exploiting or deceiving him
Preoccupied with unjustified doubts of loyalty
Is reluctant to confide in others because he believes they will use the information against him
Reads hidden demeaning meanings into benign remarks
Persistently bears a grudge
Perceives attacks on his character
Recurrent suspicions regarding fidelity of spouse or sexual partner
Schizoid personality disorder?
Pervasive pattern of detachment from social relationships and restricted expression of emotion with 4 or more the following:
Neither desires nor enjoys close relationships
Almost always chooses solitary activities
Little if any interest in sexual experiences with another person
Takes pleasure in few in any activities
Lacks close friends other than first-degree relatives
Appears indifferent to the praise or criticism of others
Shows emotional coldness or flattened affect
AKA NEGATIVE SYMPS
Schizotypal personality disorder?
A pervasive pattern of social and interpersonal deficits with reduced capacity for close relationships as well as cognitive or perceptual distortions and eccentricities of behaviour with 5 or more of the following:
Ideas of reference
Odd beliefs or magical thinking
Unusual perceptual experiences including bodily illusions
Odd thinking and speech
Suspiciousness or paranoid ideation
Inappropriate or constricted affect
Behaviour or appearance that is odd or eccentric
Lack of close friends other than first-degree relatives
Excessive social anxiety that does not diminish with familiarity
AKA POSITIVE SCZ SYMPS
Antisocial personality disorder?
CLUSTER B PD
A pervasive pattern of disregard for and violation of the rights of others occurring since the age of 15 years as indicated by 3 or more of the following:
Failure to conform to social norms with respect to lawful behaviours
Deceitfulness and conning others for personal profit or pleasure
Impulsivity or failure to plan ahead
Irritability or aggressiveness as indicated by repeated fights or assaults Reckless disregard for safety of self or others
Consistent irresponsibility
Lack of remorse
There is evidence of Conduct Disorder with onset before age 15
What has neuroimaging shown us about psychopathy
person with psychopathic tendencies showed DECREASED AMYGDALA and ORBITAL FRONTAL cortex responses to emotionally provocative stimuli which the author felt was suggestive of difficulties with basic forms of emotional learning and decision
making.
antisocial personality disorder and criminality?
Not all people with ASPD are criminals (or in jails)
Not all people in jail or considered criminal have ASPD
Not all people with ASPD are psychopaths
Course of antisocial disorder?
Course of all PDs is chronic, but overt antisocial behaviour seems to decrease after 40
Acquired sociopathy?
- most likely a consequence of impairment (lesions) in brain systems that respond to threat.
- amygdala and orbito PFC.
inability to FORM ASSOCIATIONS BETWEEN EMOTIONAL UCS (distress cutes) and CS (transgressions)
if the person is raised in a social environment where there are advantages for antisocial behaviour.. they will do so. and not experience aversion to victims’ distress
Which area of the brain do we think would be lesioned to cause acquired sociopathy
amygdala and orbito PFC
damaged system that responds to threats, and causes inability to form association between emotional distress cutes, and the transgressions…
in PET scans, what can we see in murderers?
reduced frontal lobe activity.
repeat offenders had 11% less frontal activity.
reduced PFC, pariental and corpus calloson activity
less aftivity in LHS than RHS
not aa good study though.. didnt control for a lot.
Borderline PD?
Pervasive pattern on instability of interpersonal relationships, self image and affects and marked impulsivity as indicated by 5 or more of the following:
Frantic efforts to avoid abandonment
Unstable and intense interpersonal relationships characterized by
alternating between extremes of idealization and devaluation
Identity disturbance
Impulsivity in at least two areas that are potentially self-damaging
Recurrent suicidal behaviours, gestures or threats or self-mutilating behaviours
Affective instability due to a marked reactivity of mood
Chronic feelings of emptiness
Inappropriate anger
Transient, stress-related paranoia
Cog impairment in BPD??
GLOBAL
really bad in planning organisation,
visual memory also large effect size
all else medium to small??
Histrionic pd?
Pervasive pattern of excessive emotionality and attention seeking indicated by >5 of the following:
Uncomfortable in situations in which he is not the center of attention
Interaction with others often characterized by inappropriate sexually
seductive behaviour
Displays rapidly shifting and shallow expression of emotion
Consistently uses physical appearance to draw attention to self
Has a style of speech that is excessively impressionistic and lacking in detail
Shows self-dramatization and exaggerated emotion
Is suggestible
Considers relationships to be more intimate than they are
Narcissitic PD?
A pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, lack of empathy as indicated by >5 of the following:
Grandiose sense of self-importance
preoccupied with fantasies of unlimited success, power, brilliance or
beauty
Believes he is special and can only be understood or should associate with other special or high status people
Requires excessive admiration
Has a sense of entitlement
Is interpersonally exploitive
Lacks empathy
Is often envious of others and believes others are envious of him
Shows arrogant, haughty behaviours or attitudes
Avoidant pd?
A pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation as indicated by >4 of the following:
Avoids social occupations that involve significant interpersonal contact
Is unwilling to get involved with people unless certain of being liked
Is preoccupied with being criticized in social situations
Shows restraint in intimate relationships because of fear of being
shamed or ridiculed
Inhibited in new interpersonal situations because of feeling inadequate
Views self as socially inept and unappealing
Is unusually reluctant to take personal risks or engage in any new activities because they may prove embarrassing
Oc PD
A pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control at the expense of flexibility, openness as indicated by >4 of the following:
Preoccupied with details, rules, lists, order or schedules to the extent that the major point of the activity is lost
Shows rigidity and stubbornness
Perfectionism that interferes with task completion
Excessively devoted to work and productivity to the exclusion of leisure activity and friends
Over conscientious and inflexible about matters of morals or ethics
Is unable to discard worn or worthless objects even those without sentimental
value
Reluctant to delegate tasks
Adopts miserly spending style toward self and others
treatment for PD?
Can reduce symptomatology, improve social and interpersonal functioning, reduce frequency of maladaptive behaviours and decrease hospitalizations.
Always screen for comorbid psych dx
If the personality disorder is ego-syntonic (e.g.. Antisocial and Narcissistic) it will be hard to engage the patient in treatment
Medication for PDs?
- increase serotonin levels to reduce dperssion, impulsivity and rumination
low dose antipsychotics and mood stabilisers may be effective to help mood stability.
guidelines for treating PD
Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder (for example, repeated self-harm, marked emotional instability, risk-taking behaviour and transient psychotic symptoms)
Too unequivocal/dogmatic
No definitive/robust evidence either way
Does not reflect clinical practice in secondary care though there is variation in clinical practice
problems with prescribing mood stabilisers with PD?
- concerns abour risk of OD and medication toxicity
- patient pressure, and influence of available psych therapies.
- initiating a cycle of medicatio ntrials and potential to lead to polypharcy
lack of standardised clincal approach
patient factors that impacts treatment?
- clinicians might fail to recognise its a PD, and treat symptoms thinking its depression, anxiety
- when response to treatment is poor, they will increase dose or use polypharmacy
Whata are some comorbid disorders?
Antisocial PD: Alcohol dependence and depressive disorders
BPD: alcohol and drug dependence, mood disorders, anxiety disorders including PTSD
Histrionic PD: alcohol dependence, somatization disorder
Avoidant PD: social phobia
Any PD puts patient at higher risk than the general
population for Etoh and drug dependence.
