Lecture 10 - Personality Disorders

Question 1

Are personality disorders entirely dependent on the culture the individual is in?

Answer 1

Yes.

The culture an individual is in is absolutely key to the determining whether there is a significant alteration or deviation from the “norm” when it comes to personality expression and experience.

Question 2

How are personality disorders defined?

Answer 2

An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture and is manifested in two or more of the following ways:
1. Cognition - ways of thinking about self and others.
2. Affectivity - including range, flexibility and expression of emotions and affect, such as appropriatness of emotional expression.
3. Interpersonal functioning
4. Impulse control.

Question 3

What are some core features of personality disorders?

Answer 3

1. Functional inflexibility:
   - failure or difficulty in adapting to changing environments or events.
   - tendency to apply rigid rules across all life experiences or domains, even when inappropriate.
2. Self-defeating behaviour patterns:
   - responding to situations, especially interpersonal situations, in a way that makes the situation difficult to self and others
   - inability to effectively learn from this experience and change behaviour, leading to this type of behaviour being a pattern.
3. Tenuous stability under stress:
   - marked instability in mood, thinking and behaviour in times of stress, such as confrontation.
   ….JOHN!

Question 4

Have DSM criteria and diagnoses for personality disorders changed much since the 1980s?

Answer 4

No.
They are “archaic” diagnoses - likely to fall by the wayside soon.

Question 5

What are the general diagnostic criteria in DSM-5 for PDs?

Answer 5

A. An enduring pattern of thinking and behaviour that deviates significantly from the cultural norms. This is manifested in two or more of the following ways:
- Cognition
-Affectivity
- Interpersonal functioning
- Impulse control

B. There is pervasive inflexibility and rigidity that spans most domains of life.

C. Leads to significant distress and impairment across social, self, and occupational settings.

D. This pattern of behaviour and thinking has endured and persisted since adolescence or at least for a significant portion of the individual’s life.

E. Not better explained by another mental disorder.

F. Not due to the effects of a substance or medical condition.

Question 6

Personality disorders are grouped into four categories (with no actual empirical reasoning or evidence):
Cluster A.
Cluster B.
Cluster C.
Other.

What PDs are in each cluster?

Answer 6

Cluster A:
Paranoid PD.
Schizotypal PD.
Schizoid PD.

Cluster B:
Antisocial PD.
Borderline PD.
Histrionic PD.
Narcissistic PD.

Cluster C:
Avoidant PD.
Dependent PD.
Obsessive-Compulsive PD.

Other:
Personality change due to another medical condition.
Other specified or unspecified PD.

Question 7

What is Paranoid PD?

Answer 7

A. Pattern of distrust and suspicion of other people’s motives.

B. Do not occur exclusively in psychotic disorders.

Question 8

Are individuals with Paranoid PD likely to come to treatment?

Answer 8

No.

Question 9

What is the prevalence of Paranoid PD?

Answer 9

2.3 - 4%

Usually begins in early adulthood.

Little research in most personality disorders, and is quite old.

Question 10

What is Schizoid PD?

Answer 10

A. Pervasive pattern of detachment from social relationships and retricted expression of emotions in social settings.

B. Does not occur exclusively in psychotic disorders.

Question 11

What is the prevalence of Schizoid PD?

Answer 11

2.2-4%

Most research re prevalence is not reliable.

Question 12

How is Schizotypal PD defined in DSM-5?

Answer 12

A. A pervasive pattern of social and interpersonal deficits, that make it difficult for individual to make close relationships and can present with cognitive or perceptual distortions and eccentric behaviour. Individual can experience significant discomfort in social relationships.

B. Does not occur exclusivelt during schizophrenia or other psychotic disorders.

Question 13

What tends to be the defining feature of PDs that distinguishes them from psychotic disorders?

Answer 13

PDs are a pervasive pattern of thinking and behaving, whereas psychotic disorders, such as schizophrenia, are generally more episodic.

Question 14

How is Antisocial PD defined in DSM-5?

Answer 14

A. Pervasive pattern of disregard for or violation of the rights of others.

B. Individual is at least 18 years of age.

C. Evidence of conduct disorder before or at least from 15 years,

D. Does not occur exclusively during schizophrenia or bipolar.

Question 15

Can you diagnose Antisocial PD before 18?

Answer 15

No.

Question 16

Most PDs are not diagnosed until after 18 years of age.
What is one exception?

Answer 16

Borderline personality disorder.
This is due to the fact there is some very effective treatment for adolescence experiencing BPD.

Question 17

What PD is overrepresented in prison populations?

Answer 17

Antisocial PD.
This is because to be diagnosed you need to have engaged in unlawful behaviour.

Question 18

How is Borderline PD defined in the DSM-5?

Answer 18

A. A pervasive pattern of instability in interpersonal relationships, self-image, affects and marked impulsivity.
Can manifest as frantic efforts to avoid abandonment, unstable or intense interpersonal relationships, and affective instability.

Question 19

Is BPD diagnosed more in women or men?

Answer 19

Women (75%).
There could be a diagnostic bias here.

Question 20

When does BPD become apparent?

Answer 20

Often in adolescence.

Question 21

Do many individuals who have BPD have experience with trauma in their childhood or in drastically invalidating environment?

Answer 21

Yes.
Perhaps why there is such a disparity in prevalence across genders.

Question 22

Is there a high level of comorbidity of BPD with mood and anxiety disorders?

Answer 22

Yes.

Question 23

Is there a school of thought that BPD would be better defined as a mood disorder or complex PTSD?

Answer 23

Yes.
However, it appears that there are some key differences between BPD and cPTSD, including that those with cPTSD don’t tend to experience the same frantic behaviours to avoid abandonment. Furthermore, treatments for cPTSD, such as mood stabilising medication, don’t often help those with BPD.

Question 24

What is Histrionic PD?

Answer 24

A problematic diagnosis.

A. Pervasive pattern of excessive emotionality and attention seeking.

More commonly diagnosed in women. Likely a misogynistic diagnosis.

Question 25

Why is there not much epidemiological data for PDs?

Answer 25

PDs diagnoses are not reliable. Therefore, hard to do research on them.

Question 26

How is Narcissistic PD defined in DSM-5?

Answer 26

A. Pervasive pattern of grandiosity and lack of empathy, and need for admiration.

Can show up as being interpersonally exploitative.

Question 27

What proportion of those with Narcissistic PD are men?

Answer 27

50-75%

Question 28

What are two theories of the aetiology of Narcisstic PD that we discussed?

Answer 28

1. Child’s need for affection, acceptance, and nurturing not met.
2. Child had too much praise as a child.

Question 29

How is Avoidant PD described/diagnosed in DSM-5?

Answer 29

A. Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

Can manifest as people not wanting to engage in occupations that require high levels of social interaction or being highly sensitive to criticism.

Question 30

Have schemas related to defectiveness and abandonment been associated with Avoidant PD?

Answer 30

Yes.

Question 31

How does the DSM-5 diagnose Dependent PD?

Answer 31

A. Pervasive and excessive need to be taken care of, which lead to clinging and submissive behaviour and fear of separation.

Can manifest as difficulty making daily decisions without reassurance. Difficulty engaging in conflict on confrontation.

Question 32

How is Obsessive Compulsive PD diagnosed in DSM-5?

Answer 32

A. Pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control, at the expense of flexibility, openness and efficiency.

Question 33

Is OCPD diagnosed twice as often in males as females?

What is the prevalence of OCPD?

Answer 33

Yes.

3.2-7.9%.

Question 34

In the DSM-5, what is Personality change due to another medical condition?

Answer 34

Personality changed that is a result or byproduct of a medical condition, such as a tumour or dementia.

Question 35

What are Otherspecified or Unspecified PDs?

Answer 35

Other specified is when the clinitian explains why the full criteria are not met.

Unspecified is when the clinician chooses not to specify why the criteria or how the criteria are not met.

Question 36

What are some of the limitations with DSM-5 PDs?

Answer 36

1. The DSM-5 requires that PDs are present in across time - this can be difficult to determine.
2. Culture plays a HUGE role and is the determinant of whether something is seen as a “deviation” or not.
3. Gender roles and norms play a key role in how people express themselves and this may lend themselves to being more readily diagnosed with a certain PD.

Question 37

How many Australian’s would meet a diagnosis for PD?

Answer 37

Some say 6.5%.

Some say globally it is 13%.

Some research suggests that 20-40% of individuals in a mental health setting have PDs.

Question 38

What are some further limitations and issues with DSM-5 conceptualisation of PDs?

Answer 38

1. No evidence that PDs are categories, especially no evidence that there are 10 categories of PDs.
2. Not empirically based - based on observation and analogy.
3. Many people meet criteria for multiple PDs.

Question 39

What was the dimensional model of PDs that was going to be used in the DSM-5, but was in the end was not used?

Answer 39

This model focuses on whether there is impairment in personality function and whether there are pathological personality traits.

Traits are dimensionally described.

The diagnoses included in this model are:
Antisocial PD.
Avoidant PD.
BPD.
Narcissistic PD.
OCPD.
Schizotypal PD.

The criteria that are used to diagnose PDs are:
A. Level of personality function (measured dimensionally)

B. Pathological personality traits (measured dimensionally on a scale o 25 different trait facets).

C and D. How pervasive and consistent have these experiences been?

Question 40

Is there little progress or efficacy with PD treatments (aside from BPD treatments)?

Answer 40

Yes.

This is used as evidence for why we need to reconsider the idea of ten different categorised PDs.

Question 41

What is a pro for using categories as diagnoses in mental health?

What are some cons for using categories as a way of diagnosing mental health disorders?

Answer 41

Aid in research and finding treatments.
Diagnoses can be a relief for individuals.
Can help clinicians understand client.
Can help with clinician communication.

Cons:
There is not much evidence for categories for, e.g. PDs.
Can increase stigma - including self-stigma: “there is something wrong with who I am”, or health stigma: “this is just how a person is and how they are always going to be, so why bother with treatment.”

Question 42

Does the ICD-11 use a dimensional approach to PD diagnoses?

Answer 42

Yes. Focuses on self and interpersonal functioning.
There is a BPD qualifier. There have been a lot criticisms about this qualifiers, as many experience increased stigma when “diagnosed” with BPD.

Question 43

What is one of the cognitive theories of the aetiology of PDs?

Answer 43

Through early childhood experiences we develop schemas or ways of understanding ourselves and the world around us. These schemas can be self- and other-limiting.

Proposes that each PD is characterised by maladaptive shcemas/schema patterns.

Question 44

What is ‘Schema Surrender’?

What is ‘Schema Avoidance’?

What is ‘Schema Overcompensation’?

Answer 44

Accepting that the schema is true.

Blocking out thoughts and feelings associated with the schema, such as turning to substance use.

React in extreme opposition to the schema - such as pushing people away because of fear of abandonment.

Question 45

What type of early childhood experiences are highly correlated with BPD?

Answer 45

Highly invalidating and unstable home and other environments.

The personality they have developed was the child’s best attempt at surviving the hostile environment.

Question 46

Are personality disorders the most stigmatised set of mental health disorders?

Answer 46

Yes.