Lecture 6: General introduction personality disorders

Question 1

what are personality disorders characterised by

Answer 1

rigid, inflexible thoughts, feelings, actions and impulse regulation; originates in early development; dysfunctional

Question 2

explain the difference between egosyntonic and egodystonic

Answer 2

egosyntonic = consistent with self-image; aligns with goals, values and self-view; seen as “normal”, cannot imagine otherwise
egodystonic = not consistent with self-image or part of the self, causes conflict and distress

Question 3

explain normal personality and traits

Answer 3

• they are a habitual way of thinking and acting
• consistent across situations; however, large situational variance
• personality becomes more stable with increasing age but can still change

Question 4

what traits stay stable and what kind of changes do we observe

Answer 4

• agreeableness; relatively stable throughout life, little growth in 20-30
• emotional stability; gets very much increasingly higher from age 15-20 onwards
• extraversion; declines progressively starting from age 20
• conscientiousness; goes up first around 20s, then hits peak around 40/50 and then declines again slowly
• openness; goes up a little in teenage years and then declines after age of 20/25

Question 5

what are 2 explanations for the changes in character traits over time

Answer 5

1. biological maturation = you become more mature the later in life you get
2. environmental influences = eg. increased responsibility, corrective experiences such as feedback from your environment

Question 6

what are 3 ways to distinguish personality from other pathology (3 P’s)

Answer 6

1. persistent = stable and long duration, since early childhood
2. pervasive = across most situations (and inflexible)
3. problematic = causes distress and/or impairment

Question 7

what are the 3 clusters of personality disorders and which disorders belong to them

Answer 7

1. Cluster A = strange/bizarre; variant psychotic
   - paranoid PD
   - schizotypal PD
   - schizoid PD
2. Cluster B = dramatic, emotional, impulsive; variant externalising disorders
   - histrionic PD
   - narcissistic PD
   - borderline PD
   - antisocial PD
3. Cluster C = anxious, avoidant; variant internalising disorders
   - avoidant PD
   - dependent PD
   - obsessive-compulsive PD

Question 8

what are 3 other categories for PDs that don’t fit in with the normal diagnoses

Answer 8

• personality change due to another medical condition
• other specified personality disorder (OSPD) = satisfies multiple criteria of various PDs but not the criteria for one single PD; category with the highest prevalence
• unspecified personality disorder = there is sufficient personality pathology going on but not falling under one of the labels

Question 9

what are 2 ways to approach classification

Answer 9

1. Monothetic = members must meet the same properties of criteria (eg. to diagnosed, everyone must meet all the criteria for a certain disorder)
2. Polythetic = meeting a minimal number of symptom criteria from 1 criterion set (eg. one patient meets the first 3 criteria, another meets the last 3, but both get a diagnosis because you have to meet a minimum of 3)

Question 10

what is the prevalence of having minimum of 1 PD in the general population

Answer 10

9-13%

Question 11

risk integration transmission

Answer 11

= increased risk of giving your child a PD when you have one as a parent

Question 12

to what cluster is emotional abuse specifically related to and why

Answer 12

cluster C; because it has a very strong impact on how we view ourselves, which is something that tends to be related to people with these kinds of disorders

Question 13

what are 3 treatment guidelines

Answer 13

1. specialized psychotherapy; determine what should be treated first in the case of comorbidity, additional treatment can be effective, integrated treatment for syndrome disorders
2. social psychiatric treatment; (if first choice is not possible, lack of motivation)
3. pharmacotherapy is not useful for treatment of PDs, only dampens symptoms; possible for comorbid disorders or specific symptoms, should not interfere with treatment

Question 14

what are the criteria for obsessive-compulsive PD

Answer 14

For a diagnosis of obsessive-compulsive personality disorder (1), patients must have;
- A persistent pattern of preoccupation with order; perfectionism; and control of self, others, and situations

This pattern is shown by the presence of ≥ 4 of the following:
1. Preoccupation with details, rules, schedules, organization, and lists
2. A striving to do something perfectly that interferes with completion of the task
3. Excessive devotion to work and productivity (not due to financial necessity), resulting in neglect of leisure activities and friends
4. Excessive conscientiousness, fastidiousness, and inflexibility regarding ethical and moral issues and values
5. Unwillingness to throw out worn-out or worthless objects, even those with no sentimental value
6. Reluctance to delegate or work with other people unless those people agree to do things exactly as the patient wants
7. A miserly approach to spending for themselves and others because they see money as something to be saved for future disasters
8. Rigidity and stubbornness

Also, symptoms must have begun by early adulthood.

Question 15

what is the transdiagnostic trait that OCPD shares with OCD

Answer 15

perfectionism

Question 16

what are psychosocial factors that contribute to OCPD

Answer 16

• high parental overprotection
• low parental care –> may influence adult attachment style
• emphasis on compliance and rules in exchange for acceptance and love

Question 17

what is remarkable in OCPD patients in the initial interview

Answer 17

• well-groomed
• highly intellectualised
• speak with detail
• patients often want to be the “perfect patient” but undermine treatment by avoiding emotions

Question 18

how can we differentiate OCPD from OCD (4)

Answer 18

• in OCD, symptoms fluctuate over time and in response to stress, in OCPD they’re pervasive and persistent
• greater capacity to delay rewards in OCPD
• egosyntonic for OCPD, egodystonic for OCD
• OCD patients tend to seek help because their symptoms are bothersome, OCPD patients seek help because of secondary reasons

Question 19

what are the diagnostic criteria for avoidant PD

Answer 19

For a diagnosis of avoidant personality disorder (1), patients must have
- A persistent pattern of avoiding social contact, feeling inadequate, and being hypersensitive to criticism and rejection

This pattern is shown by the presence of ≥ 4 of the following:
1. Avoidance of job-related activities that involve interpersonal contact because they fear that they will be criticized or rejected or that people will disapprove of them
2. Unwillingness to get involved with people unless they are sure of being liked
3. Reserve in close relationships because they fear ridicule or humiliation
4. Preoccupation with being criticized or rejected in social situations
5. Inhibition in new social situations because they feel inadequate
6. Self-assessment as socially incompetent, unappealing, or inferior to others
7. Reluctance to take personal risks or participate in any new activity because they may be embarrassed

Also, symptoms must have begun by early adulthood.

Question 20

what are 6 descriptors of AVPD (6)

Answer 20

1. Triggering event(s)
2. Behavioral style (eg. chronic tenseness, self-consciousness, controlled speech/behavior, self-critical)
3. Interpersonal style (eg. sensitive to rejection, distanced from others)
4. Cognitive style (eg. hypervigilant, scanning for threats, overemphasis on shortcomings downplay triumphs)
5. Affective style (eg. shyness, apprehensiveness, sadness, loneliness, tension)
6. Attachment style (preoccupied and fearful, desire to be liked accepted and fear of rejection abandonments)

Question 21

how would AVPD be explained from a CB/schema therapy perspective

Answer 21

patients maintain the core belief of rejection which explains their fearfulness and avoidance, as well as having maladaptive schemas and dysfunctional beliefs about the self and others and they attribute everything to themselves and their deficiencies

Question 22

what is remarkable in AVPD patients in the (initial) interview

Answer 22

• guarded
• responding with one-word answers
• anxious/suspicious
  –> empathy and reassurance must be employed to develop trust

Question 23

explain CBT for AVPD

Answer 23

• initial goal is to build trust and reduce social anxiety/avoidance of emotions and cognitions
• correcting social skills deficits and encourage a safe environment
• anxiety management strategies early in treatment
• challenging automatic thoughts and restructuring maladaptive schemas
• paradoxical intention = patient is prompted to seek rejection in a predictable/controllable way to reduce sensitivity to it

Question 24

explain the 4 maladaptive schemas typically identified in AVPD and how schema therapy deals with those

Answer 24

1. defectiveness = the belief that one is defective, bad, unwanted
2. social isolation = the belief that one is different from others, alienated, and unable to be accepted into any group
3. self-sacrifice = the belief that one must sacrifice one’s needs for the needs of others
4. approval-seeking = the belief that the need to belong supersedes all other needs, and one must always be accepted, even at the expense of authenticity
   –> schema therapy deals with this by focusing on changing core beliefs and schemas, for example with cognitive restructuring

Question 25

explain why group therapy can be especially helpful for AVPD patients

Answer 25

• it can help to develop interpersonal trust and rapport with peers
• gives a feeling of belonging/being wanted
• feedback may contradict negative self-image
• problems with mentalizing can be addressed
• social skills training

Question 26

what are 3 reasons why diagnosis based on clinical expertise has low reliability

Answer 26

• stereotypes
• premature closing
• confirmation bias; interviews force disconfirmation