Module 3 - Personality Disorders Flashcards
What is personality and personality disorder?
Personality: ‘an enduring pattern of perceiving, relating to, and thinking about the environment and oneself’
Personality disorder: ‘a set of personality traits that are pervasive, ingrained, maladaptive and create significant functional impairment or subjective distress’
Cluster A: F60.0 Paranoid
F60.1 Schizoid
Prefer isolation, very limited number of close relationships, tendency to introspection and fantasy, suspiciousness of others, strange beliefs and interests
Stay away from services, Δ Δ for schizophrenia, disputes among paranoid
Cluster B: F60.2 Dyssocial (antisocial)
F60.3 Emotionally unstable (borderline)
F60.4 Histrionic
Main features: Emotional instability, aggression to self or others, impulsiveness, selfishness, self-dramatisation, irresponsibility
Emotionally unstable seek help from services, self harm and Δ Δ for mood disorders
Cluster C: F60.5 Anankastic (Obsessive-Compulsive)
F60.6 Anxious (Avoidant)
F60.7 Dependent
Main features: Anxiety-prone, meticulous, help-seeking, rigid, fearful of new situations, abnormal high standards
Dependent seek help from primary care, anankastic and Δ Δ for OCD, anxious and complaints
Neuroticism - sensible, sensitive
Extraversion - high energy level, people person, gets stimulated by being around others
Openness - emotional, adventurous, curious
Conscientiousness - self-disciplined, result oriented and structured, tradition and dutiful
Agreeableness - compassionate, cooperative, ability to forgive and being pragmatic, lets get the thing done
What is borderline personality disorder?
ICD 10:
Marked tendency to act impulsively
Affective instability
Minimal ability to plan ahead
Outbursts of intense anger may often lead to violence or “behavioural explosions“
Two variants: Impulsive type; Borderline type
Share general theme of impulsiveness and lack of self-control
DSM-5: 5/9: Affective: Inappropriate intense anger or difficulty controlling anger, chronic feelings of emptiness, affective instability (engagement, commitment, motivation?)
Cognitive: Transient paranoid ideation or severe dissociative symptoms, Identity disturbance
Behavioural: Recurrent suicidal behaviour, threats, or self mutilating, impulsivity harmful acts other than suicidal behaviour
Interpersonal: Frantic efforts to avoid abandonment
Unstable and intense interpersonal relationships
What is antisocial personality disorder?
Pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three or more of the following:
- failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest;
- deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
- impulsivity or failure to plan ahead;
- irritability and aggressiveness, as indicated by repeated physical fights or assaults;
- reckless disregard for safety of self or others;
- consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations;
- lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
What is the pathophysiology of personality disorders?
Environment > genetic
Except impulsiveness and cluster A
Unstable family background – NEGLECT
Parental mental illness/drug misuse, social care
Childhood physical and sexual abuse (19% Salman 1993 to 71% Herman 1989
The response of caregivers to abuse
Borderline personality disorder: Insecure attachment? Poor sense of self with maladaptive cognitions.
Infant internalises caregiver’s representation to form psychological self. (Inference from infant to carer.)
Incongruent mirroring: representation of internal state corresponds to nothing real -> pretend mode
Un-marked mirroring: caregiver’s expression seen as externalisation of experience (no difference between externalisation and internalisation) -> psychic equivalent mode
What is the epidemiology for personality disorder?
Community (4%) - Prisons (70-80%)
Cost: £7000 per patient (Glen-Baker et al. 2010)
High rates in people with substance misuse - 50% of opiate misuses. Higher rates of cluster B in inner city areas and cluster A and OCPD in rural areas
Increased in countries with conflicts - correlates fairly well with rates of homicide.
75% had one or more co-morbid mental disorders
What is the prognosis of personality disorders?
Cluster B improve – reduced impulsivity and self-harm (50% ‘recovered at 2 years, 80% at 10) 40% of people who die by suicide 70% of people with drug dependence 60% of prisoners Reduced life expectancy (18 years)
What is transference?
Redirection of a patient’s feelings for a significant person to the clinician/ therapist
Counter-transference Redirection of a clinician’s/ therapist’s feelings toward a patient - eg. doctors prescribing drugs to “take action”, especially as patients feel abandoned if no action
Eg. Patients with PD seen as:
more difficult
less deserving of care
attention-seeking
annoying
in control of their suicidal urges Lewis 1989
What is the management of personality disorder?
Staying calm - containing anxiety
Acknowledge distress
Find out what’s going on
Avoiding extremes e.g. dismissing - taking over
Active participation of patient in working out what to do (what helped in the past?)
Being consistent as a service
Know your limits and boundaries
Therapies:
50% do not engage and 30% of those who do drop out before completion)
Mentalization Based Treatment - 18 months, twice a week
Avoid simplified explanations - interpretations
Model honesty and courage via acknowledgement of your own mistakes
(Bateman & Fonagy, 2001, trial in 2009 showed superior to treatment as usual. Statistically significant reductions in suicide attempts (3% vs 25% at 18 months), self-harm (24% vs 43%), improved mental health, social function (GAF = 61 vs 53) and reduced use of inpatient care (mean days 12-18 months = 0.2 vs 1.3).
Maladaptive cognitions -> Schema Focused Therapy (Young 1990) Longer duration and intensity 2x week 18-24 months
Emotional and inter-personal skills -> Dialectical Behaviour therapy Lindehan 1999,
Especially for women who self harm
Mindfulness: The capacity to pay attention, non judgmentally, to the present moment - living in the moment.
Interpersonal effectiveness Strategies for asking for what you need, saying no, and coping with interpersonal conflict.
Distress tolerance: The ability to accept, in a non judgmental fashion, both oneself and the current situation
Validation: psychoeducation how temperament or past experiences may have led them to feel/ react the way they did, WHILE being clear about the current impact on themselves and others.
Dialectics: the inter-related nature of actions and behaviour. How hard it can be to change established patterns of behaviour.
Teaching new skills: mindfulness, emotional regulation, interpersonal effectiveness, distress tolerance
Mind wandering: to gain control over your attention
Distraction – focusing on taste of a grape!
Enhancing motivation: use of diary card and behavioural chain analysis
Crisis planning (there will be crises)
Weekly 1 hr sessions + weekly 150 min group + telephone consultation + weekly therapists meeting
12-18 months
Largest trial by McMain (2009) comparing it with high quality general psychiatric care (No difference)
Individual seems better than group therapy - eg. problem solving therapy, which is 4 sessions and then 12 sessions of problem solving - good for depression and anxiety, but when it came to personality disorder, not effective (high drop out rate) and if anything more adverse events (although not statistically significant)
Pharmacotherapies:
Antidepressants - 7 trials (poor methodological quality)
Findings – 6 no evidence of beneficial effects, 1 trial of Amitriptyline reported reduction in depressive symptoms
Comorbid personality disorder with depression was associated with a doubling of the risk of a poor outcome for depression compared with no personality disorder
Antipsychotics - 13 trials
(2) Haloperidol, (4) Olanzapine, (1) Aripiprazole, (1) Ziprasidone - Some evidence of reductions in hostility, anger and impulsivity BUT Short term: 1-3 months, High attrition rate (35 to 50% not followed up)
Side effects: e.g. olanzapine
Clozapine in case series, eg. Frogley 2013 (18 months, reduced aggression and symptoms, greatest at 6 months, but weight gain side effect.
Mood stabilisers:
9 trials: (1) Carbamazepine, (3) Valproate, (3) Topiramate, (2) Lamotigine
Findings – evidence that they lead to reductions in anger, depression and impulsivity, BUT Small (<50) and poor methodological quality
NICE (2009)
‘Do not use drug treatment specifically for borderline personality disorder or for the individual symptoms or behaviour associated with it’.
Cochrane review (Lieb et al 2010)
‘Mood stabilisers and second-generation antipsychotics may be effective in treating symptoms associated with borderline PD’.
Methodological problems, Difference between clinical and research populations (eg. compliance)
Audit of West London hospitals, 123 patients (85%) prescribed one or more medication, 78 (54%) prescribed two or more, half of those on antidepressant had no record of depression, 37% on drugs for more than three years.
POMH-UK 12a:
33% more than one antipsychotic, 13% - three or more in last 12 months
Those who did NOT have an axis one disorder recorded, there was LESS likely to have documented evidence of check for side effects
Review and STOP medications prescribed during crises (1-2 weeks)
What is mentalising?
Interpreting the actions of oneself and other as meaningful on the basis of intentional mental states (e.g., desires, needs, feelings, beliefs, & reasons)
May be implicit (unconscious e.g. mirroring) or explicit (conscious e.g. interpreting). Subjective and inter-subjective (having the other persons’ mind in mind, as well as your own)
Thoughts are just thoughts…they are not ‘you’ or ‘reality’ (can help free someone from the distorted reality that thoughts create). It promotes openness and mentalization.
‘mind-mindedness’, the ability to see ourselves as others see us, and others as they see themselves; to appreciate that all human experience is filtered through the mind and therefore that all perceptions, desires and theories are necessarily provisional. (Wardipedia)
Ability to metalize varies according to mental state
Impaired by mental illness and substance misuse
Reduced at states of heightened emotional arousal – new relationships, close relationships (attachment)
Impaired in people with BPD when relations end
What are the assessments for personality disorders?
Multiple interviews to uncover personality and not affect. Especially if issues with crisis at time of presentation.
Staying calm - containing anxiety
Acknowledge distress
Find out what’s going on
Avoiding extremes e.g. dismissing - taking over
Active participation of patient in working out what to do (what helped in the past?)
Being consistent as a service
Know your limits and boundaries
