Personality Diosorders

Question 1

Definition of personality

Answer 1

An individual’s characteristic way of behaving, experiencing life, and of perceiving and interpreting themselves, other people, events, and situations.

Question 2

ICD-11 classification of a personality disorder. What are the three Ps that distinguish a disorder from a trait?

Answer 2

A marked disturbance in personality functioning, which is nearly always associated with considerable personal and social disruption (i.e when personality traits are persistently disabling or distressing.)

• Persistent: typically emerge in childhood/ adolescence and endure indto adulthood
• Pervasive: occur in most if not all areas of life
• Pathological: cause distress, affect relationships and impair occupational/ social functioning

Question 3

What are the central manifestations of personality disorders

Answer 3

Impairments in:

• Aspects of the self
• Problems in interpersonal functioning
• Impairments in self-functioning and/or interpersonal functioningà manifested in maladaptive patterns of cognition, emotional experience, emotional expression, and behaviour

Question 4

What criteria must a personality disorder NOT meet

Answer 4

A personality disorder must NOT be developmentally appropriate (generally given diagnosis above the age of 18), be explained primarily by social or cultural factors and must cause distress or significant impairment in personal, family, social, education or occupational functioning. Additionally, symptoms cannot be caused by direct effects of a medication or substance, including withdrawal or by another psychiatric or medical illness.

Question 5

How can a personality disorder be classified

Answer 5

Can be classified as mild, moderate, or severe personality disorder. Alternatively can be classified as a personality difficulty, where the symptoms are not pervasive (do not significantly impair function). This classification is made based on the following factors:

• Emotional- range and recognition
• Cognitive- accuracy of appraisals in situations, making accurate decisions, stability and flexibility
• Behavioural- flexibility, impulse control, appropriateness of behavioural responses, violence etc.

Question 6

What is the OCEAN model of personality factors

Answer 6

Openness to experience: curiosity, imagination and appreciation of art, adventure and emotion

Conscientiousness: ability to plan and be self-disciplined to achieve goals

Extraversion: predisposition to experience positive events

Agreeableness: tendency to be cooperative, trusting and kind

Neuroticism: predisposition to negative emotions e.g. anxiety, anger or depression

Question 7

How can personalities be grouped/ clustered (what are the characteristics of these groups

Answer 7

The DSM-5 classifies personalities according to groups/Clusters

• Cluster A ‘Odd and Eccentric’- Paranoid, schizoid or schizotypal
• Cluster B ‘Dramatic, Emotional or Erratic’- Antisocial, borderline, histrionic, narcissistic
• Cluster C ‘Anxious and Fearful’- Avoidant, dependant, obsessive-compulsive

Question 8

What are the two main predisposing factors in personality disorder

Answer 8

1. Genetics: Personality traits show a MZ:DZ concordance of 50%:30%. Additionally genetics are thought to determine 50% of our personality. PD is associated with a fhx of PD, schizophrenia (A), depression and anxiety (B and C), and substance abuse disorders (B).
2. Childhood factors: Temperament describes our innate characteristics, which can be observed clearly in childhood- these can predict adult personality traits. Children with difficult temperaments have more trouble coping as adults (harder to develop supportive relationships, more distressed by negative experiences.) Distressing childhood experiences and insecure attachments make PDs more likely- abuse, neglect and chaotic parenting mean the child is less likely to validate and manage their own emotions

Question 9

What theories exist to explain the developemnt of a PD

Answer 9

1. Psychological theories: Expectations tend to be fulfilled and perpetuated (warm people get a warm reception whereas aggressive people are treated with hostility, reinforcing the belief that people are threatening.) Attachment theory suggests that the quality of early relationships influence personality. PDs could also arise as a defence mechanism- people with PDs can rely heavily on ego defences such as acting out, splitting (viewing things in a polarised way), projection or fantasising to manage uncomfortable feelings.
2. Neurochemical theories: Associated with dysfunction of dopaminergic systems
3. Neuroanatomical theories: Cluster B is linked to functional underactivity in the Prefrontal cortex

Question 10

Cluster and clinical presentation of a paranoid personality disorder

Answer 10

• Cluster A
• Excessive sensitivity to setbacks, suspicious, can perceive others as hostile or contemptuous (misconstruing neutral or friendly actions)
• Can feel easily rejected and tend to hold grudges
• May have excessive self-importance

Question 11

Cluster and characteristics of a Schizoid personality disorder

Answer 11

• Cluster A
• Withdrawal from affectional, social and other contacts, perceived as emotionally ‘cold,’
• Have a preference for fantasy, solitary activities and introspection.
• Often they have a limited capacity to express feelings and to experience pleasure

Question 12

Cluster and characteristics of a Schizotypal personality disorder

Answer 12

In ICD-10 is classified as associated with Schizophrenia and not as a PD. Have:

• Cluster A
• Inappropriate or constricted affect
• Socially withdrawn
• Behavior or appearance that is odd, eccentric or peculiar
• Odd beliefs or magical thinking that can influence behavior and are inconsistent with subcultural norms. These can be suspicious or paranoid
• Unusual perceptual experiences including somatosensory (bodily) or other illusions, depersonalization or derealization
• Occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations and delusion-like ideas, usually occurring without external provocation

Question 13

Cluster and characteristics of a BPD

Answer 13

• Cluster B
• Have difficulties managing emotions and behaviour
• Impulsive without consideration for consequences
• Unpredictable mood and unstable affect
• May have ‘chronic feelings of emptiness’
• Have difficulty maintaining relationships which are often intense and unstable.

Question 14

Cluster and characteristics of an antisocial PD

Answer 14

• Cluster B
• Persistent disregard for morals, social norms, and the rights of others. Callous about the feelings of others with lack of remorse
• Low tolerance to frustration
• Have aggressive tendencies, are impulsive and show behavior that is not readily modifiable by adverse experience.
• These patients are more likely to present to forensic department.

Question 15

Cluster and characteristics of a histrionic personality disorder

Answer 15

• Cluster B
• Shallow and labile affect.
• Self-dramatization and theatricality with exaggerated expression of emotions
• Seek appreciation, excitement, and attention.
• Are self-centred and lack of consideration of others

Question 16

Cluster and characteristics of an avoidant PD

Answer 16

• Cluster c
• Often express feelings of tension and apprehension as well as insecurity and inferiority.
• Have a continuous yearning to be liked and accepted and are hypersensitive to rejection and criticism.
• Restricted personal attachments. Tendency to avoid certain activities by habitual exaggeration of the potential dangers or risks in everyday situations.

Question 17

Cluster and characteristics of an Obsessive compulsive personality disorder (‘Anankastic PD’):

Answer 17

• Custer C
• Express feelings of doubt
• Perfectionism, Excessive conscientiousness. Checking and preoccupation with details, Stubbornness, caution, and rigidity
• There may be insistent and unwelcome thoughts or impulses that do not attain the severity of an obsessive-compulsive disorder

Question 18

How can we investigate personality disorders

Answer 18

Diagnosis requires multiple sources of information across multiple meetingsà follow-up interviews might utilise:

• screening questionnaires (‘Standardised Assessment of Personality Abbreviated Scale’ SAPAS)
• semi-structured interviews (‘International Personality Disorder Examination’ IPDE)

Also require a collateral history and an assessment of psychological mindedness (if somebody is resilient and reflective enough to use therapy.)

Question 19

What is the management of personality disorders

Answer 19

PD is treatable but requires a long-term approach. Involves psychological therapy and psychotropic medication:

• Psychological therapy is generally related to CBT (focusing on interaction between thoughts, moods and current behaviours) and psychoanalysis (how the past relates to interpersonal difficulties):
  
  • Dialectical Behavioural Therapy (DBT)- Useful in PDs which cause patients to experience emotions very intensely. Reduces self-harm in borderline PD. Involves presentation of an alternative viewpoint- particularly useful where a patient is ‘one-tracked.’ Introduces validation- accepting that your emotions are acceptable and dialectics- showing you that things in life are rarely black and white and helping to be open-minded.
  • Cognitive Behavioural Therapy (CBT)
  • Mentalisation Based Therapy (MBT)- mentalisation is thinking about thinking- allows patients to step back and reduce the ‘acting out’ of emotion. Also allows patients to think through other peoples’ thought processes and accept that their interpretation might be wrong. (12-18 months)
  • Dynamic psychotherapy- how past relates to present
  • Therapeutic community- teaching social skills to a group of patients with psychological conditions.
• There are no officially licenced psychotropic medications, however, some benefit is seen with antidepressants, low dose antipsychotics, mood stabilisers and sedatives (in the short-term)