Personality Disorder Flashcards
What is a personality disorder?
- When ‘traits’ are thought to lead to significant levels of distress for self and/or others
- When ‘traits’ are thought to be associated with considerable personal and social disruption
PD if
- Problematic
- – Clinically significant distress or problems for self or others
- – May be difficulties in social life, work, law
- Persistent
- – Pattern is stable and long-standing
- – Present since early adulthood or adolescence and continues to adulthood
- Pervasive
- – Pattern is inflexible in broad range of personal or social situations
What are the DSM IV cluster A disorders?
Paranoid = distrust and suspicious of others
Schizoid = detached from social relationships; restricted range of emotional expression
- Do not enjoy social relationships
- Usually have no close friends
Schizotypal = discomfort with close relationships; cognitive/perceptual distortions; eccentric behaviour
- Same as schizoid but with eccentric thoughts and behaviours
- More research has been done on schizotypal cluster A
— May be due to behaviour having some similarity to schizophrenia and a possible genetic link with schizophrenia
- Anti-psychotic drugs → very limited improvement (also side-effects)
- Therapy: aim to reconnect client to social world and recognise limits of their thinking
— Limited success
What are some difficulties with cluster A disorders?
- Often considered odd/eccentric
- Leads to difficulties forming relationships
- Vicious circle:
- – Odd behaviour → poor relationships → social isolation → negative emotions, mood disorders, anxiety, unhappiness → increase in odd/eccentric behaviour
How can cluster A be treated?
- Little research evidence
- Rarely present for treatment
- If present to service then offer help for mood/anxiety problems
- – Plus interventions aimed at assisting with social consequences (e.g. family disruption, employment, housing)
What are some typical reasons that people with cluster A disorders don’t seek treatment?
- Paranoid: do not seek help, suspicious and distrustful of others, if do present then tend to drop out of therapy
- Schizoid: socially withdrawn, tend not to engage with therapy, treatments presently offered are not very effective
What are the DSM IV cluster B disorders?
- Antisocial (psychopathy): disregard for and frequent violations of the rights of others
- Borderline: instability of relationships, self-image, emotions, control over impulses
- Histrionic: excessive emotionality and attention seeking, dramatic, manipulative
- Narcissistic: grandiosity, need for admiration, lack of empathy, fantasies of great success
What is borderline personality disorder?
- Intense emotionality
- Attitudes and feelings about other people vary without reason leading to unstable relationships
- Pervasive pattern of instability in:
- – Relationships
- – Self-image
- – Affect
- – There is also marked impulsivity
- 5 of these characteristics need to be present:
- – Fear of abandonment
- – Unstable and intense personal relationships
- – Identity disturbance
- – Impulsivity
- – Recurrent deliberate self-harm
- – Unstable affect
- – Feelings of emptiness
- – Difficulties controlling anger
- – Stress related paranoid ideas or dissociation
- No single psychosocial or biological factor is either necessary of sufficient to cause PD
What are some risk factors for BPD?
- Family breakdown
- Neglectful parenting (not loving and supportive)
- Overprotective parenting (not encouraging independence and autonomy)
- History of severe physical, emotional and/or sexual abuse
How can BPD develop?
Linehan:
- A tendency to have difficulties regulating one’s emotions (a heritable trait)
- Leads to increased experiences/perceptions that others do not understand the intensity of one’s feelings
- This leads to the self feeling invalidated by one’s social environment
- – E.g. feelings dismissed/denied
- May lead to “BPD like” characteristics or a less severe case of BPD
- In extreme invalidating environments
- – E.g. child experiences abusive acts
- – Leads to violation of autonomy, respect, freedom of choice
- – More severe BPD characteristics develop
What are the DSM IV cluster C disorders?
- Avoidant: social inhibition, feelings of inadequacy, hypersensitive to negative evaluation
- – Often appear anxious or fearful
- – Of being put down/rejected
- – See others as highly critical and superior
- – Few close friends/close partner – but not from choice or lack of interest - leads to loneliness/depression which is often the reason they are seen by services
- – Many similarities between this and social anxiety
- – The fear is more about being in close relationships (and being rejected)
- Dependent: excessive need to be taken care of, leading to submissive and clinging behaviour
- – Self as inadequate
- – Believe need others for protection/to cope with life
- – Root of problem: attachment (bonding disrupted) → behaviourism (parents rewarded dependency and disapproved of independence)
- Obsessive-compulsive: preoccupied with orderliness and perfectionism at expense of flexibility
- – Detail-oriented style
- – Perfectionism/impossible standards
- – Low flexibility, impacts on productivity
- – Minor similarities to OCD (an anxiety disorder) (e.g. low flexibility) but not related
- – OCD anxiety – really don’t want symptoms
- – OCPD = like way they think and behave
What evidence is there for the use of day hospital interventions (psychosocial) for the treatment of BPD?
Piper et al, 1993
- Day hospital program
- Randomised treatment versus control (delayed treatment)
- Programme components:
— Community meetings
— Small group exploration of difficulties
— Self-awareness groups
— Psychodrama sessions
— Expressive arts (art therapy)
— Family relations group
— Problems re-entering community group
— Daily living skills
— Recreation/exercise
— Career help
- Measures included:
— Social dysfunction
— Family dysfunction
— Interpersonal behaviour
— Mood severity
— Life-satisfaction
— Self-esteem
- Results = significant improvement
— Average treated patient scores exceeded 76% of patients in control group
— Improvements maintained at 8-month follow-up
— Waiting list did not improve
— Drop out rate near 30%
- Limitation
— No comparison with other forms of treatment
— No comparison with level of attention received (placebo)
— Program evaluated as a whole (not program components)
Bateman and Fonagy, 1999
- Day hospital program
- Mentalisation-based treatment
- A complex psychoanalytic and attachment theory-based treatment
- Aims = to increase patient awareness and understanding of how they impact on the feelings of others and how others impact on the client’s feelings
- Randomised treatment vs control (standard psychiatric care)
- Components of therapy
— Community meeting
— Group analytical psychotherapy
— Psychoanalytic psychotherapy
— Expressive psychotherapy (e.g. art therapy, psychodrama)
— Medication review
— Case review
- Measures included:
— Frequency of suicide attempts/self harm
— Number/duration of inpatient admissions
— Use of psychotropic medication
— Self reported depression/anxiety/distress
— Interpersonal functioning
— Social adjustment
- Results:
— Significant improvement on all variables for those who were partially hospitalised
— Hence psychoanalytically oriented partial hospitalisation is superior to standard psychiatric care for patients with BPD
— Improvement began at 6 months and continued to end of treatment at 18 months
— Improvements maintained at 18 month follow-up (Bateman & Fonagy (2001))
— And there was additional improvement
— Suggests the partial hospitalisation patients developed the psychological capacities necessary to withstand the normal stresses and strains of everyday life
- Small study group size
- 12% dropout rate
— Low!
- Limitations:
— Only 38 participants
— Did not use the minimisation method of randomisation
Bateman and Fonagy (2009)
- Tested the effectiveness of an 18 month mentalisation based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of BPD
- Patients were also prescribed medication
- Primary outcome = the occurrence of crisis events
— Hospitalisation and severe self-injurious behaviours
- Secondary outcomes = social and interpersonal functioning, self-reported symptoms
- Substantial improvements were observed for both treatments across all outcome variables
- There was a difference between 2 active treatments, but it was over a short period and was unrelated to the amount of therapist contact
- Outpatient MBT was superior to outpatient SCM in terms of effects on suicide attempts, severe incidents of self-harm and on self-reported measures
— This suggests that psychotherapy focusing on psychological functions relevant to symptoms of BPD can enhance a structured, integrated treatment program providing generic psychological support
- Self-harm improved more slowly with MBT than SCM
- Mood, interpersonal measures and social adjustment improved more rapidly
- MBT is relatively undemanding in terms of training so may be useful for implementation into general mental health services
- Structured treatments improve outcomes for individuals with BPD
- Longer term follow up is needed
- Risk of bias because the developers of the method were central in designing and delivering its evaluation
- Replication by independent groups is urgently required
What evidence is there for the use of behavioural (psychosocial) interventions for the treatment of BPD?
Linehan group (1991)
- Dialectical behaviour therapy (DBT)
- DBT = integration of behaviour therapy and cognitive therapy with other perspectives and practices
- Dialectical reasoning = places opposite and contradictory ideas side by side as part of a wider understanding
— Therapist and client to think in dialectical way
— Not polarised but to see value of opposing viewpoints and find an appropriate synthesis
—- Fundamental dialectic = need for therapist to both fully accept client (as they are) AND insist on change.
- Aims of DBT = to reduce self-harm in women with BPD
— Decrease behaviours interfering with treatment
— Cope with difficult feelings
— Increase self-respect
— Achieve own goals in life
— Increase behaviours associated with positive quality of life
- Randomised treatment versus control (standard psychiatric care)
- Primary modes of treatment:
— Individual therapy
— Group: skills (psychoeducation/training)
— Telephone contact (24hr contact available)
— Therapist consultation team to support therapist
- Measures:
— Frequency of suicide attempts/self harm
— Number/duration of inpatient admissions
— Self reported anger, depression, etc.
— Social adjustment
- Results
— Reductions in frequency/severity parasuicidal acts and number of medically treated episodes/days in hospital
— Improvements in anger
— No improvements in depression or hopelessness
— Improved social adjustment
- In general, improvements maintained at 6- and 12-month follow-up
- Drop out rate 16%
Clarkin, Levy, Lenzenweger and Kernberg – 2007
- Examined 3 year-long outpatient treatments for BPD: dialectical behaviour therapy, transference focused psychotherapy (focuses on developing greater self control through the integration of representations of self and other as they are activated in the relationship with the therapist) and a dynamic supportive therapy
- 90 participants – random assignment
- Received medication when indicated
- Far more women than men
- Prior to treatment and at 4 month intervals during a 1 year period, blind raters assessed the domains of suicidal behaviour, aggression, impulsivity, anxiety, depression and social adjustment
- Patients in all 3 treatment groups showed significant positive change in depression, anxiety, global functioning and social adjustment across 1 year of treatment
- Both DBT and transference-focused psychotherapy were significantly associated with improvement in suicidality
- T-F psychotherapy and supportive treatment were associated with improvement in anger and in facets of impulsivity
- T-F psychotherapy was significantly predictive of changes in irritability and verbal and direct assault
- T-F psychotherapy had changes across the most domains
- Need to examine the mechanism of these changes
Turner, 2000
- DBT vs client-centred therapy control condition
- 24 participants – random assignment
- Outcomes showed that the DBT group improved more than the CCT group on these measures
— Suicide attempts
— Self harm episodes
— Psychiatric hospitalisation days
— Suicidal ideation
— Depression
— Impulsiveness
— Anger
— Global psychological functioning
- DBT therapy also maintained patients in therapy for slightly longer than CCT
- The quality of the therapeutic alliance accounted for significant variance in patients’ outcomes across both treatments
- CCT = supportive treatment model, treatment emphasises empathic understanding of the patient’s sense of aloneness
What evidence is there for the use of biological interventions for the treatment of BPD?
Bogenschutz and Nurnberg, 2004
- Olanzapine (atypical antipsychotic) vs placebo
- 40 participants
- Olanzapine was found to be significantly superior to placebo on the Clinical Global Impressions scale modified for BPD
- Weight gain was significantly greater in the olanzapine group
- Side effects??
Criticisms of psycho-social interventions for BPD
- CBT: development of a good therapeutic alliance will be challenging, due to the instability of the patient. This is an important part of the therapy so it may be difficult to access the full effectiveness of CBT
- Day care programs: variety of activities implemented - how do you know which will be effective unless each is evaluated for its effectiveness throughout the program. If one of the activities is much more or less efficacious than the others, then this may affect the results
- – It could also be that the combination of the treatments is effective only; if they were given separately they would be less effective
- DBT: (Scheel, 2000)
- – All the studies have had small numbers of participants
- – Exclusion criteria usually includes multiple diagnoses (BPD commonly overlaps with other psychiatric disorders)
- – DBT only appears to be efficacious for the parasuicidal aspect of BPD, rather than for BPD as a whole (Vermeil et al., 2003)
- – Research on the later stages of therapy (after 1 year follow up) are still needed
- – It has not been established that standard outpatient DBT is more effective across the range of outcome variables than any other comparatively consistent form of treatment
- – It is unclear how the individual elements of DBT contribute to treatment outcome
