Personality Disorder

Question 1

Define personality

Answer 1

Your personality is an enduring pattern of perceiving, relating to, and thinking about the environment and oneself

Question 2

What is a personality disorder?

Answer 2

A personality disorder is a set of personality traits that are pervasive, ingrained, maladaptive and create significant functional impairment or subjective distress.

• Pervasiveness meaning it touches all aspects where applicable. For example, someone may be stubborn towards their parents, but not towards their piers.
• Ingrained meaning it has been a trait for a long time
• Maladaptive meaning it is not constrictive, and gets in the way of life

Question 3

What are the big five personality traits?

Answer 3

• Neuroticism - sensible, sensitive
• Extraversion - high energy level, people person, gets stimulated by being around others
• Openness - emotional, adventurous, curious
• Conscientiousness - self-disciplined, result orientated and structured, tradition and dutiful.
• Agreeableness - compassionate, cooperative, ability to forgive and be pragmatic, lets get the thing done.

A-CONE.

Question 4

What are the ICD-10 classifications of Personality Disorders? (and their clusters?

Answer 4

Cluster A - Eccentric

• F60.0 Paranoid
• F60.1 Schizoid

Cluster B - Dramatic

• F60.2 Dyssocial (antisocial)
• F60.3 Emotionally unstable (borderline)
• F60.4 Histrionic

Cluster C - Anxious

• F60.5 Anankastic (Obsessive-Compulsive)
• F60.6 Anxious (Avoidant)
• F60.7 Dependent

Question 5

What are the features of Cluster A personality disorders?

Answer 5

• Schizoid and paranoid (ICD-10).
• Main features: 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.

Question 6

What are the features of Cluster B personality disorders?

Answer 6

• Emotionally unstable (impulsive and borderline), dissocial, histrionic.
• Main features: Emotional instability, aggression to self or others, impulsiveness, selfishness, self-dramatization, irresponsibility.
• Emotionally unstable seek more help from services because of the increased risk of self-harm and Δ Δ for mood disorders.

Question 7

What are the features of Cluster C personality disorders?

Answer 7

• Anankastic (stubbornness, rigidity), dependent, anxious
• Main features: Anxiety-prone, meticulous, help-seeking, rigid, fearful of new situations, abnormally high standards.
• Dependent seek help from primary care, anankastic and Δ Δ for OCD, anxious and complaints
• People with really strong dependent personality traits will have strange relationships with health professionals - seek a lot of advice from GPs.

Question 8

What is the DMS criteria for bordaline personality disorder?

Answer 8

The DSM criteria states that Borderline Personality disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment.
   
   • Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
3. Identity disturbance: markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, Substance Abuse, reckless driving, binge eating).
   
   • Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5.
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
6. Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights)
9. Transient, stress-related paranoid ideation or severe dissociative symptoms
   
   • When people are in a high state of stress they can present as if they have some features of a more severe mental health disorder e.g. psychosis.

Question 9

What is the DSM criteria for Antisocial personality disorder?

Answer 9

3 of the 7 criteria

1. There is a 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:
   
   1. Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
   2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
   3. Impulsivity or failure to plan ahead
   4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults
   5. Reckless disregard for safety of self or others
   6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
   7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
2. The individual is at least age 18 years.
3. There is evidence of Conduct Disorder with onset before age 15 years.
4. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

Question 10

What is the proposed ICD-11 change on personality disorder classification?

Answer 10

The classification of personality disorders are currently being revised. They are moving away from specific personality trait disorders to more about the severity.

• Difficulty - present but not associated with pervasive dysfunction
• Mild - limited interpersonal dysfunction in one cluster
• Moderate - marked dysfunction, in more than one cluster, clear risk to self or others
• Severe - severe dysfunction, more than one cluster, severe risk (endangering life)
• It is more about a spectrum of personality traits.

Question 11

What are the diffculties in assessing personalities?

Answer 11

• It is not easy, what kind of questions do you ask to gauge people’s personality.
• Their personality history rather than their current mental state is more beneficial.
• Someone with emotional instability may present in different ways at different times/days of the week which can make diagnosis difficult. Especially those with cluster B personality disorder - where emotional instability is a key feature.
• If someone has a current mental state disorder it can be difficult to get an idea of what they are normally like.
• It takes time (more than one interview)
• May not be a priority especially with an agitated or uncooperative patient.
• Complicated by presence of mood disturbance or other ‘axis 1’ disorder
• Patient may not provide a reliable account (ASPD)
  
  • People with ASPD present to services trying to achieve one thing and will be manipulative and deceitful to achieve this.

Question 12

What are the reccomended approaches to assessing persoanlity?

Answer 12

• Use information from personal, employment, social and forensic history.
• Start with a general question: ‘I would like to ask you some more questions about the sort of person you generally are’
• ‘How would people who know you describe you?’
• Try to interview the person on more than one occasion.
• Interview a relative or friend who knows the person well.
• People with emotional instability have a poor sense of themselves as they feel fragmented.
• Sometimes it is better to ask them what a relative thinks they are like, they find this easier and will probably give you a better answer.

Question 13

Describe the aetiology of Personality Disorders

Answer 13

A lot of personality disorder is environmental, but most personality traits (e.g. extroversion/introversion) are hereditary. With most of psychiatry, the aetiology is a mix of environment interacting with temperament (genetic factors - temperament is seen very early on in life).

Environment (50%) = genetic (50%). There is often a massive focus on environmental factors and stories, but a large part of who we are is genetic.

• This influence varies from cluster to cluster. Cluster A and Cluster C are more genetic
  
  • Can be attenuated forms of psychosis.

The biggest environmental factor is an unstable family background – NEGLECT.

• Parental mental illness/drug misuse, social care
• Childhood physical and sexual abuse - particurly for people with borderline personality disorder, studies have shown around 60% had been subject to physical and/or sexual abuse.
• The response of caregivers to abuse
• High levels of physical abuse are reported.

Question 14

Describe the theory of attachment

Answer 14

The impact on abuse and neglect centres around attachment: The bond that develops between a child and caretaker and the consequences this has for sense of self and adult relationships.

There are three attachment patterns, and these relate to infant reaction and development:

• Secure - Responds appropriately, promptly and consistently to needs
  
  • Protests caregiver’s departure seeks proximity and is comforted on return.
  • May be comforted by the stranger but shows clear preference for the caregiver.
• Avoidant - Little or no response to distressed child. Discourages crying and encourages independence.
  
  • Little or no distress on departure. Little or no visible response to return. Treats the stranger similarly to the caregiver.
• Ambivalent - Inconsistent between appropriate and neglectful responses.
  
  • Seeks proximity before separation occurs. Distressed on separation with ambivalence, anger, reluctance to warm to caregiver and return to play on return.
  • Seeks contact but resists angriIy when it is achieved.
  • Not easily calmed by stranger.

Question 15

What are the consequences of ambivalent attachment?

Answer 15

Ambivalent attachment has implications on:

• Development of a sense of self
• Self-hatred and self-harm
• Ability to tolerate distress
• Ability to calm yourself
• Ability to stop and think and consider alternatives
• Ability to trust others
• Ability to trust yourself
• Knowing how to express needs (scream or withdraw)

This all leads to impaired social and interpersonal functioning –> personality disorder

Question 16

What is the prevalence of Personality Disorders?

Answer 16

• Community (4%) (<1% severe)
• Primary care (27-33%) (5% severe) particularly because of the tendency of cluster C people to seek primary care.
• Psychiatric clinics (35-44%) (10% severe)
• Prisons (70-80%) (50% severe) due to antisocial personality disorder.
• Higher rates of cluster B in inner city areas and cluster A and OCPD in rural areas

Question 17

What is the international distribution of personality disorders?

Answer 17

Countries which are more stable may have less levels of personality disorder. There seems to be link between civil arrest and personality disorder; should not be a surprise taking into account the importance of a stable family in the aetiolohy of PD.

Question 18

What is the prognosis and complications of personality disorders?

Answer 18

Overall, outcome is poor because these personality traits tend to be ‘Ingrained’

• Over 20 years – cluster A and C increase in severity (paranoia, rigidity and stubbornness)
• Cluster B improve – decreased impulsivity and self-harm (50% ‘recovered at 2 years, 80% at 10yrs)

Concomitant problems:

• 40% of people who die by suicide have evidence of PD
• 70% of people with drug dependence
• 60% of prisoners
  
  • Offending behaviour from impulsivity and aggression.

Reduced life expectancy (18 years)- similar to psychosis.

• Antipsychotics can place you at risk of metabolic syndrome.
• Smoking rates are high.
• Less likely to seek treatment for cardiovascular disease, or physicians may prejudice against you because of PD.

Question 19

Describe the psychodynamic concept of transference and why it is important in assessing patients.

Answer 19

• Transference: Redirection of a patient’s feelings for a significant person to the clinician/ therapist.
  
  • Transferring something from the past into this room with you.
• Counter-transference: Redirection of a clinician’s/therapist’s feelings toward a patient.

Transference is important, as it gives us clues about the nature of the underlying psychological difficulty. It is a psychodynamic term.

Question 20

What are the general principles in the approach to management for PD?

Answer 20

Principles of management

• Staying calm - containing your anxiety
• Acknowledge distress, not justifying their behaviour, but acknowledging their distress.
• Simple thing to do but it can be helpful.
• Find out what’s going on

More PD specific:

• Avoiding extremes e.g. dismissing - taking over
  
  • People who present in extreme ways can sometimes provoke extreme reactions e.g. want to do an awful lot for them or to dismiss them entirely.
• Active participation of patient in working out what to do (what helped in the past?)
  
  • I need you to calm down, how could you do this? Going for a walk? Smoke?
• Being consistent as a service - quite difficult because patients who have these interpersonal issues can bring out different responses from different healthcare professionals.
  
  • People with emotionally unstable PD sometimes see some clinicians as good or bad.
• Know your limits and boundaries.
  
  • “Don’t worry I’ll sort it out” is bad practise.

Question 21

What are the pros/cons in labeling someone with a PD?

Answer 21

Pros:

• Helping inform patients and relatives
• Guiding patient management
• Avoiding treatments that don’t work
• Being able to offer treatments that do

Cons:

• Mislabelling social deviance
• Diverts limited resources from those who need them most
• Undermining personal responsibility
• Creating dependency

Question 22

What are the challenges in delivering psychological treatments to people with personality disorders?

Answer 22

Delivering psychological treatments for people with personality disorders is extra hard because they are/have:

• Lack of trust - Engagement more difficult to attain
• Affective instability - Commitment more difficult
• Unstable relationships - Motivation to continue therapy if they don’t like their therapist.
• ‘Frantic efforts to avoid abandonment - Treatment endings

Question 23

What are the consequences of insecure attachment?

Answer 23

Insecure attachment leads to:

• Poor sense of self
• Poor development of social and emotional skills
• Development of maladaptive cognitions

One of the concepts used to link insecure attachment to personality disorder is the concept of mentalising

Question 24

What is mentalising, and the types of mentalising?

Answer 24

Mentalising is the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes. It is a profoundly social construct in the sense that we are attentive to the mental states of those we are with, physically or psychologically. I.e. what the mental processes is behind someone doing/saying something. E.g. if someone is not paying attention, the lecture will mentalise to think they are not liking their lecture, or maybe mentalise they had a long night.

• 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 mentalisation. Thinking about mentalisation allows the separation of what reality is suggesting, and how this translates to what we’re thinking.

Question 25

Describe the development of the self in an infant

Answer 25

The infant does not have a sense of self. The infant internalises caregiver’s representation to form psychological self.

• The child does something and sees what the response is from the attachment figure. From this they have a representation of the attachment’s figure’s identity.
• In a secure attachment, this process of inference of the care-giver by their response, and the subsequent internalisation is repeated over and over again. Eventually this leads to the concept of self.

This process is referred to as mirroring, and helps to build the sense of self.

Question 27

Describe the process of mirroring

Answer 27

The infant does not have a sense of self. The infant internalises caregiver’s representation to form psychological self.

The child does something and sees what the response is from the attachment figure. From this they have a representation of the attachment’s figure’s identity.

In a secure attachment, this process of inference of the care-giver by their response, and the subsequent internalisation is repeated over and over again. Eventually this leads to the concept of self.

This process is referred to as mirroring, and helps to build the sense of self.

Question 28

What constitutes a healthy form of mirroring

Answer 28

There is some evidence to suggest that mirroring needs to be contingent and marked by the parent. ?Mirroring is something that the caregiver tends to do, i.e. match the infant’s emotional state. In supportive psychological environments, mirroring is contingent and marked.

• Contingent mirroring is where what you give, is in keeping with what you get back.
• Marked is referring to its modification.

Question 29

How does mirroring contribute to the ability to accurately mentalise?

Answer 29

• If the mirroring is incongruent, i.e. the baby laughs, and the parent yells, the representation of internal state does not match the environment. (Pretend mode)
• Un-marked mirroring means the infant will develop a sense that whatever is going in in their head, is going on in the environment. I.e if I am scared, the environment is scary (Psychic equivalence mode)
• Whereas a contingent and marked response tells the child their emotions are acknowledged but not reflective of the environment.

Question 30

What influences the adult’s ability to mentalise?

Answer 30

Mirroring and attachment as infants.

Our ability to mentalise varies according to mental state.

• Impaired by mental illness and substance misuse.
• Reduced at states of heightened emotional arousal – new relationships, we mentalise less when we develop close relationships (attachment). There may be a biological basis for this.
• Impaired in people with BPD when relations end.

Question 31

What are the psychological treatments for personality disorders?

Answer 31

• Mentalisation Based Therapy
• Schema Focused Therapy
• Dialectical Behaviour Therapy

Question 32

What is Mentalisation Based Therapy (MBT)?

Answer 32

Mentalization Based Treatment (MBT) is a modified psychoanalytical psychotherapy – counter-transference, tolerance of anxiety, interpretation. Used for borderline personality disorder, where people have obvious problems with metalisation.

• Focuses on developing a patient’s mentalising capacity
• Here and now rather than why people have these problems.
• Individual and group work
• 18 months (twice weekly sessions)

Question 33

Describe the process by which how MBT helps the patient mentalise

Answer 33

The therapists stance is that we cannot know why someone is doing something simply by their actions. Patients with BPD are very quick to make assumptions about why someone is doing something. Therapists are trying to make this explicit mentalisation of the environment, to mentalisation that is implicit. To do this, therapists will:

• Ask questions to promote exploration
• Ask about patient’s understanding of motives
• Highlight alternative perspectives
• Avoid simplified explanations - interpretations
• You are only thinking that because you are tired etc.
• Model honesty from the therapists and courage via acknowledgement of your own mistakes. Mentalisation is affected by mental states (as discussed earlier), so the therapist may also be wrong. Important that the therapists admits to this to show complexity.

Example questions:

• Why do you think he said that he…..
• I think what you are really telling me is…
• I can’t be sure, but it seemed to me that…

A stance that we can never be clear about people’s intentions.

Question 34

Why is group therapy particularly helpful for MBT?

Answer 34

Group therapy is useful. Having theoretical conversations about mentalisation is not very helpful. Furthermore, if the patient is mentalising with a therapist that is fairly consistent, you will find that the patients is able to mentalise well within that psychological environment, but not outside it. The best way for letting patients see when they’re not mentalising is bringing groups of patients together who have trouble mentalising - this often leads to discussions/arguments/misunderstandings. This can be facilitated by:

• Highlight who feels what
• Identify how each aspect is understood from multiple perspectives
• Identify how messages feel and are understood, what reactions occur
• What do you think it feels like for X?
• Can you explain why he did that?
• Can you think of other ways you might be able to help her really understand what you feel like?

Question 35

What is the evidence base to support motivation based therapy?

Answer 35

(Bateman et al 2009) Three randomised trials of MBT compared to TAU. You see

• Markedly superior improvements 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).
• However, differences less marked when compared with better TAU - ‘structured clinical management’

Question 36

Describe how the development of (mal)adaptive cognitions can lead to personality disorders

Answer 36

Children with problems with temperament mixed with a neglectful environment, will try to make sense of their environment. I.e. form schemas. (Schema – superordinate/organising thoughts are how people organise and make sense of their world). These are the ‘generals’ of information processing, and influence how people generally see themselves, or see the world. These schema/cognitions can be

• Adaptive - processing information that is helpful in the context of neglect/ trauma
  
  • May cease to become helpful later on in life, and therefore by definition become maladaptive.
• Maladaptive - when the context changes and these linked thoughts impair functioning

Oversimplifications:

• You may have a child with average temperament, but in childhood experiences threats and victims of minor assaults. They therefore develop adaptive schema that ‘other people are a treat’, which becomes maladaptive in later life when this schema is not relevant in their new context. This is seen as a paranoid personality.
• Parents who do not show their children much attention, may have children who develop dependent personalities: The schema the child developed is that they are helpless à they trying to cling to others.

Question 37

Describe Schema Focused Therapy and how its used to treat Personality Disorders

Answer 37

Modified CBT – to learn about the early maladaptive schema the person developed. Bring the aetiology of this thought to the patient, and allow them to understand the impact these thoughts are having on the patient.

• Longer duration and intensity 2x week 18-24 months
• People seek consistency and predictability. Schema help people make sense of something new.
• Identification and exploration of the role of these ‘higher order’ cognitive processes in individual sessions or in a group.
• EVIDENCE BASE: Three randomised trials showing that it is cost effective and may be more effective than alternative psychodynamic psychotherapy.

Question 38

Describe the process of Dialectical Behaviour Therapy for PD

Answer 38

The most widely used psychological treatment for borderline personality disorder in the UK.

• Focuses on the patient’s failure to develop emotional and interpersonal skills.
• Has more of a focus on training and self-calming behaviours. Tends to be more of a training than psychological inquiry.
  
  • Mindfulness: The capacity to pay attention, non-judgmentally, to the present moment - living in the moment. Useful skill that develops psychological resilience across a whole range of settings.
  • 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.

Question 39

How is Dialectical Behaviour Therapy delivered?

Answer 39

Delivery

• Teaching new skills: mindfulness, emotional regulation, interpersonal effectiveness, distress tolerance.
• Distraction – focusing on taste of a grape!
• Enhancing motivation: use of diary card and behavioural chain analysis.
• Weekly 1 hr sessions + weekly 150 min group + telephone consultation + weekly therapists meeting.
• 12-18 months

Question 40

Describe the evidence-base for Dialectical Behavioural Therapies

Answer 40

• Eight randomised trials (n = 10 to 180)
• Marked reductions in self-harm. But the effect size is not different to general psychiatric management.
  
  • Largest trial by McMain (2009) comparing it with high quality general psychiatric care (No difference).
  • Some of the psychological treatments may only be effective as they are consistent which standard therapy may not always be. If standard care if good then you sometimes don’t see a difference to DBT.

Raises the question about, how much are specific psychological aspects of the treatment contributing towards this effect, and how much is the general psychological aspect such as providing consistency, care etc.?

Question 41

What are the NICE reccomendations for treatment of personality disorders?

Answer 41

• Avoid treatments of short term duration
• Use an explicit and integrated approach which is shared with the service user
• Frequency should be adapted to needs, but twice-weekly sessions may be considered
• For women with borderline PD for whom reducing self-harm is a priority consider a programme of dialectical behaviour therapy

Question 42

What are the problems of treating personality disorders?

Answer 42

• Many people with severe PD do not want psychological treatment (50% do not engage and 30% of those who do drop out before completion)
• Medication?
• What else might work?