Personality Disorder

Question 1

What is personality?

Answer 1

There is no universally agreed definition - behaviour is due to personality and situation

BPS - coherant and enduring features of individual + processes underlying these
View of self and others, attitudes/beliefs
Made up of traits which influences situations
Big 5

Question 2

What is personality disorder?

Answer 2

Variations/exaggerations of normal personality attributes
Impairs wellbeing and social functioning
Not necessarily antisocial behaviour
Reduces effectiveness of usual treatments

Question 3

What is ICD-11 definition of PD?

Answer 3

An enduring disturbance characterised by problems in functioning in aspects of the self and in interpersonal functioning
Self made up of identity, self-worth, accuracy of self-view, self-direction

Question 4

What is the difference between ICD and DSM?

Answer 4

DSM is the American version

Question 5

How were PD characterised in the past?

Answer 5

Diagnostic systems characterise them into a number of different types - borderline, emotionality personality disorder, narcissistic, avoidant etc

Question 6

What are the problems with the way PD used to be characterised?

Answer 6

Few people fit neatly into one box - often characteristics of several and reliability of diagnosis is poor between different practitioners

In practise, only a few of the categories are used in clinical practise (borderline/emotionally unstable, antisocial and narcissistic)

Question 7

What is a better way to categorise PD?

Answer 7

A dimensional model of degree of severity is more helpful (into different clusters) - also identifies different traits or domains which represent the more pathological end of the OCEAN personality factors

ICD identifies negative affectivity, detachment, disinhibition, dissociality and anankastia

Question 8

What is borderline personality disorder / emotionally unstable PD?

Answer 8

Significant instability of interpersonal relationships, self-image and mood
Impulsive behaviour
Rapid fluctuations of mood 
Fear of abandonment and rejection
Suicidal behaviour and self-harm
Transient psychotic systems - voices
Substantial impairment

Question 9

What are the issues around diagnosing a PD?

Answer 9

Validity of diagnosis and classification systems - low reliability, not discrete categories
Atheoretical basis of diagnositic classification (no theory)
Overlap with over diagnosis - such as complex as PTSD
Hard to pick up in females
Stigma - bad person, negative views of themselves

Question 10

What are the benefits of retaining concept of PD?

Answer 10

Pragmatism - success of doing it
Communication between staff - awareness of someone with BP is good
Choice of treatments with better outcomes - specialised treatment for them
Service development and research
Basis for internal conceptual framework for staff
Increasing use of term ‘complex emotional difficulties’ - people more likely to open up and feel less scared

Question 11

How common is PD?

Answer 11

10% of general population
Higher prevalence in MH population
50-70% of adult prisoners
Similar incidence in men and women diagnosis of PD
Differences in which categories more frequently in men and women

Question 12

Are females and males as likely to develop a PD?

Answer 12

Yes - similar incidence but there are differences in which categories they have

Question 13

What are the causes of PD?

Answer 13

Combination of biological, psychological and social factors:

biology - variable heritability
genetic difference impact resilience
insecure early attachments
emotional neglect biggest factor
social and psychological dysfunction in family (parents who are substance users/domestic abuse)
childhood trauma - complex

Stress vulnerability model - interaction between early vulnerability and stress

Question 14

What is the attachment theory?

Answer 14

Developed by Bowbly, later developed by Ainsworth

Believes attachment is the universal human need to form close relationships to obtain protection - attachment involves a behavioural system triggered by need a fear, which is reciprocated by care-giving behaviour

If we have a secure attachment - learn world is safe and learn what our feelings are by our caregiver monitoring out feelings so we know world isn’t frightening

Question 15

What are the types of attachment?

Answer 15

Either secure or insecure

3 types of insecure attachment: avoidant, ambivalent, disorganised

Question 16

When do the types of insecure attachment develop?

Answer 16

Avoidant attachment develops when distress is ignored: child turns emotions in on itself and rejects carers

Ambivalent attachment develops when there are inconsistent responses: child becomes both resistant and over dependent

Disorganised attachment develops when there is a frightened/frightening caregiver: child experiences fear without solution and alternates between flight, freezing, fighting

Disorganised attachment particularly associated with later development of BPD

Question 17

What are the models of disorganised attachment?

Answer 17

Attachment system triggered by fear
When feel stressed, activate attachment system so that they will seek proximity
but if the person they are seeking, is the one who causes problems and they aren’t attached too, will cause more stress and expose them to maltreatment - fear without solution

Question 18

What are the models of therapy for BPD?

Answer 18

Mentalistion based therapy
Dialectical behavioural therapy
Schema based theory
STEPPS programme
Structured clinical management

Question 19

What is metallisation based therapy (MBT)?

Answer 19

Developed in England
Based on attachment
Mentalisation - working out what is going on in your mind and the minds of others (mental states)
Understanding that behaviour arises from own mental states
Capacity to mentalists arises from attachment relationships - internalise representation of self from responses of attachment figues

Question 20

What happens in disorganised attachments develop in MBT?

Answer 20

If disorganised attachment develops, capacity to mentalize fails to develop sufficiently and attachment system tigger too easily
In later life develop intense, dependent relationships
Difficulties with mentalization underlie all BDP features

Question 21

How does MBT work?

Answer 21

Focus on promoting mentalization about the self, others and relationships
Aim to develop capacity even when in an emotional state
Attitude of curious enquiry
Collaborative approach
Emphasis on working to understand breakdowns in mentalization
Theraputic relationship focusses on keeping emotional arousal at optimum level
Delivered via weekly group and 1.1 therapy

Question 22

What is dialectical behavioural therapy?

Answer 22

Developed in America
Incorporates CBT and Zen buddhist techniques
Views primary dysfunction as difficulty in emotional regulation
Biosocial model - biological factors interacting with invalidating early environment

Question 23

What is taught in dialectical behavioural therapy?

Answer 23

Skills training to improve emotion regulation, distress tolerance and interpersonal functioning (CBT based)

Key skill taught is “Mindfulness” (Zen approach)
Mindfulness = open attention to current experience or present reality
Dialectics = balancing opposites e.g. acceptance and change

Delivered via weekly skills group and 1:1 therapy (18 months)

Question 24

What is schema based therapy?

Answer 24

Comes from cognitive therapy tradition
Behaviours are expressed of underlying core belief/schema (people are going to leave me)
Schema is deep structure concerning beliefs about nature of self and others
PD involves early maladaptive schemas (EMS) - which provides templates for processing later experiences

Interfers with self-expression, autonomy, interpersonal relatedness, social validation, social integration

Question 25

What goes on in schema based theory?

Answer 25

In therapy EMS are explored and related to developmental origins

Focus on constructing personal narrative and identifying what is adaptive

Emphasis on quality of therapeutic relationship – usually 1:1 therapy

Question 26

What is the STEPPS program?

Answer 26

Widely delivered across Sussex trust
Highly structured psycho-educational 20 week program
1.1 reinforcement and teaching for reinforcement group
includes teaching about schemas
Taught to identify these during emotional intensity episodes

Other CBT techniques taught - relaxation, distraction, distancing, problem-solving, lifestyle)
followed by less intensive year long stairways program

Question 27

What is structured clinical management?

Answer 27

Based on research evidence into effectiveness of treatments for BPD
Draws on MBT understandings and uses some DBT skills
Delivered by generalist mental health professionals
Emphasis is on clear structure to treatment and active and collaborative clinician approach

Question 28

What goes on in structured clinical management?

Answer 28

Includes weekly 1:1 sessions and weekly group which uses a problem-solving approach

Focus is learning to tolerate emotions and mood management, managing impulsivity, and interpersonal sensitivity/problems

Includes teaching about schemas (filters)

Taught to identify these during “emotional intensity episodes”

Other CBT techniques taught (relaxation, distraction, distancing, problem-solving, life-style and relationship issues, avoiding self damaging behaviours)

Followed by less intensive year long “Stairways” programme

Question 29

What are the current best practise recommendations for BPD?

Answer 29

• Based on NICE Guidelines 2009 and BPS report 2006
BPD considered treatable - ensure it is seen as treatable

Goals focus on modification

No clear evidence of superiority of one treatment model

Treatment should be intensive, long-term, theoretically coherent, well-structured and well-integrated - everyone uses the same terminology and same sort of treatment

Intervention needs to focus on engagement and collaborative quality of therapeutic relationship

Gradually improves over time

Question 30

What are early maladaptive schemas?

Answer 30

An early maladaptive schema has been defined by Jeffrey Young as ‘a broad pervasive theme or pattern regarding oneself and one’s relationship with others, developed during childhood and elaborated throughout one’s lifetime, and dysfunctional to a significant degree

Question 31

What are the big 5 personality traits?

Answer 31

Openness to Experience (Closed to Experiences)
Conscientiousness (Lack of Conscientiousness)
Extraversion (Introversion)
Agreeableness (Disagreeableness)
Neuroticism (Emotional Stability)

Question 32

What are the different clusters?

Answer 32

Cluster A - odd/ecentric (paranoid, schizoid, schizotypal)

Cluster B - dramatic/erradic (antisocial, boderline, histrionic, narcissistic)

Cluster C - anxious/fearful (avoidant, dependent, obsessive)