Personality Disorder

Question 1

What is personality?

Answer 1

No universally agreed definition. BPS - coherent and enduring features of the individual and processes underly personality. Involves view of self and others, attitudes and beliefs, relationships, coping and emotions. Made up of traits. Your personality with influence how you experience situations.

Question 2

What are the “Big 5 “ traits (OCEAN)?

Answer 2

O = openness to experience (rigidity on the opposite end).
C = conscientiousness (impulsivity on the opposite end).
E = extroversion (introversion on the opposite end).
A = agreeableness (antagonism on the opposite end).
N = neuroticism (emotional stability on the other end).
Seen as biologically driven basic tendencies.

Question 3

What is personality disorder?

Answer 3

Variations/exaggerations of normal personality attributes. Impairs well-being and social functioning – capacity to have relationships, sustain a social life. Not necessarily antisocial behaviour. Reduces effectiveness of usual treatments.

Question 4

What is the ICD-11 definition of personality disorder?

Answer 4

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

Question 5

What are categorical versus dimensional models?

Answer 5

¥ Until now diagnostic systems have categorised personality disorder into a number of different types – could be borderline, narcissistic etc.
¥ Problems with this is that few people fit neatly into one box, and reliability of diagnosis is poor between different practitioners
¥ In practice only a few of the categories are used in clinical practice (borderline/emotionally unstable, antisocial and narcissistic?)
¥ Recognition that a dimensional model of degree of severity is more helpful
¥ Also identify different “traits” or “domains” which represent the more pathological end of the OCEAN personality factors
¥ ICD-11 identifies negative affectivity (go with neuroticism), detachment(extraversion/introversion), disinhibition(impulsive), dissociality (antagonism) and anankastia (rigidity, obsessive, need things to be very ordered)

Question 6

What is borderline personality disorder/emotionally unstable PD?

Answer 6

¥ Significant instability of interpersonal relationships, self image and mood
¥ Impulsive behaviour
¥ Rapid fluctuations of mood
¥ Fear of abandonment and rejection
¥ Strong tendency to suicidal behaviour and self harm
¥ Transient psychotic symptoms – usually hearing voices, most of the time these negative voices convey negative messages
¥ Substantial impairment – gets into the way of work and being able to maintain stable relationships
¥ Risk of suicide – a lot of the time meant for attention seeking

Question 7

What are issues around diagnosis of personality disorder?

Answer 7

¥ Validity of diagnosis and classification systems - low reliability, not discrete categories
¥ Atheoretical basis of diagnostic classification – less so for new models. Not based on theory, just something observed
¥ Overlap with Complex PTSD – experience repeated trauma, neurodevelopmental disorders (underlying autistic spectrum disorder)
¥ Stigma – “bad person”; negative views of self

Question 8

What are benefits of retaining the concept of personality disorder?

Answer 8

¥ Pragmatism
¥ Communication between staff
¥ Choice of treatments with better outcomes – once considered untreatable, not longer the case
¥ Service development and research
¥ Basis for internal conceptual framework for staff
¥ Increasing use of term “Complex Emotional Difficulties”

Question 9

How common is personality disorder?

Answer 9

¥ 10% of general population- but difficulty to count numbers based on problems diagnosing. Previously people may have diagnosed as depression
¥ Higher prevalence in mental health population
¥ 50 – 70% of adult prisoners
¥ Similar incidence in men & women diagnosis of PD
Differences in which categories diagnosed more frequently in men and women

Question 10

What are the causes of personality disorder?

Answer 10

¥ Combination of biological, psychological, social factors
¥ Biology – dimensions have variable heritability
¥ Genetic differences impact on resilience – if closer to emotionally unstable side, need lesser degree of adversity to end up with difficulties
¥ Insecure early attachments – has commonly been associated with previous sexual abuse, but most harmful experience for children is emotional neglect
¥ Emotional neglect biggest risk factor
¥ Social and psychological dysfunction in family – mediated by attachment. If had parents who were substance abusers, they would be unreliable attachment figures
¥ Childhood trauma – complex (but not always present)
¥ Stress-vulnerability model – interaction between internal vulnerability and stress, and at a certain point you get a tipping point .

Question 11

What is attachment theory?

Answer 11

Attachment theory was developed by John Bowlby and later elaborated by Mary Ainsworth and others. Attachment is the universal human need to form close relationships, to obtain protection. Attachment involves a behavioural system triggered by need and fear, which is reciprocated by care-giving behaviours. If we have secure attachment relationships we learn that the world is reasonably safe and predictable. We also learn what our feelings are, why we have them and to not be scared of them. We learn this by our caregiver “mirroring” our feelings, in a way that shows that they are not frightening.

Question 12

What are the three sub-types of insecure attachment, and how do they develop?

Answer 12

3 sub-types of insecure attachment: avoidant, ambivalent, disorganised (worst, particularly associated with subsequent diagnosis of borderline personality disorder)
¥ 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 13

What is a model of disorganised attachment?

Answer 13

Distress/fear will lead to activation of attachment system, which will lead them to seek proximity. However, if they seek proximity from the person causing this they are exposed to maltreatment, and then the cycle begins again.

Question 14

What are models of therapy for BPD?

Answer 14

¥ Mentalization Based Therapy (MBT)
¥ Dialectical Behaviour Therapy (DBT) – most well known
¥ Schema Based Therapy – development out of CBT
¥ STEPPS programme
¥ Structured Clinical Management (SCM)

Question 15

What is mentilisation based therapy?

Answer 15

Developed by Anthony Bateman and Peter Fonagy, developed in England. Based on Attachment Theory. Mentalization = working out what is going on in your mind and the minds of others (mental states). Many with this disorder know they feel bad, but don’t know why. Won’t know the difference between anxiety and anger, not in tune to body, feel people are out to hurt rather than help them. Involves understanding that behaviour arises from mental states. Capacity to mentalize arises from attachment relationships – internalise representation of self from responses of attachment figure. If disorganised attachment develops, capacity to mentalize fails to develop sufficiently and attachment system triggered too easily. In later life develop intense, dependent relationships. Difficulties with mentalization underlie all BPD features.

Question 16

How does MBT work?

Answer 16

Focus on promoting metallisation about self, others and relationships, teaching about what it means. Aim to develop capacity even when in an emotional state -very emphatic toward other people, helpful, but don’t have it about themselves, and particularly don’t have it when they become emotional aroused. Attitude of curious enquiry. Collaborative approach. Emphasis on working to understand breakdowns in mentalisation. Therapeutic relationship focuses on keeping emotional arousal at optimum level – not too little or too much emotionally aroused. Delivered via weekly group and 1:1 therapy (18 months).

Question 17

What is dialectical behaviour therapy?

Answer 17

Developed by Marsha Linehan, developed in America. Incorporates CBT and Zen Buddhist techniques. Views primary dysfunction as difficulty in emotion regulation – ability to keep emotions within window of tolerance. Biosocial model – biological factors interact with invalidating early environment – having experiences validated, feel deeply rejected. 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, its about noticing but not being caught up in it. Dialectics = balancing opposites e.g. acceptance and change (using skill to do something different). Delivered via weekly skills group and 1:1 therapy (18 months).

Question 18

What is schema based therapy?

Answer 18

Developed by Jeff Young. Comes from cognitive therapy tradition. Behaviours are expression of underlying core belief / schema. Schema is deep structure concerning beliefs about nature of self and others – abandonment schema would be “everyone is going to leave me”. PD involves Early Maladaptive Schemas (EMS). EMS provides template for processing later experiences. Interferes with self expression, autonomy, interpersonal relatedness, social validation, social integration – everything that makes up personality. 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 19

What is the STEPPS programme?

Answer 19

Developed by Nancee Blum. Widely delivered across Sussex Trust. Highly structured psycho-educational 20-week group programme. 1:1 reinforcement and teaching for “reinforcement group” – helps them to go over material they would have covered in previous group, also given homework. Includes teaching about schemas (filters). Taught to identify these during “emotional intensity episodes” – learning to understand it changes, and being able to understand you can turn it around if you do something early on. 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 20

What is structured clinical management?

Answer 20

Developed by Anthony Bateman, Peter Fonagy & Roy Krawitz. 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, usually community psychiatric nurses. Emphasis is on clear structure to treatment and active and collaborative clinician approach – relationship between clinician and person being treated. 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 21

What is the current best practice recommendations for BPD?

Answer 21

Based on NICE Guidelines 2009 and BPS report 2006:
¥ BPD considered 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 between other services
¥ Intervention needs to focus on engagement and collaborative quality of therapeutic relationship.

Question 22

What are the three personality disorders recognised by the DSM?

Answer 22

(1) Cluster A (odd/eccentric)
(2) Cluster B (dramatic/flamboyant) - borderline
(3) Cluster C (anxious/fearful).

Question 23

What is an overview of PD?

Answer 23

1 in 20 people in the UK has difficulties that would meet the criteria for a diagnosis of personality disorder. Normally a mix of more than one disorder. Often have a range of physical health problems, e.g. liver/kidney disorders, HIV, and chronic pain. PD has its origins in infancy, but becomes apparent in early adolescence/young adulthood. Most have experienced some form of abuse, neglect or significant invalidation in childhood.

Question 24

What is ‘emerging personality disorder’?

Answer 24

The strategies for managing emotions and managing relationships differ for each PD and for each individual.

Question 25

What are the most commonly diagnosed personality disorders?

Answer 25

Antisocial personality disorder (ASPD) and borderline personality disorder (BPD). ASPD commonly associated with criminal behaviours. They lack remorse for their actions, don’t respond to standard punishments. People with BPD engage in impulsive and self-harmining behaviours - suicide attempts and self-harm rates are high.

Question 26

What psychological therapies have shown to be effective for personality disorder?

Answer 26

CBT, dialectical behaviour therapy, mentalisation-based therapy, therapeutic communities, cognitive analytic therapy, and psychodynamic therapies. Outcomes include reduced suicide attempts and self-harm behaviours, reduced readmission rates to psych wards.

Question 27

What is the cognitive-behavioural approach to personality disorders?

Answer 27

Based on the ABC model by Beck - A (activating event), B (beliefs), C (consequences - emotional, behavioural, and psychophysiological). According to CBT framework, there are two types of core beliefs - cold cognitions (e.g. ideas of “unlovability” and “helplessness” coded in the human mind as schemas), and hot cognitions (demandingness, catastrophising, and frustration intolerance). The CT model for PD is mainly focused on the cold general core beliefs and the mechanisms to cope with them.

Question 28

What does the CBT intervention for PD include?

Answer 28

The CBT intervention for personality disorders typically includes clinical assessment, cognitive conceptualisation, technical interventions, and building and using the therapeutic relationship, much the same as treatment for symptomatic disorders. The CBT intervention for personality disorders is typically longer than the CBT intervention for other clinical conditions and often includes more experimental techniques, creating a multimodal approach. The interventions could be delivered individually or in a group.

Question 29

Is psychotherapy effective for PD?

Answer 29

Strong support for the use of psychotherapy for PDs in terms of efficacy and effectiveness. Found patients treated for MD also improved in regard to an identified personality disorder.