Personality Disorder II

Question 1

Antisocial PD Assumption and Causes

Answer 1

• Assumption: People act in a rational manner guided by logic, rules & social convention/mores
  
  • So why does a subgroup of individuals engage in repeated behaviours that are:
  • Carried out with scant regard for consequences
  • Reflect an inability to delay gratification
  • Apparently self-defeating (cause harm to themselves or to others)
  • Irrational in that aversive outcomes outweigh reward?

Question 2

Aetiology of Antisocial PD

Constitutional Factors

Answer 2

• Causes not fully understood
• Constitutional factors (neurobiological correlates) establishes predisposition with expression of antisocial variant determined by environmental & familial influences
  
  • Externalising vulnerabilities: heritable broad trait-dispositional factor reflecting disinhibitory personality & risk-taking found in childhood conduct disorders, adult antisocial behaviour, and substance-use disorders

Question 3

Aetiology of Antisocial PD

Biological Factors

Answer 3

• Reduced levels of serotonin (impulsive behaviours)
• Low resting heart rate >> physiological hypo-arousal >> sensation seeking
• Neuropsychological deficits on frontal lobe executive functioning
  
  • Weak behavioural inhibition & emotional reactivity (less responsive to threat & punishment)
  • Evolutionary advantage(?)

Question 4

Aetiology of Antisocial PD

Psychosocial Factors

Answer 4

• Personality & temperament, shaped by environment & learned coping skills to deal with stress
• Social factors: childhood dysfunctional role modelling & interactions with family
• Peer group interactions: deviant sub-cultures - cause or effect?

Question 5

Antisocial PD: Treatment

Answer 5

• Literature reviews indicate inherent difficulties and ineffectiveness of psychological interventions (e.g., CBT, psychotherapy)
• Pharmacological agents to reduce aggressive​ impulsivity (lithium, serotonin selective reuptake inhibitors)
• Multifaceted interventions targeting impulsivity, aggression, addictive urges, and narcissistic traits required BUT outcomes not positive, particularly for the severe end of the spectrum (psychopathy)

Question 6

Aetiology of Borderline PD

Genetic Factors

Answer 6

Brain structure

• Threatening/aversive stimuli activate amygdala >> anterior cingulate >> prefrontal cortices
• Anterior cingulate: cognitive evaluation/processing of mood & affect regulation (implicated in response to conflicts)
• Prefrontal cortex: inhibition of impulsive aggression by regulating amygdala

Brain chemistry

• Serotonin regulates impulses, aggression & affect: linked to emotional instability, suicidal behaviours & impulsivity behaviours
• Low levels of serotonin impair control of destructive urges

Question 7

Aetiology of Borderline PD

Childhood complex traumas

Answer 7

• Emotional/sexual/physical childhood abuse implicated in aetiology >> developmental arrest
• BUT abuse alone neither necessary/sufficient
• Child-parent relationship mediating factors (unstable, non-nurturing, lack of parental empathy & invalidation of experiences) hinders/distorts development of secure attachments >> emotion dysregulation
• Exacerbated if family member is perpetrator
• Attachment theory: infants construct internalised concepts of self & others based on experiences
• Sense of security & self-worth enhanced by family members shapes personality traits
• Parental failure to teach child to label & regulate emotional arousal, tolerate emotional distress, and when to trust own emotional responses during distress
• In adulthood, individuals invalidate their own emotional experiences & depend on others for accurate reflections of external reality

Question 8

Primary characteristics manifestations of BPD psychopathology

Answer 8

• Emotional dysregulation
• Behavioural dysregulation
• Interpersonal dysfunction

Question 9

What does BPD treatment target?

Answer 9

IMPULSIVE​

• Impulsive
• Moodiness
• Paranoia under stress
• Unstable self-image
• Labile & intense relationships
• Suicidality
• Inappropriate anger
• Vulnerability to abandonment
• Emptiness (sense of identity)

Question 10

Dialectical behaviour Therapy (DBT) for BPD

Answer 10

• Developed for Borderline PD by Marsha Lineham (1993)
• CBT-based intervention for chronically suicidal behaviours
• A bio-psycho-social model that builds on / modifies traditional behavioural approaches

Question 11

Goals of DBT

Answer 11

• CHANGING behaviours causing suffering whilst simultaneously
• ACCEPTING oneself and current situation/life circumstances
• to enhance behavioural, emotional thinking & interpersonal interactions

Question 12

4 modules of DBT

Answer 12

Each containing coping skills used to achieve specific goals:

• ACCEPTANCE skills
  
  • Mindfulness
  • Distress tolerance
• CHANGE skills
  
  • Interpersonal effectiveness
  • Emotion regulation

Question 13

DBT Mindfulness

Answer 13

• Observing/attending to events, emotions & behavioural responses even if distressing
  
  • step back & allow experience with awareness rather than leave or terminate emotions
• Learning to apply verbal labels to behaviours and environmental events
  
  • overcome tendency for literal reflection – “I feel unloved” interpreted literally as “I am unloved”
• Participating with attention as opposed to mindlessly engage in an activity

Question 14

DBT Distress tolerance

Answer 14

• Assumes ability to tolerate and accept distress is essential for mental health
• Skill is to accept non-judgmentally current situation
  
  • Experience current emotional state without attempt to change it
  • Observe own thoughts & actions without controlling or stopping these
  • Acceptance of reality does not mean approval of reality
    
    • distress is accepted but does not mean that it is not nevertheless still painful

Question 15

DBT Emotion regulation skills

Answer 15

• Difficulties in regulating pain emotions are central to behavioural reactions
• Assumption is that emotional distress is a secondary response to intense shame, anxiety or rage
• Skills in identifying and labelling affect. Observe & describe:

1. Event triggering emotion
2. Interpretation of event
3. Phenomenonological experience (physical & emotional feelings)
4. Behaviours associated with emotions
5. After effects on functioning

Question 16

DBT Interpersonal effectiveness

Answer 16

• Skills in specific interpersonal problem-solving, social & assertiveness skills to modify aversive environments & develop effective relationships
• how to ask for things and say ‘no’ to other people, while maintaining self-respect and important relationships.
• Limit setting on demanding behaviours => need for reassurance and acceptance

Question 17

The role of schemas in BPD

Answer 17

• Long-standing self-defeating patterns/themes in thinking, feeling & behaving/coping (life-traps) e.g., “I’m unlovable”, “I’m a failure”
• Broad, pervasive dysfunctional themes developed during childhood developmental phase and persisting into adulthood
• Composed of memories, emotions, & cognitions defining perspective of self and relationship with others that result in significant degrees of impaired functioning

Question 18

Schema-focused therapy for BPD

Answer 18

• Integrative approach to treatment, combining aspects of cognitive-behavioral, experiential, interpersonal and psychoanalytic therapies into one unified model (Young, 1990; 1999)
• Three stages:

1. Assessment: schemas are identified (use of questionnaires)
2. Emotional awareness & experiential phase: identifying how schemas operate in day-to-day living
3. Behavioral change: replacement of negative, habitual thoughts & behaviours with new, healthy cognitive and
4. behavioral options

Question 19

18 schemas elicited in Schema Questionnaire

Answer 19

• Abandonment
• Mistrust
• Emotional Deprivation
• Defectiveness
• Social Isolation
• Dependence
• Vulnerability to Harm
• Enmeshment
• Failure to achieve
• Entitlement
• Insufficient self-control
• Negativism
• Self-punitiveness
• Emotional inhibition
• Unrelenting standards
• Subjugation
• Self-sacrifice
• Approval seeking

Question 20

Schema therapy: Modes

Answer 20

• ​MODE: consists of current mood state, behaviours & cognitions (exist along a continuum of dissociation)
  
  • Innate Child Modes: Vulnerable / Angry / Impulsive / Contented child
  • Maladaptive Parent Modes: Punitive / Demanding / Critical parent
  • Healthy Adult Mode
• Task for therapist & patient: to track the rapid shifts among modes

Question 21

Schema perpetuation

Answer 21

• Tendency for schemas to be strengthened over time
• Schemas influence information processing such that the individual selectively perceives and interprets information so as to
  
  • confirm maladaptive schemas
  • AND filters out disconfirming information

Question 22

Schema theory: Coping styles

Answer 22

• Personality trait
• While making life more manageable in the short term, serve ultimately to reinforce the schema
• ‘schema surrender’: the individual accepting the truth of the schema and behaving in consistent ways
  
  • e.g. choosing an abusive partner in the case of someone with a mistrust/abuse schema
• ‘schema avoidance’: blocking features of the schema (such as the associated thoughts, images or feelings) OR avoiding situations that trigger the schema because of the distressing nature of the schema content
  
  • e.g. substance misuse OR avoiding relationships in someone with an abandonment schema
• ‘schema overcompensation’: reacting against the schema by embodying its polar opposite
  
  • e.g. for someone with a defective schema overcompensation might include arrogance >> problem not recognised AND risk of confirming schema because of interpersonal consequences (alienation and rejection by others)

Question 23

Beck’s cognitive model for treating general PDs

Answer 23

• Relies on 2 key premises
• Each PD is thought to be characterised by specific maladaptive core beliefs
• These beliefs influence the processing of social information in such a way that maintains the person’s dysfunctional beliefs
  
  • Filtering out inconsistent information
  • Interpreting ambiguous information as consistent with dysfunctional belief

Question 24

CBT for PDs

Answer 24

• Cognitive case formulation
  
  • drawing together theory, research and the client’s experiences in order to explain the causal and maintaining factors relating to their problems
• Cognitive restructuring
  
  • identifying and challenging dysfunctional cognitions that give rise to negative feelings and behaviours
• Supporting behavioural change
  
  • using strategies such as learning the skills of problem-solving to decrease unhelpful behaviours and increase adaptive solutions to problems