Personality disorders

Question 1

Describe personality disorder

Answer 1

Pervasive, persistent inflexible maladaptive patterns of behaviour that deviate from expected cultural norms

• affect 5-10% of the population
• frequent amongst recurrent attenders tot he ED

Borderline

• more common in women
• pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships and self image
• chronic emotional lability
• trouble interpersonal relationships
• impulsive behaviour
• poor self esteem

Long term management

• psychotherapy
• dialectical behaviour therapy

Anti social personality disorder

• more common in men
• aggresive and often violent behaviour
• inability to maintain employment or shcool attendance
• substance abuse
• frequent legal problems
• diminished capacity to experience guilt

Histrionic

• dramatic, extroverted, attention seeking behaviour
• seductive and impulsive behaviours
• frequent suicidal gestures
• no psychosis

Question 2

Define somatisation, somatoform disorders

Answer 2

Somatisations: tendency to experience, conceptualise and communicate mental states and distress as physical symptoms or altered bodily function

Somatoform disorders

• presence of physical symptoms that suggest but are not fully explained by medical conditions, effects of drugs or another mental disorder
• the symptoms cause clincially signfiacint distress or impairment in social occupational or other areas of functioning
• as opposed to factitious disorders and malingering the physical symptoms are subconscious and not intentional

Question 3

Discuss somatoform disorder

Answer 3

Multiple physical symptoms with no organic basis
May mimic organic diseases such as MS, SLE< hyperparathyroidism or porphyria

Management may be challenging as patients may have no insight into subconscious nature of the cause of their symtpoms

Question 4

Describe conversion disorder

Answer 4

Loss or change of physical fucntion suggesting a physical disorder but caused by a psychological conflict

• Usually single symptom or sign
• rare and incidence declining

90% of symptoms are neuo

• seizures
• syncope
• LOC
• Paresis
• paraylsis

Diagnositc criteria ( 5 required)

1) a change or loss of physical function suggestive of a physical disorder
2) recent psychological stress of conflict
3) patient unconsciously produces the symptom
4) the symptom cannot be explained by an organic cause
5) the symptom is not limited to pain or sexual dysfunction

Question 5

Describe factitious disorder

Answer 5

• Intentional production or feigning of physical or psych signs or symptoms associated with identified deception
• motivation for the behaviour is to assume the sick role
• external incentives for the behaviour may be absent
• behavious is not better accounted for by another mental disorder

Greater incidence in females than in males
often have a background in health occupations
age of onset commonly in late adolescences to mid 30s

Question 6

Discuss factitious disorder by proxy

Answer 6

Affected adult present child with factitious illness

• perpetrators are usually caregiving mother who ahve high rates of early childhood privation neglect and abuse
• > 50% of perp have a somataform or factitious disorder
• > 75% have co-existing personality disorder particularly cluster B

Suspicious features

• the child presentation shows discrepancy with finding of examinations assessment or ix
• symptoms and signs are only observed or appear in the presence of the parent or carer
• inexplicably poor response to effective treatment
• new symptoms are repeatedly reported
• biolofically unlikley history of events
• various second opinions are sought and disputed by the parent or carer

Question 7

Discuss malingering

Answer 7

Intentional production of false or grossly exaggerated physical or psychologgical symptoms motivated by external incentives such as

• avoiding work
• obtaining compensation
• evading criminal prosecutions
• obtaining drugs

Question 8

Discuss frequent ED presenter

Answer 8

Defined as >5 presentations/year 
associated with recurrent ED attendance 
-alcohol substance abuse 
-mental illness 
-male 
-exposure to violence 
-unemployment 
-homelessness

Managemement

1) Immediate
- senior staff ideally should manage
- avoidance of unecessary ix
- manage underlying disease
2) long term
- notifications of state drug and poisons if seeking
- management plan