Personality Disorders Flashcards
Personality Disorder (ICD-11 2018)
- enduring disturbance characterised by issues w/functioning of:
SELF
INTERPERSONAL DYSFUNCTION - endures +2y
- maladaptive patterns of inflexible/poorly regulated cognition/emotional experience or expression
- manifests across social/personal situation range
PD: Associations
- substantial distress
- significant family/social/educational/occupational function deficit
PD: “Explanation”
- developmentally inappropriate (not only due to society/culture/medication/substance abuse)
- unexplainable via other mental/behavioural disorders/NCS diseases
PD: The Self
- identity
- self-worth
- self-view
- self-direction
PD: Interpersonal Function
- development ability
- maintenance of satisfying relationships
- alternative perspective understanding
- conflict management
PD: Persistence
- not episodic
- ZANNARINI (2012); 93% remission (less acute symptoms/better psychosocial functioning) in borderline personality disorder at 16y follow up
- MCMAIN (2012); most sufferers show persistent social functioning impairment despite therapy
PD: Diagnostic Systems
- DSM-5 (APA)
- ICD 11 (WHO)
- categorical approaches include:
CLUSTER A: - paranoid/schizoid/schizotypal
CLUSTER B: - antisocial/borderline/histrionic/narcissistic
CLUSTER C: - avoidant/dependent/obsessive-compulsive
PD: Diagnostic Systems (Criticisms)
DMS-5 (APA): - remains categorical ICD 11 (WHO): - dimensional - diagnosis present (?) - level of severity - descriptive trait domains - borderline pattern qualifier
PD: Diagnostic Systems (ICD-11 Severity)
MILD:
- disturbances affect some personality functioning; unapparent under some contexts
MODERATE:
- disturbances affect multiple personality functioning areas; some may be less relatively affected
SEVERE:
- severe disturbances in function of self (ie. unstable; no sense of identity OR excessive identity rigidity)
- self-view = self contempt/grandeur; highly eccentric
PD: Trait Domains
NEGATIVE AFFECTIVITY (our of proportion frequency/intensity)
DETACHMENT (social/emotional)
DISSOCIALITY (disregard for others feelings/empathy; self-centeredness)
DISINHIBITION (acting rashly w/o consideration of negative consequences)
ANANKASTIA (focus on rigid perfection standards/controlling self/others behaviour)
PD: Trait Domain Qualifiers/Features
NEGATIVE AFFECTIVITY = anxiety/anger/fear/vulnerability/shame/depression/guilt
DETACHMENT = reserved/aloof
DISSOCIALITY = self-centeredness/manipulation/deceit
DISINHIBITION = impulsivity/recklessness
ANANKASTIA = concern w/rules/norms; emotional/behavioural constraint
Borderline Personality Disorder
- defined by pervasive pattern of interpersonal relationship/self-image instability
- marked impulsivity
BPD: Qualifiers
- hypersensitivity to real/imagined abandonment/rejection
- pattern of unstable/intense interpersonal relationships characterised by alternating extremes/idealisation/devaluation
- marked unstable identity (contempt/isolated)
- recurrent self-harm episodes (ie. suicide attempts/mutilation)
- emotional instability via mood reactivity triggered internally (ie. own thoughts)/externally resulting in hour/day long dysphoria
- chronic “emptiness”
- inappropriately intense/uncontrollable anger
- transient dissociative/psychotic symptoms (ie. hallucinations/paranoia) during highly arousing events
PD: Why is it Important?
- common (1-16% worldwide)
- BJORKENSTAM (2015); presents w/significant morbidity/mortality; PD men die 18y early; PD women die 19y early; 8-10% suicide success
- co-morbid conditions harder to treat
- NEWTON-HOWES (2010); substantial health economic burden; cost frequent hospital attendance
- treatable
PD: Distribution
- 12% = community
- 10-20% = primary care
- +30% = secondary care
- 60% = inpatient
- +70% = prisons
PD: Co-Morbid Mental Health Issues
- SKODOL et al (1999); 40% BPD w/depression (chronicity risk); 13% bipolar disorder
- CRIMLISK et al (1998); 45% w/Mus Motor symptoms w/PD
- SUBSTANCE ABUSE = 37% drug misusers; 53.2% alcohol misusers
- EATING DISORDERS = bulimia nervosa w/BPD; anorexia nervosa w/OCPD
Complex Trauma
- HERMAN (1992)
- chronic repetitive trauma w/PTSD symptoms; includes:
DISSOCIATION
SOMATISATION
RE-VICTIMISATION
AFFECT DYSREGULATION
IDENTITY DYSRUPTIONS
Complex PTSD (ICD-11)
- re-experiencing the past
- avoidance
- excessive current threat
- disturbances in self-organisation
- affect dysregulation
- negative self-concept
- relationship disturbances
CT: Adverse Childhood Experiences (ACE)
- FELITTI et al (2002); USA; 17,000 pps; linked w/toxic stress response affecting child physical/mental health; 10 abuse categories (% = TSR): PHYSICAL ABUSE (28%) PARENTAL SUBSTANCE MISUSE (27%) SEPERATION/DIVORCE (23%) SEXUAL ABUSE (22% (28% women)) HOUSEHOLD MENTAL ILLNESS (17%) EMOTIONAL NEGLECT (15%) VIOLENT MOTHER (13%) OVERT EMOTIONAL ABUSE (11%) PHYSICAL NEGLECT (10%) INCARCERATED RELATIVE (6%)
BPD: Psychosocial Factors
- Parental separation/loss for at least 3 months in first 5 years
- History of mood disorder/substance abuse.
- Abnormal parenting attitudes (ie. low care w/high overprotection).
- Childhood trauma (high reported neglect).
PD: Genes
- little evidence of BPD/schizophrenia/mood disorder link
- SKOGLUND et al (2021); BPD heritability (degree of phenotype trait in pop via genetic variation) = 46%
PD: Theoretical Models
ICD-11 ATHEORETICAL
COGNITIVE MODEL (LINEHAN (1993))
PSYCHOANALYTIC (KERNBERG (1975))
- excessive aggression + childhood adversity = splitting
ATTACHMENT THEORY (BOWLBY (1969))
- increased anxious-ambivalent/avoidant attachment in BPD
PD: Medication Treatment
- GUNDERSON (2018); issues of overmedication via treating symptoms rather than conditioning; limited effectiveness of mood stabilisers; used current clozapine
PD: Psychosocial Treatment
BPD NICE Guidelines (2009): - poor evidence base for PD treatment - best evidence in psychosocial BPD therapy programmes: DIALECTICAL BEHAVIOUR THERAPY (DBT) MENTALISATION-BASED THERAPY (MBT) TRANSFERENCE FOCUSED THERAPY (TFT) THERAPEUTIC COMMUNITY SCHEMA FOCUSED CBT
