Personality Disorders Flashcards
Personality disorder definition and how to distinguish from personality trait
Set of personality traits that are pervasive, ingrained, maladaptive and create significant functional impairment or subjective distress
To distinguish:
Pervasive: affects everything consistently; occurs in all/most areas of life
Persistent: constantly been like that (at least 2 years); evident in adolescence and continues
Pathological: causes distress to self or others, impairs function
Behaviour is not attributable to brain damage or disease
Classification: clusters and severity
Cluster A Personality disorder (odd/eccentric) - Paranoid - Schizoid Cluster B personality disorder (dramatic, erratic, emotional) - Dyssocial (antisocial) - Emotionally unstable (borderline) - Histrionic Cluster C personality disorder - Anankastic (Obsessive-compulsive) - Anxious (avoidant) - Dependent
Difficulty: present but not associated with pervasive dysfunction
Mild: limited interpersonal dysfunction
Moderate: marked dysfunction, in more than one cluster, clear risk to self others
Severe: severe dysfunction, more than one cluster, severe risk (endangering life)
Paranoid personality disorder features and differentials
S ensitive U nforgiving S picious P ossesive and jealous of partners E xcessive self-importance C onspiracy theories T enacious sense of right
Ddx: schizophrenia, persistent delusional disorder
Schizoid personality disorder features and differentials
Basically negative Sx of schizophrenia
A nhedonic L imited emotional range L ittle sexual interest A pparent indifference to praise/criticism L acks close relationships O ne-player acticvities N ormal social conventions are ignored E xcessive fantasy world
Ddx: Asperger’s, agoraphobia, social phobia, psychosis, depression
Histrionic personality disorder features and differentials
A ttention seeking C oncerned with own appearance T heatrical O pen to suggestion R acy and seductive S hallow affect
Ddx: hypomanic/manic episode, substance misuse
Emotionally unstable personality disorder associated features and common features in both subtypes
Associated with self-harm, rapidly changing mood, common
Features of both subtypes: A ffective instability E xplosive behaviour I mpulsive O utburst of anger U nable to plan or consider consequences
Features and differentials of EUPD subtype: borderline personality
S elf-image unclear C hronic empty feelings A bandonment fears R elationships are intense and unstable S uicide attempts and self-harm - associated with splitting - defence mechanism sees things as black or white
Ddx: adjustment disorder, depression, psychosis
Features and differentials of EUPD subtype: impulsive type
L acks impulse control O utbursts or threats of violence S ensitivity to being thwarted or criticised E motional instability I nabillity to plan ahead T houghless of consequences
Ddx: affective disorder, adjustment disorder, ADHD
Dissocial/antisocial personality disorder features and differentials
F orms but cannot maintain relationships I rresponsible G uiltless H eartless T empter lost easily S omeone' elses fault
Ddx: acute psychotic episode, mani episode
Anankastic personality disorder features and differentials
A voids social contact F ears rejection/criticism R estricted lifestyle A pprehensive I nferiority D oesn't get involved unless sure of acceptance
Ddx: social phobia, ASD, schizophrenia, depression
Dependent personality disorder features and differentials
S ubordinate U ndemanding F eels helpless when alone F ears abandonment E ncourages others to make decisions R eassurance needed
Ddx: reliance due to cognitive impairment, anxiety disorder
Aetiology of personality disorders
Genetics/temperament - hereditary aspect of personality; childhood temperament predicts coping as adult
Environment: unstable family background; childhood physical and sexual abuse, insecure attachment
Theories:
Attachment: early relationships/environment influence expectations of themselves and the world
Psychological defence: unconscious strategies to manage uncomfortable feelings
- Acting out - expresses action without awareness of underlying emotion
- Splitting - polarising people/seeing things in black and white
- Projection - own uncomfortable feelings about someone projected onto them as about you
- Passive aggression - anger/disagreement though negative/passive resistance, rather than verbalising
- Fantasising
NT theory: low serotonin level in dissocial personality disorder
Investigations into personality disorders
Multiple interviews for Hx, asking general questions to start,
Collateral history
Psychological/ psychotherapy assessment; assess if will resist or seek Tx
General management options for personality disorders
Encourage pt to take responsibilities for their actions
Boundaries are essential
Meds:
- Antipsychotics - may reduce impulsivity and aggression (e.g. rispiridone)
- Antidepressant - may reduce impulsivity and anxiety
- Mood stabilisers - may be used for labile effect (not evidence based)
Psycho:
- CBT - not that good for personality disorders
- DBT - good for EUPD
- CAT
- Mentalisation - think about own thinking and of other ppls thinking
- Group therapy
- Psychodynamic and psychoanalytic psychotherapy
Social:
- Psychoeducation for pt and family
- Support to minimise disruption to relationships, education and employment
- Care with transition to other services
Tx for comorbids - substance misuse, affective and anxiety disorders
NICE guidelines EUPD
Partnership to explore Tx options together
If suspect BPD:
- Refer to community MH service for assessment
- If <18 refer to CAMHS
Crisis management (in established BPD)- primary care
- Risk assess
- Hx prev eps and effective management strategies
- Enhance coping skills to help anxiety
- Encourage to identify manageable changes
- Offer follow up appt
- Refer to comm MH team if they ask or distress/risk to self/others is increasing or not subsided despite attempts to reduce anxiety and improve coping skills
Crisis: may req referral to HCATT or admission; only admission if managing crisis involves risk unmanageable by other services or under MHA.
Psych
- Don’t use brief psych interventions (esp in BPD)
- Explicit and integrated approach
- Freq adapted to needs
- For BPD women w/ recurrent self-harm - consider DBT
Drug Tx
- Don’t use esp BPD or Sx/behaviours of BPD
- Short term sedative - cautiously considered in Tx of crisis
