Personality disorders

Question 1

What is a personality?

Answer 1

Personality is who we are. It comprises ingrained, persistent traits: characteristics that determine how we think, feel, behave, and experience ourselves, the world, and other people.

“an individual’s characteristic way ofbehaving, experiencing life, and of perceiving and interpreting themselves,other people, events, and situations.”

Question 2

Define Personality Disorder.

Answer 2

When traits are persistently disabling or distressing, they might constitute a personality disorder

“marked disturbance in personality functioning, which is nearly always associated with considerable personal and social disruption.” - ICD-11

• Not developmentally appropriate
• Cannot be explained primarily by social or cultural factors
• Causes distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Question 3

What are the central manifestations (impairments) of PDs?

Answer 3

• aspects of the self
• problems in interpersonal functioning
• Impairments in self-functioning and/or interpersonal functioning are manifested in maladaptive patterns of cognition, emotional experience, emotional expression, and behaviour.”

Question 4

How do we diagnose PDs?

Answer 4

3 ‘P’s distinguish personality disorder from traits

Pervasive: occurs in all/most areas of life

Persistent: evident in adolescence and continues through adulthood

Pathological: causes distress to self or others; affects relationships, impairs occupational/social function

PD isn’t diagnosed where other psychiatric disorders, substance use, or brain damage/ disease explains the person’s behaviour.

Lecture:

• Enduring problems in functioning of aspects of the self, and/or interpersonal dysfunction
• Persisted over an extended period of time (usually >10yrs)
• Is manifest in patterns of cognition, emotional experience, emotional expression, and behaviour that are maladaptive
• It manifest across a range of personal and social situations
• Associated with distress or impairment in personal, family, social, educational, occupational or other important areas of functioning.

Question 5

What is the exclusion criteria for diagnosing PDs?

Answer 5

Should not be diagnosed if:

• The symptoms due to the direct effects of a medication or substance, including withdrawal effects, by another mental disorder, a Disease of the Nervous System, or another medical condition.
• developmentally appropriate
• can be explained primarily by social or cultural factors, including socio-political conflict.

Question 6

What are the three broad clusters for PDs?

Answer 6

DSM-5 Classification

• Cluster A “Odd and Eccentric” - •Paranoid •Schizoid •Schizotypal
• Cluster B “Dramatic, Emotional or Erratic” - •Antisocial •Borderline •Histrionic •Narcissistic
• Cluster C “Anxious or Fearful” - •Avoidant •Dependent •Obsessive- Compulsive

Question 7

Describe paranoid personality disorder.

Answer 7

 Excessive sensitivity to setbacks

 Suspicious

 Can perceive others as hostile or contemptuous (misconstruing neutral or friendly actions)

 Can feel easily rejected

 Tend to hold grudges

 May have excessive self-importance

Question 8

Describe schizoid personality disorder

Answer 8

 Withdrawal from affectional, social and other contacts

 Perceived as emotionally ‘cold’
 Preference for fantasy, solitary activities and introspection.

 There is a limited capacity to express feelings and to experience pleasure.

Question 9

Describe schizotypal personality disorders

Answer 9

 In ICD-10 is classified as associated with Schizophrenia and not as a PD

 Inappropriate or constricted affect

 Socially withdrawn

 Behavior or appearance that is odd, eccentric or peculiar

 Odd beliefs or magical thinking, influencing behavior and inconsistent with subcultural norms

 Suspiciousness or paranoid ideas

 Unusual perceptual experiences including somatosensory (bodily) or other illusions, depersonalization or derealization

 Occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations and delusion-like ideas, usually occurring without external provocation.

Question 10

Describe antisocial personality disorder.

Answer 10

 Persistent disregard for morals, social norms, and the rights of others

 Callous about the feelings of others

 Low tolerance to frustration

 Aggressivetendencies

 Frequently offenders

 Impulsive

 Lack of remorse

 Behaviour that is not readily modifiable by adverse experience

Question 11

Describe borderline PDs

Answer 11

 Difficulties managing emotions and behaviour

 Impulsive without consideration of consequences

 Unpredictable mood

 Emotional instability

 Lack of impulse control

 Chronic feelings of emptiness

 Intense and unstable interpersonal relationships

Question 12

Describe histrionic personality disorder.

Answer 12

 Shallow and labile affect

 Self-dramatization, theatricality, exaggerated expression of emotions

 Seeking for appreciation, excitement and attention

 Self-centered

 Lack of consideration of others

Question 13

Describe narcissistic PDs.

Answer 13

 Grandiosity with expectations of superior treatment from other people

 Fixation on fantasies of power, success, intelligence, attractiveness, etc.

 Self-perception of being unique, superior, and associated with high-status people and institutions

 Need for continual admiration from others

Question 14

Describe avoidant personality disorders.

Answer 14

 Feelings of tension and apprehension

 Insecurity and inferiority

 Continuous yearning to be liked and accepted

 Hypersensitivity to rejection and criticism

 Restricted personal attachments

 Tendency to avoid certain activities by habitual exaggeration of the potential dangers or risks in everyday situations.

Question 15

Describe dependant PDs.

Answer 15

 Pervasive passive reliance on other make decisions

 Great fear of abandonment

 Feelings of helplessness and incompetence

 Passive compliance with the wishes of elders and others

 Weak response to the demands of daily life

Question 16

Describe obsessive compulsive PDs.

Answer 16

 Feelings of doubt

 Perfectionism

 Excessive conscientiousness

 Checking and preoccupation with details

 Stubbornness, caution, and rigidity

 There may be insistent and unwelcome thoughts or impulses that do not attain the severity of an obsessive- compulsive disorder

Question 17

Describe the epidemiology of PDs.

Answer 17

• Men have overall higher rate
  
  • particularly detachment
  • dissociality
  • anankastic traits
• Women: disinhibited and borderline patterns are more common

Question 18

What is the aetiology of personality disorders based on?

Answer 18

• Genetics
• Childhood factors
• Psychological Theories
• Neurochemical theories
• Neuroanatomical theories

Question 19

What is the genetic aspect of personality disorders?

Answer 19

• Heritability 25%. to 70%
• PD is associated with a FH of PD, schizophrenia (cluster A), depression and anxiety (clusters B and C), and disorders due to substance us (cluster B)

Question 20

What are the childhood factors of personality disorders?

Answer 20

Childhood temperament - innate characteristics, seen most clearly in infancy e.g. activity pattern, attention span, response to new situations and intensity of emotional responses
o Personality of child aged 3 can predict personality traits in adulthood

o Children with ‘difficult’ temperaments have greater problems coping as adults, possibly because they find it harder to develop supportive relationships, and are more distressed by negative events; they’re also at greater risk of developing PD

Childhood experiences
o PD associated with insecure attachment and traumatic, neglectful or chaotic upbringing

o Those with PD (particularly borderline patterns) are more likely to have experienced childhood abuse.

o Abuse and neglect may mean that the child doesn’t learn to validate and manage their own emotions. It’s unclear why some people are unaffected longterm by childhood abuse, while others develop PD or other mental health problems, including depression, eating disorders, or psychosis

Question 21

What is the psychological aspect of personality disorders?

Answer 21

Behaviour is motivated by a combination of beliefs and desires; cognitive theories favour beliefs and psychodynamic/ analytic theories emphasize desire. Both agree that our expectations tend to be fulfilled and perpetuated.

Attachment theory - The quality of early relationships and the nature of the environment in which someone is raised influence their expectations about themselves and the world.

Defense mechanisms - Defence mechanisms are unconscious strategies used to manage uncomfortable feelings, especially fear and guilt.

o Become problematic when people become overly reliant on them
o Examples include

• Acting out - expressing impulses through actions, without conscious awareness of the underlying emotion e.g. self-harming rather than feeling sad
• Splitting - viewing people in polarized terms, either idealizing or denigrating them
• Projection - ‘putting’ uncomfortable feelings onto someone else (e.g. feeling ashamed for hating colleagues, so believing that they hate you).
• Fantasising - using imagination to escape from painful reality
• Passive Aggression - showing anger or disagreement through negativity or passive resistance, rather than verbalizing problems

Question 22

What is the neurochemical aspect of personality disorders?

Answer 22

Dysfunctional dopaminergic systems may be implicated in detached and anankastic trait domains.

Serotonin has a role in regulating impulsivity and aggression; lower levels are linked to cluster B disorders.

Dysfunctional noradrenergic systems have also been associated with PD

Question 23

What is the neuroanatomical aspect of personality disorders?

Answer 23

Cluster B personality disorders have been linked to functional underactivity in the prefrontal cortex, as well as volume reductions in the amygdala and hippocampus.

These changes may be linked to traits such as lack of empathy in dissociality or difficulties regulating emotions in borderline patterns

Question 24

What other comorbidities are associated with PDs?

Answer 24

People with PD have higher rates of depression, anxiety disorders, and substance use disorders.

Cluster B disorders are associated with childhood conduct disorder, ADHD, bipolar disorder, and somatoform disorders; borderline patterns are associated with PTSD, eating disorders, substance use disorders, and dissociative disorders.

People who have anankastic traits are more likely to experience OCD and eating disorders

Question 25

What is the clinical presentation of PDs?

Answer 25

The ICD- 11 recognizes that our personality characteristics are on a spectrum.

For a specific PD diagnosis,people need to show the 3Ps over an extended period (at least 2 years). The severity is then assigned according to the degree of impairment of self (identity, self- worth) and interpersonal (maintaining close and healthy relationships, empathizing and managing conflict) functioning

One or more trait domain qualifier may then be added, describing the prominent personality traits. In general, more severe PD is associated with multiple trait domain qualifiers (i.e. more complexity)

Question 26

How do we determine the severity of personality disorders?

Answer 26

Question 27

What are the investigations of PDs?

Answer 27

• Follow-up interviews
  
  • Screening questionnaires e.g. Standardised Assessment of Personality Abbreviated Scale (SAPAS)
  • Diagnostic semi-structured interviews e.g. International Personality Disorder Examination (IDPE)
  • Collateral History
  • Assessment of psychological mindedness i.e. whether someone’s resilient and reflective enough to use therapy.
    
    • Type R - treatment resisting
    • Type S - treatment seeking (people with borderline pattern are more personally distressed by their symptoms and likely to seek treatment)

Question 28

How do we manage personality disorders?

Answer 28

• They are treatable
• Long-term approach is needed, with non-judgemental, empathic therapeutic relationships that promote engagement.
• Encourage the individual to take responsibility for their actions
• Boundaries are essential
• Classifying the severity in PD helped inform prognosis and intensity of tx and trait qualifiers determine the focus and style of tx.
• Biological - no medications are licensed for PD itself and there’s a limited evidence base. Some medications can be used for distressing symptoms to facilitate psychological tx
  
  • Antipsychotics - may reduce impulsivity and aggression (e.g. risperidone) + reduce auditory pseudo hallucinations in borderline PD
  • Antidepressants - may reduce impulsivity and anxiety
  • Mood stabilisers - may be used for labile affect (effects aren’t evidence-based)
  • Sedatives or anxiolytics - sometimes used short term (e.g. 1 week), as part of a crisis plan
• Treat Comorbid Problems
  
  • Substance misuse, affective and anxiety disorders require management
• Psychological Interventions
  
  • Most approaches are related to CBT (focusing on the interaction between thoughts, moods and behaviours right now) and psychoanalysis (explores how the past relates to interpersonal difficulties)
  • Therapies:
    
    • Dialectical behaviour therapy (DBT) - Type of CBT that has been adapted for people who experience emotions very intensely
      
      • Used to treat borderline personality disorder
      • Focuses on changing unhelpful behaviours AND accepting who you are at the same time
      • This can be a weekly group, individual session and reinforcement through diaries and telephone support.
      • For about 1 yr
    • Cognitive analytical therapy (CAT)
      
      • Promotes self-awareness. Current problems understood by exploring past relationships and experiences
      • Usually 12-16 individual sessions (q. short)
    • CBT
    • Mentalisation-based therapy - Integrative form of psychotherapy that brings together aspects of psychodynamic, CBT and systemic approaches
      
      • Think about thinking - exploring thoughts and feeling in emotive situations and consider what’s happening in someone else’s mind.
      • Delivered to individuals and/or groups and last 12-18 months (hourly session)
    • Therapeutic communities
      
      • Group-based approach to long-term mental illness
      • Housing placements where the residents make their own rules
    • Psychodynamic and psychoanalytical psychotherapy
      
      • Both use the relationship between therapist and patient to understand the past and how it relates to current interpersonal difficulties. Individual or group therapy is provided over months, or sometimes years
• Social Interventions
  
  • Psychoeducation for the person with PD and their family improves autonomy, decision- making about treatment, and life choices. Peer support is an important part of many people’s recovery

Question 29

Who benefits from psychological therapies? What types are offered?

Answer 29

Especially for Cluster B

 Mentalisation Based Therapy (MBT)
 Cognitive Behavioural Therapy (CBT)

 Dialectical Behavioural Therapy (DBT)

 Dynamic Psychotherapy
 Cognitive Analytical Therapy
 Therapeutic Community

Question 30

What is the prognosis of PDs?

Answer 30

• Prognosis
o Personality disorders disrupt relationships, education and employment → may be associated with domestic violence or child maltreatment

o Although they are persistent, they may change in severity over time e.g. cluster B reduce with age, due to maturation, gradual ‘burning out’ of symptoms and elevated mortality through suicide and accidents.

10% die through suicide.

Question 31

How would you counsel a patient with Personality disorder?

Answer 31