Personality Disorders Flashcards
Define
Personality disorders must be…
- Pervasive: occurs in all/most areas of life
- Persistent: evident (starts) in adolescence and continues through adulthood
- Pathological: causes distress to self or others, impairs function
- ICD-10: a set of consistent thoughts, feelings, and behaviours shown across time in a variety of settings which may lead to suffering of the individual or others (‘exaggerated personality traits’):
Outline the classification of personality disorders
Cluster A- Odd or Eccentric -> more psychotic disorders, more common in men
1.Paranoid
2.Schizoid
3.Schizotypal (ICD-10 includes this as part of psychotic disorders)
Cluster B- Dramatic, Emotional or Frantic -> can present with psychotic symptoms, features of both
1.Antisocial/ Dissocial
2.Borderline
3.Histrionic
4.Narcissistic (DSM-5 only)
Cluster C- Anxious or Avoidant ->more like a neurotic disorder
1.Avoidant
2.Dependent
3.Obsessive-compulsive
4.Anankastic personality disorder is ego syntonic (in line with what you want) and doesn’t cause distress, but in OCD it is ego dystonic as (not in line with what you want) and causes you distress
(REMEMBER: mad, bad, sad or weird, wild, worried)
NOTE: neurosis: all mental illness that is NOT psychotic (e.g. depression, OCD)
Epidemiology/ Aetiology
Epidemiology
- Men have higher rates than women, Female > men for EUPD
Aetiology
Different genetic, environmental and social factors are implicated
Genetics:
- Personality disorder is associated with a family history as well as a history of depression and alcohol dependency
Childhood temperament + experience:
- Children with ‘difficult’ temperaments have greater problems coping as adults
- Early detachment difficulties are associated
- Associated with insecure attachment and traumatic, neglectful or chaotic upbringing
RESPONSIVE PARENT -> Secure attachment style
INCONSISTENT PARENT -> Anxious / Ambivalent
UNRESPONSIVE PARENT -> Avoidant
Style
Anxious => to get attention of parents
Avoidant => constant crying doesn’t have any affect as parent not around so feels nothing
Factors in childhood: sexual abuse, physical abuse, emotional abuse, neglect, being bullied
Cognitive and psychoanalytical theories
- confirmation bias perpetuation (i.e. if you’re negative, you spark ‘negativity’ in others, confirming your thoughts)
Psychological defences
- overly reliant on psychological defences such as ‘acting out’, ‘splitting’, ‘projection’, ‘fantasising’, etc.
Neurotransmitter theories
- lower 5-HT levels in dissocial (cluster B) personality types
- Early adverse social circumstances, physical or emotional neglect, violence are associated
Symptoms of Cluster A
**Paranoid **
S - Sensitive
U - Unforgiving (bears grudges)
S -Suspicious of others harming/ deceiving them – perceive others as hostile
P - Possessive and jealous of partners
E - Excessive self-importance
C - Conspiracy theories
T - Tenacious sense of rights
EXAMPLE: Reuben suspected that his colleagues at the Post Office were getting preferential treatment, despite his certainty that he was the best worker there. When he was offered overtime, it was ‘only the shifts that no-one else wanted’. This confirmed his suspicion, and so he resigned, feeling insulted. Five years later he is still convinced that his boss was corrupt.
DDx: schizophrenia, delusional disorder
Schizoid
Basics -ve schizophrenia symp
A - Anhedonic
L - Limited emotional range - flattened affectivity/ emotional coldness (Limited capacity to express warm, tender feelings for others as well as anger)
L - Little sexual interest
A - Apparent indifference to praise/criticism
L - Lacks close relationships - detachment
O - One-player activities
N - Normal social conventions ignored - unintentional
E - Excessive fantasy world
EXAMPLE: Masson was a night security guard, content with solitude and daydreaming his shift away. His manager passed on complaints from the day staff that he left a ‘body odour smell’ in the office, but he didn’t try to wash. Although people thought he was odd, he really didn’t care. He wasn’t interested in having friends or a sexual partner, preferring his own company. He was neither happy nor sad about this; that was just life.
DDx: depression, ASD, psychosis, phobia
Schizotypal
(ICD-10 includes this in psychotic disorders)
Some +ve schizophrenia symp
- Eccentric behaviour, odd beliefs or magical thinking, unusual perceptual experiences (e.g. ‘sensing’ another’s presence),
- Ideas of reference, suspicious or paranoid ideas, vague or circumstantial thinking
- Social withdrawal
- Occasional transient quasi-psychotic episodes (intense illusions, delusion-like ideas, no hallucinations)
Symptoms of Cluster B
Borderline/ Emotionally Unstable
Borderline-type
- Unstable, intense relationships
- Unstable self-image
- Chronic feelings of emptiness
- Repetitive suicidal or self-harm behaviour
- Fear of abandonment (real or imagined (pseudohallucinations))
- Transient paranoid ideation
- Disorders of the sick role - munchausen
- Poor self image
EXAMPLE: Phoebe had been on two dates with her perfect university lecturer — she already knew they’d get married! When he cancelled a date because of work, Phoebe felt so alone. A familiar numb feeling of emptiness returned, reminding her of when her ex-boyfriend left. Phoebe told him she was going to kill herself and it was his fault. She slammed down the phone and cut her wrists with scissors—she couldn’t bear to be alone again.
Impulsive type
- Impulsivity (sex, binge eating, substance abuse, spending money)
- Outburst or threats of violence
- Sensitivity to being criticised or thwarted
- Emotional instability- fluctuations in mood
- Inability to plan ahead
- Thoughtless of consequences
Example: Layla and her dad had a great day together. When he went out to collect her mum, she suddenly decided to cook a surprise roast dinner. There were no potatoes and not enough time, so dinner was only half ready when her parents returned with a takeaway. Her dad asked why she had bothered going to the trouble of cooking, and Layla’s patience snapped. She swore at him and threw all the food away. Why did this always happen to her?
Antisocial
- Repeated unlawful or aggressive behaviour, deceitful, lying, reckless irresponsibility, low tolerance to frustration, impulsive
- Lack of remorse or incapacity to feel guilt
- Often have conduct disorder in childhood (but cannot diagnose antisocial until > 18 years)
EXMAPLE: Jake joined the local snooker club and was getting on well with the other members until he accused his opponent of cheating during a ‘friendly’ game. Jake quickly lost his temper, breaking the other man’s nose with his cue and storming out. He was banned from the club but felt that it was ‘the other guy’s fault’ for cheating; he deserved his broken nose.
DDx: substance misuse, psychosis, manic
Histrionic
A - Attention-seeking (seeking attention, appreciation and excitement)
C - Concerned with appearance
T - Theatrical (Dramatic)
O - Open to suggestion
R - Racy and seductive
S - Shallow labile affect - exaggerated expression of emotion
EXAMPLE: Paige met her boyfriend for lunch. He suggested a bottle of wine, so she ordered champagne! Tottering on her pink stilettos, she fell into his lap as she got out of her chair. Everyone stared but Paige shrieked with laughter! She became bored and flirted with the waiter, but when he ignored her, she left, announcing loudly, ‘I’ll never eat here again!’
DDx: BPAD, substance
Narcissistic
- Grandiose sense of self-importance, lacks empathy, takes advantage, need for admiration
- Continuously demeaning/ bullying/ belittling others
- Fixation on fantasies of power, success, intelligence, attractiveness etc.
- Self-perception of being unique, superior, associated with high-status people and institutions
- Sense of entitlement to special treatment and to obedience from others
- Intense envy of others, and the belief that others are envious of them
Symptoms of Cluster C
Dependent
S - Subordinate
U - Undemanding and clingy
F - Fears abandonment
F - Feels helpless when alone
E - Encourages others to make decisions
R - Reassurance needed (XS need to be cared for)
EXAMPLE: Hanne lived with her younger sister Rebecca. Hanne did the housework but needed Rebecca’s advice for even the simplest tasks: ‘Rebecca is so clever and capable — she makes all the important decisions! How would I ever cope without her if she got married and left me alone?’
DDx: cognitive impairment, anxiety disorder
Avoidant/ Anxious
A - Avoids social contact
F - Fear rejection/criticism - continuous yearning to be liked/ accepted
R - Restricted lifestyle (timid)
A - Apprehensive
I - Inferiority/ insecure
D - Doesn’t get involved unless sure of acceptance
EXAMPLE: Luca had wanted to attend an evening class for ages but was too anxious to go alone. When a friend finally took him, Luca kept silent. He knew he wasn’t as clever as everyone else and worried they would dislike him. He also worried that his friend would stop going and he wouldn’t have anyone to talk to. Better to stay at home than be rejected.
DDx: phobia, ASD, schizophrenia, depression
Obsessive-compulsive/ Anankastic
D - Doubtful - overly cautious
E - Excessive detail and orderliness (perfectionism)
T - Tasks not completed
A - Adheres to rules
I - Inflexible - rigid/ stubborn
L - Likes own way / control
E - Excludes pleasure and relationships
D - Dominated by intrusive thoughts
EXAMPLE: Reece, the cricket club’s treasurer, had developed his own detailed filing system. When the chairman delivered a big box of receipts, the day before the committee meeting, Reece was annoyed—this would take ages to sort out! The chairman tried to help, but kept ruining the system, and Reece sent him away, staying up all night to do the job properly. The next day, he couldn’t stop wondering whether he had made mistakes.
DDx: OCD, ASD
Ego Defences and general defence mechanisms:
Avoidance – (AKA: denial) pretend a problem doesn’t exist
Splitting – an immature response where a person cannot reconcile the good and bad in someone and only views people as all-good or all-bad (i.e. often ending relationships explosively and cannot maintain relationships) – EUPD/borderline PD
Dissociation – an immature ego defence where one assumes a different identity to deal with a situation
Sublimation – a mature ego defence where one takes an unacceptable personality trait and uses it to drive a respectable work that does not conflict with their ego/values (i.e. a youth with anger issues signs up to a boxing academy)
Reaction formation – an immature ego defence where one suppresses unacceptable emotions and replaces them with their exact opposite (i.e. a man with homoerotic desires becomes a champion of anti-homosexual policy)
Regression – revert to an immature behaviour in a stressful situation (i.e. bang a desk in frustration)
Identification – someone models the behaviour of someone else (i.e. someone abused as a child becomes a child abuser as an adult; a widow taking over her late husband’s voluntary work; an older brother playing with a dead younger brother’s toys)
Displacement – defence mechanism when someone takes out their emotions on a neutral person (not likely to respond to them)
Projection – a person assumes an innocent/neutral character is responsible or as guilty as the patient, for the patient’s actions
Investigations
Examination
- Basic observations
- Imaging if suspected organic cause e.g. brain tumour
- Psychology/ psychotherapy assessment
- NEEDS A SECOND INTERVIEW
- ICD-10 requires following criteria for a diagnosis of personality disorder (REPORT)
1.Relationships affected
- Markedly disharmonious attitudes and behaviours, involving usually several areas of functioning e.g. affectivity, arousal, control, relationships
2.Enduring
- Presenting in broad range of personal and social situations
3.Pervasive- prevailing, chronic abnormal behaviour patterns, not limited to discrete episodes, which are pervasive and clearly maladaptive
4.Onset in childhood/ adolescence (manifestations appear <18 years old and continue into adulthood)
5.Result in distress- considerable personal distress caused by these patterns of behaviour (although this may only become apparent later in the course)
6.Trouble in occupational/ social performance- associated with significant problems in occupational and social performance (usually but not always)
Management
RISK ASSESSMENT!
Principles of management
- Autonomy and choice should be encouraged, with patient being actively involved in deciding treatment options and finding solutions to their problems
- Optimistic, trusting and non-judgemental relationship should be developed
- MDT approach
- Involve family/ friends if possible
- Crisis Management
- Self-management strategies
- Sources of support (family, friends, telephone-based services)
- Details of how to access emergency care
- Short-term drug treatments to alleviate distress
- Liaison with crisis resolution and home treatment team
Psychological Interventions
Dialectical behaviour therapy (DBT)
- 1st Line for CLUSTER B
- Useful for borderline personality disorder
- Focuses on factors contributing to emotional instability
- Aims to introduce two important concepts:
Validation: accepting that your own emotions are acceptable
Dialectics: showing you that things in life are rarely black or white, and helping you be more open to ideas and opinions that contradict your own
- Both individual and group components
- Focuses on changing unhelpful behaviours AND accepting who you are
Mentalisation based therapy- used for CLUSTER B
- Mentalisation is the ability to think about your thinking (examining your own thoughts and assessing them based on reality)
- Use mindfulness techniques- reflection on your feelings and how others feel
- Teaches you to recognise how to recognise other people’s thought patterns and accept that your interpretation may not be correct
- Usually lasts around 18 months
CBT
- Can be adapted for borderline personality disorder
- Used for antisocial personality disorder in order to address problems such as impulsivity, interpersonal difficulties and antisocial behaviour
- Offer interventions focused on reducing offending and other antisocial behaviour
- 12 - 16 wkly session for 1-2yrs
Younger age groups
- Psychodynamic therapy- used for CLUSTER A
- Often over a long period of time (minimum 1 year)
- This focuses on unconscious processes as manifest currently
- Focus on the interaction between the patient and the therapist- helps to understand what is going on from a subconscious or unconscious point of view
Cognitive Analytical Therapy (CAT)
- Try to identify all the problems and difficulties between them and other people
- This does NOT help to try and fix the underlying issues with the patient, it analyses why certain interactions may have occurred
Therapeutic Community
- Long term
- Good for emotionally unstable as well
- People with different diagnoses live together, help take care of themselves, responsible
- Not widely available
Pharmacological Treatments
- None licenced
- May be used for comorbid problems
- NOT routinely used for antisocial or borderline personality disorder
- Short term sedation may be considered cautiously as part of overall treatment for those going through a crisis- treatment should NOT be longer than 1 week
May use:
Antipsychotics (low dose)
- may reduce impulsivity and aggression (e.g. risperidone)
- CLUSTER B
Antidepressants
- Useful for borderline personality disorder
- SSRIs- may be used to reduce impulsive behaviour
- CLUSTER B CLUSTER C
Mood stabilisers (lithium)
- CLUSTER B
Social Interventions- more for CLUSTER C
- Social skills training e.g. applying for a job, looking for a house
- Treat comorbid problems
- Substance misuse
- Affective and anxiety disorders
Complications and Prognosis
Complications
- Adverse effects on relationships/ society
- Depressive illnesses
- Alcohol and substance abuse
- Self-harm or suicide
- Violence towards others and other criminal activities
Prognosis
- Personality disorders disrupt relationships, education and employment
- Although they are persistent, may change in severity over time
- Prognosis is generally poor
Cluster A- no change
Cluster B- varied, some improve slowly
Cluster C- get better with time
PACES
The word ‘personality’ refers to the pattern of thoughts, feelings and behaviour that makes each of us the individuals that we are. Generally speaking, personality doesn’t change very much, but it does develop as we go through different experiences in life, and as our circumstances change. We are usually flexible enough to learn from past experiences and to change our behaviour to cope with life more effectively.
However, if you have a personality disorder, you are likely to find this more difficult. Your patterns of thinking, feeling and behaving are more difficult to change and you will have a more limited range of emotions, attitudes and behaviours with which to cope with everyday life. This can lead to distress for you or for other people.
If you have a personality disorder, you may find that your beliefs and attitudes are different from most other people’s. They may find your behaviour unusual, unexpected and may find it difficult to spend time with you. This, of course, can make you feel very hurt and insecure; you may end up avoiding the company of others.
The diagnosis applies if you have personality difficulties which affect all aspects of your life, all the time, and make life difficult for you and for those around you. The diagnosis does not include personality changes caused by a life event such as a traumatic incident, or physical injury.
Personality disorders usually become noticeable in adolescence or early adulthood, but sometimes start in childhood. They can make it difficult for you to start and keep friendships or other relationships, and you may find it hard to work effectively with others. You may find other people very scary, and feel very alienated and alone
Explain their type of personality disorder and link to the symptoms they are having
Personality disorders often improve as you get older, suggesting that as you gain life experience and mature you learn better ways of relating to others, gain better understanding of your responses and reactions to people and events, and learn to manage things better.
Successful treatments aim to help you to make this happen by focussing on the way you think and behave, how to control your emotions, developing successful relationships and getting more out of life.
Treatment plans need to include group and individual therapies; encouragement for you to continue with the programme; education; and planning for crisis. [talk about specific therapy
Dialectical Behavioural Therapy (DBT)
Focuses on the factors contributing to emotional instability
Being emotionally vulnerable and sensitive to stress
Growing up in an environment where your emotions were dismissed by those around you
These factors lead to a vicious cycle where you experience intense and upsetting emotions, which make you feel guilty and worthless and leads to actions that can make you feel upset again
DBT aims to help you accept that your emotions are acceptable and shows you that things are rarely black and white and helps you be open to ideas/ opinions that contradict your own
Mentalisation based therapy
Mentalisation teaches you how to take a step back and scrutinise your thoughts and impulses
It also teaches you how to recognise other peoples’ thought
patterns and accept that your interpretation may not be
correct
There are no drugs specifically for personality disorder, but we can prescribe them to treat additional problems, such as irritability or depression.
We can also find a way of supporting you to find a job/ looking for a house
Charities such as mind, emergence, first steps to freedom (for BPD) may be of use
For more information www.personalitydisorder.org.uk
Treating a Crisis - give numbers for
Community mental health nurse
Out-of-hours social worker
Local crisis resolution team
