Personality Disorders Flashcards
What term is used to refer to Ps diagnosed with personality disorder?
Patients with complex emotional difficulties
What is personality?
Collection of characteristics or traits - developed as we grow = shape us in terms of our attitudes, thoughts, feelings and behaviours and our responses to different situations.
What is temperament?
The emotional and behavioural characteristics of children
When is our personality developed by?
Usually by late teens / early 20s
Which is one of the most widely used models to describe personality?
The Big 5 Model
- Openness to experience
- Conscientiousness
- Extraversion - intraversion
- Agreeableness
- Neuroticism
Each of these are a continuum
In what ways is personality formed?
Childhood experiences
Attachment theory
Genetics
Psychoanalytic theories
Name 3 psychiatrists concerned with psychoanalytic theories of personality development.
Freud
Jung
Erikson
Who proposed attachment theory?
Bowlby
What is the basis of attachment theory?
We are born with a drive to form attachments with others - initially with one primary attachment (base for exploring the world) - done as part of survival.
All relationships in our life will be affected by our primary attachment.
When is the critical period for forming attachment?
0-5 years
Name 4 types of attachment styles
Secure
Anxious (Ambivalent)
Avoidant
Disorganised (Fearful)
Which attachment style is this?
Primary caregiver at times appears to the child as frightened and frightening.
Relationships are characterised by features of both anxious and avoidant styles, want but also avoid intimacy.
Disorganised (fearful)
Which attachment style is this?
Less confident in the primary caregiver’s responsiveness.
Relationships are characterised by the belief that other will not reciprocate the wish for intimacy - need for reassurance / validation, fear of abandonment.
Anxious (ambivalent)
Which attachment style is this?
Believes that the primary caregiver will respond to needs.
Relationships are characterised by trust, adaptive response to being abandoned, belief that one is worth of love.
Secure
Which attachment style is this?
Child internalises the belief that they cannot depend on the primary caregiver or any other - perceives them as rejecting / easily angered.
Relationships are characterised by an avoidance of intimacy.
Avoidant
Why is attachment theory felt not to be the only explanation for personality development?
Focuses entirely on the mother (oppressive to women)
Reductionist - children who grow up with abuse can still form loving and stable relationships as adults. Vice versa - children with nurturing and loving caregivers can struggle to form relationships as adults.
Does temperament dictate attachment? I.e. - is there a genetic component too?
Why are personalities between family members often similar?
Social learning
Genetics
What percentage for heritability of personality was determined by twin studies?
35-50%
How does personality change throughout adulthood?
Pretty much set by late 20s, can still undergo changes but at a very slow rate - especially after 30.
How can you assess personality?
Scales and questionnaires (although not often used in clinical practice)
Patients description of their thoughts, feelings and behaviour (How would your friends and family describe you as a person?)
Collateral Hx
Wider picture - nature of relationships with others, usual mood, daily routine, hobbies/activities, substance use, religious beliefs, attitudes towards illness, work, change, family
When is a personality disorder deemed to occur rather than just being a personality trait?
When it causes significant problems with social and personal function.
What is a personality disorder defined as?
Marked disturbance in personality functioning - almost always associated with considerable personal and social disruption.
Enduring.
Manifests across a range of personal and social situations (more than just 1).
What impairments are seen in personality disorder?
Impairment in functioning of aspect of the self (e.g. self-worth, identity, capacity to self-direct)
Impairments in interpersonal relationships (can’t develop or maintain them, can’t understand the perspective of others, problems managing conflict)
Cause maladaptive patterns of cognition, behaviour and emotional expression / experience
Why is there controversy about whether personality disorder is a mental illness?
Because it is persistent and stable throughout life - rather than having a period of illness for which the patient has a definable onset, is treated and recovers.
How is personality disorder classified?
Historically - by categories - involved a checklist of symptoms, often overlapping and based on observations made decades ago. Lacked scientific basis.
Today - is a dimensional approach under ICD11- disorder is defined by overall severity with personality traits grouped in domains.
What type of personality is:
Suspicious, preoccupied with conspiratorial explanations, self-referential, distrust of others, feel easily rejected, tend to hold grudges.
Paranoid
What type of personality is:
Interpersonal discomfort (struggle to get on with others) with peculiar ideas, perceptions, appearance and behaviour but does not reach threshold for delusion or perceptual abnormality,
Often found in first degree relatives of Ps with schizophrenia
Schizotypal
What type of personality is:
Emotionally “cold”, detached, lack of interest in others, excessive introspection and have a rich fantasy world.
Schizoid
What type of personality is:
Callous lack of concern for others, irresponsibility, irritability, aggression, inability to maintain enduring relationships, disregard and violation of other’s rights, evidence of childhood conduct disorder?
Antisocial
What diagnosis can be seen as a severe form of antisocial personality disorder?
Psychopathy
Are patients with antisocial personality disorder called sociopaths?
No - unhelpful term
How is psychopathy different to antisocial personality disorder?
It does overlap but not everyone with antisocial personality disorder has psychopathy.
Psychopaths = selfish and remorseless use of others. Shallow emotional responses, lack of empathy, impulsivity and increased likelihood for antisocial behaviour
Which tool is used to assess psychopathy?
Hares Psychopathy Checklist
Which type of personality is this?
Inability to control anger or plan,
Unpredictable affect and behaviour.
Emotionally unstable personality (impulsive)
Which type of personality is this?
Unclear identity - feel “empty”, feel bad about themselves
Intense and unstable relationships
Unpredictable affect
Threats or acts of self-harm
Impulsivity
When stressed may hear noises or voices
Emotionally unstable (borderline)
Which type of personality is this?
Over-dramatize events, self-centered, strong transient emotions, suggestible, worry about their appearance, crave new things and excitement, seductive.
Histrionic
Which type of personality is this?
Strong sense of own self-importance, dream of unlimited success and power, crave attention from others but show few warm feelings in return, take advantage of others.
Narcissistic
Which type of personality is this?
Tension, worry, self-consciousness, fear of negative evaluation by others, timid, feel insecure and inferior, have to be liked and accepted.
Anxious / avoidant
Which type of personality is this?
Doubt, worry, indecisive, caution, rigidity, perfectionist, preoccupation with orderliness and control.
Obsessive-Compulsive
Which type of personality is this?
Passive, clinging, submissiveness, excess need for care, feels helpless when not in relationship.
Dependent
Why did ICD 11 move away from the traditional categories of personality disorder?
In practice - most categories were rarely used - mostly antisocial and EUPD - borderline were used. They also didn’t capture the level of dysfunction or severity of the disorder.
How is personality disorder characterised by ICD11?
Mild
Moderate
Severe
Personality difficulties
Can also state which domains of personality traits are dominant
What is personality difficulty under ICD11?
A problem associated with interpersonal interactions - pronounced personality characteristics that may affect the treatment but do not have sufficient severity to merit a diagnosis of personality disorder. Can be intermittent or low intensity problem.
What are the 5 personality trait domains under ICD11?
Negative affectivity
Dissociality
Disinhibition
Anankastia
Detachment
Which personality trait domain describes the following?
Distressing emotions (anxiety, depression, feat
Emotional lability
Negativistic attitudes
↓Self-confidence/esteem
Mistrustful of others
Negative affectivity (aka neuroticism)
Which personality trait domain describes the following?
Disregard for others’ feelings and rights
Self-centredness
Lack of empathy
Sense of entitlement
Dissociality
Which personality trait domain describes the following?
Impulsivity
Irresponsibility
Distractability
Recklessness
Disinhibition
Which personality trait domain describes the following?
Perfectionism
Concern with rules and obligations
Orderliness
Constraint
Stubbornness
Inflexibility
Anankastia
Which personality trait domain describes the following?
Emotional/interpersonal distance
Social withdrawal
Indifference to people
Avoid intimacy
Aloof, passive
Reduced experience of emotion
Detachment
What has the borderline personality disorder diagnosis from ICD10 become under ICD11?
Borderline qualifier
What diagnosis would the following describe? (one diagnosis for all of the following)
- Frantic efforts to avoid real or imagined abandonment.
- A pattern of unstable and intense interpersonal relationships, which may be characterized by vacillations between idealization and devaluation, typically associated with both strong desire for and fear of closeness and intimacy.
- Identity disturbance, manifested in markedly and persistently unstable self-image or sense of self.
- A tendency to act rashly in states of high negative affect, leading to potentially self-damaging behaviours (e.g., risky sexual behaviour, reckless driving, excessive alcohol or substance use, binge eating).
- Recurrent episodes of self-harm (e.g., suicide attempts or gestures, self-mutilation).
- Emotional instability due to marked reactivity of mood. Fluctuations of mood may be triggered either internally (e.g., by one’s own thoughts) or by external events. As a consequence, the individual experiences intense dysphoric mood states, which typically last for a few hours but may last for up to several days.
- Chronic feelings of emptiness.
Inappropriate intense anger or difficulty controlling anger manifested in frequent displays of temper (e.g., yelling or screaming, throwing or breaking things, getting into physical fights).
- Transient dissociative symptoms or psychotic-like features (e.g., brief hallucinations, paranoia) in situations of high affective arousal.
- Other manifestations of Borderline pattern, not all of which may be present in a given individual at a given time, include the following:
- A view of the self as inadequate, bad, guilty, disgusting, and contemptible.
- An experience of the self as profoundly different and isolated from other people; a painful sense of alienation and pervasive loneliness.
- Proneness to rejection hypersensitivity; problems in establishing and maintaining consistent and appropriate levels of trust in interpersonal relationships; frequent misinterpretation of social signals.
Borderline qualifier
What is a patient’s affect?
Their immediate expression of emotion -sad, depressed, anxious, agitated, irritable, angry, elated, expansive, labile, inappropriate, incongruent with content of speech
What are the most prominent features of a borderline qualifier diagnosis?
Negative affectivity
Dissociality
Disinhibition
Under ICD11 how is personality disorder diagnosed?
1) According to severity
2). With relevance to which personality trait domains are dominant
3) Whether there is a borderline pattern to be included
What is mentalisation?
The ability to understand the mental state of oneself or others.
What is the prevalence of personality disorder in
- community
- psychiatric outpatient
- criminal justice system
Community - 4-15%, M=F
Psychiatric outpatient - 50& - F>M (different help-seeking behaviour?)
CJS - 2/3rds of prisoners
What is the aetiology of personality disorder?
Genetics (20% 1st degree, 60-70% monozygotic concordance)
Adverse childhood experiences (inc risk but not inevitable!)
Poor emotional development
Neurobiology (50% have EEG abnormalities, low serotonin in CSF ass with aggression and violence)
How does personality disorder change across the life course?
Personality changes more in Ps with personality disorder over the life course.
Negative affectivity, disinhibition and dissociality decrease
Why is evidence limited for tx of personality disorder?
Hard to measure the outcome as such - rather have to measure impact of the disorders (e.g. readmission, reduced offending).
What are the key principles of management of personality disorder?
Be open about the diagnosis
Role for psychological therapy (if P onboard)
Therapeutic communities for severe Ps
Little role for medications
Hospital admission only if all other options exhausted (can reinforce unhelpful patterns) - e.g. in crisis
What is NICE’s position on pharmacological tx for personality disorder?
They do not advocate pharmacological tx except in crisis in borderline personality disorder (but cautious use - limited to 1w). Use drugs least likely to cause dependence or toxicity in OD (e.g. sedative antihistamine)
What is your personality made up of?
Personality traits
Are personality disorders recognised by UK law?
Yes - mental disorder is defined as “any disorder or disability of the mind”
Why do you not diagnose a personality disorder during a clear episode of mental illness?
Because for some people - when suffering from a mental illness their troublesome personality traits become more prominent than they would be otherwise. Does not mean that they have personality disorder.
How common are psychiatric comorbidities in personality disorder?
Very common - tend to be very difficult to treat. Are less likely to respond to standard treatments.
Interpersonal relationships are often very difficult for people with personality disorder. How can this affect tx?
It can be hard to form a therapeutic relationship - makes the outcomes of tx less good.
The following are criteria of the 5-factor model. What is the ICD-11 trait domain that corresponds to each?
5-Factor Model:
Openness
Conscientiousness
Extroversion
Agreeableness
Neuroticism
ICD11 Trait Domain:
Negative affectivity
Anankastia
Detachment
Dissociality
Disinhibition
Openness - No ICD11 domain
Conscientiousness - Disinhibition
Extraversion - Detachment
Agreeableness - Dissociality
Neuroticism - Negative Affectivity
No 5 Factor Correlate - Anankastia
